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Destabilising primary healthcare: Digitalised remote consulting and post- COVID-19 patient care

Nathan Davies28 September 2020

Sophie Park1, Yathavan Premadasan1, and Chris Salisbury2

Sophie Park MBChB M.Med. Sci (dist) FRCGP SFHEA, EdD. Professor of Primary Care and Medical Education. sophie.park@ucl.ac.uk

Yathavan Premadasan, BSc. Medical Student, University College London. zchaypr@ucl.ac.uk

Chris Salisbury, MBChB, MSc, MD, FRCGP. Professor of Primary Health Care, University of Bristol. c.salisbury@bristol.ac.uk

1 Research Department of Primary Care and Population Health, UCL, Royal Free Campus, Rowland Hill St. Hampstead, London NW3 2PY

2 Centre for Academic Primary Care, Bristol Medical School, University of Bristol. Canynge Hall, 39 Whatley Road, Bristol BS8 2PS

The COVID-19 pandemic has changed Primary Care dramatically(1), with most consultations conducted remotely by telephone, video or online messaging. But is this a short-term adjustment or the future norm? In General Practice, clinical care has been based on long term face-to-face contact, establishing trusting relationships through continuity of care, and using knowledge of patients’ personal circumstances and social context to provide holistic support. Now, these fundamental principles are challenged.

Matt Hancock (UK Health Secretary) has welcomed rapid changes towards digitalised clinical practice as an overdue development, stating that wherever possible, all future consultations should be conducted remotely(2). But is the pandemic ‘crisis’ simply being used to introduce unscrutinised change? The WHO recently considered the opportunities and challenges of digitalising healthcare systems(3) to address global healthcare workforce shortages and support delivery of universal healthcare, interprofessional working and patient engagement. The report also highlighted potential challenges to equality and social justice posed by private companies keen to exploit the healthcare “market”.

Accessing healthcare through digital services initially seems cheap and even democratizing – what could be easier than emailing your GP? But the reality can be very different. It potentially undermines core primary care principles: the importance of patient interaction; treatment of the whole patient; and situated use of evidence to individualise care, for example negotiating competing priorities in the context of multimorbidity. Worse, it widens health inequality: the healthy, the wealthy and those requiring simple transactional interactions benefit; whilst those with complex health problems struggle to get the care they need.

Remote digital consultations work well for simple transactions(4), for example, where a straightforward problem leads to a clear-cut disease diagnosis and treatment. But the main users of Primary Care are young children, the elderly, and those with multiple problems associated with long-term health and social conditions. Telephone and video provide less rich information than face-to-face consultations, making management of these complex situations difficult(4). The move towards remote consultations is a shift towards less personal and more transactional healthcare and away from an individualised, whole-person approach built on a patient-doctor relationship. Using an online form or telephone consultation means problems risk becoming over-simplified, over-investigated, medicalised and stripped of context and nuance. There is less opportunity for in-depth exploration of patients’ concerns and health beliefs, or for shared decision-making.

Studies in different countries have consistently shown that patients choosing remote consultations are predominantly young adults who are healthier, more educated and more affluent than average(5,6). These are the opposite of the characteristics associated with health need. Older, less educated patients and those with chronic illness are motivated to access digital healthcare, but face more difficulties in doing so because of lack of access to technology, the confidence and skills to use it, or physical or cognitive limitations(7). This should be no surprise to those looking at the “digital divide” in other sectors. For example, over 1 million Lloyds Bank customers (16%) required help to access internet and digital services; moving universal credit on-line increased claimants’ use of Citizens Advice; and, it is the over-75s who comprise most internet non-users(8).

Digitalised access to healthcare does not therefore equate to equitable access, nor does it necessarily reduce professional workload(9). Digital access can increase demand, as a ‘quick and convenient’ patient option(6) and can increase the need for follow-up(10).

These changes impact how primary care is perceived. For patients, those with simple health needs may appreciate the convenience of remote consulting but those with important personal issues to discuss may resent barriers to seeing a doctor in person. For GPs, it can undermine their sense of purpose and identity(10): many doctors choose to work in primary care because they want to offer high-quality, holistic care to a patient they know. If a large proportion of their day is spent emailing or telephoning unfamiliar patients, it degrades both the quality of care and satisfaction in their work. Doubtless it will influence career choices of future doctors.

Short-term, we need to make patient care during the pandemic safe. This requires dynamic and personalised risk-assessments with patients to ensure that face-to-face contact is only used when clinically needed, and in the patients’ overall best interests. While more remote consultations are needed, teams can maximise collaborative learning about how best to conduct and utilise digital patient interactions. However, we should resist normalising remote-first healthcare in the longer-term. Remote consultations offer advantages in specific situations. ‘Digital First’ interactions remain, however, problematic for many patient groups and long-term strategies need to retain agile, flexible and human-centred services, enabling patient choice about access and quality of care.

 

References

  1. Webster P. Virtual health care in the era of COVID-19. Lancet. 2020;395(10231):1180-81. doi: 10.1016/S0140-6736(20)30818-7
  2. ‘More Zoom medicine needed’ in NHS says Hancock: BBC; 2020 [Available from: https://www.bbc.co.uk/news/health-53592678 accessed 28/08/2020.
  3. ‘Future of Digital Health Systems: Report on the WHO Symposium on the Future of Digital Health Systems in the European Region’. Copenhagen, Denmark 6-8th February 2019. World Health Organisation (Regional Office for Europe).
  4. Hammersley V, Donaghy E, Parker R, et al. Comparing the content and quality of video, telephone, and face-to-face consultations: a non-randomised, quasiexperimental, exploratory study in UK primary care. Br J Gen Pract 2019;69(686):e595-e604. doi: 10.3399/bjgp19X704573
  5. Rodgers M, Raine G, Thomas S, et al. Informing NHS policy in ‘digital-first primary care’: a rapid evidence synthesis. Health Services and Delivery Research 2019;7(41) doi: 10.3310/hsdr07410
  6. Pearl R. Kaiser Permanente Northern California: current experiences with internet mobile, and video technologies. Health Aff (Millwood) 2014;33(2):251-7. doi:10.1377/hlthaff.2013.1005
  7. Nijland N, van Gemert-Pijnen JEWC, Boer H, et al. Increasing the use of econsultation in primary care: Results of an online survey among non-users of econsultation. Int J Med Inf 2009;78(10):688-703. doi: 10.1016/j.ijmedinf.2009.06.002
  8. Elahi F. Digital Inclusion: Bridging Divides: Cumberland Lodge; 2020 [Available from: https://www.cumberlandlodge.ac.uk/read-watch-listen/digital-inclusion-bridgingdivides-cumberland-lodge-report accessed 28/08/2020.
  9. Salisbury C, Murphy M, Duncan P. The Impact of Digital-First Consultations on Workload in General Practice: Modeling Study. Journal of medical Internet research 2020;22(6):e18203. doi: 10.2196/18203
  10. Atherton H, Brant H, Ziebland S, et al. The potential of alternatives to face-to-face consultation in general practice, and the impact on different patient groups: a mixed methods case study. Health Services and Delivery Research 2018;6(20) doi: 10.3310/hsdr06200

 

Contributors

All authors contributed to the conception and design of this blog, and YP undertook searches of relevant literature. SP and CS drafted the manuscript and YP commented on and approved it.

 

This blog was originally posted on the NIHR School for Primary Care blog. 

UCL Medical School Leading the UK Culinary Medicine Teaching Movement

Nathan Davies21 September 2020

In this post, Jessica Xie (final-year UCL medical student) shares why UCL medical students have been swapping their scrubs for aprons for an eventful day of learning in a teaching kitchen.

Nutrition education in the first three (pre-clinical) years of the  UCL undergraduate medical (MBBS) curriculum includes nutritional science and public health nutrition. In every medical specialty from Paediatrics to Geriatrics, there is increasing evidence to suggest that nutrition plays a central role in determining morbidity and mortality. Thus, it is increasingly important for students to learn about nutrition in a clinical context. 

The aims of the course are to equip students with the knowledge and skills to recognise patients whose health and wellbeing may be improved through dietary modification, and to be able to provide basic dietary advice.

Set in a teaching kitchen at Westminster Kingsway College, the course provides a unique learning experience. Students engage in a variety of teaching methods, including an online module, face-to-face tutorials, case-based discussions, role play and culinary skills training. Topics that have been taught on the course so far include types of diet and their evidence base, dietary interventions to treat or as an adjunct for disease management and socioeconomic determinants of dietary patterns and access to food. The skills that students gain from Culinary Medicine teaching include food identification and preparation, and communication skills, including motivational interviewing (MI). The latter is the art of empowering an individual to change their behaviour to achieve health and wellbeing improvement. A doctor’s role in MI is to highlight to patients aspects of their lifestyle that could be improved, collaborate with patients to create achievable goals and to support patients to make, and sustain, the behaviour change(s) themselves.

A nutritious meal cooked by UCL medical students during the Culinary Medicine course kitchen session.

Since March 2020, teaching has been delivered online via Blackboard Collaborate and new topics have been introduced to educate students about nutrition challenges exacerbated by COVID-19, for example access to food. One such topic is Nutrition Insecurity which is centred around a case study which highlights the disproportionate effect of COVID-19 on ethnic minorities, people of low socioeconomic status and those with pre-existing co-morbidities. Not only do students have the task of considering nutrition priorities from a patient’s perspective, they must also produce an appropriate management plan that addresses both the patient’s health and social needs. This task increases students’ understanding of socioeconomic determinants of health and emphasises the importance of an interdisciplinary approach to health and wellbeing. 

In June 2020, the UCL Primary Care team and CMUK organised a live cook-along webinar, led by CMUK founder (Dr Rupy Aujla) and Culinary Lead for CMUK (Chef Vince Kelly). Recipes were created using ingredients that are typically found in food bank parcels and were emailed to students in advance to encourage participation. The two hosts had a cook-off with Chef Vince producing an impressive four-course meal that won the majority of students’ votes, securing his victory! 

In future teaching sessions, students can look forward to webinars on culinary skills training, motivational interviewing role play and Q&A sessions with patients about their experiences of nutrition in healthcare. The topic Food Sustainability will also feature to teach students how to eat well whilst reducing their carbon footprint. 

Elements of nutrition education will be woven into other aspects of the MBBS curriculum. For example, students will be encouraged to incorporate nutrition advice into their General Practice reflective essays about a patient with chronic disease.

The UCL Culinary Medicine course was recently featured on BBC London news for being an innovative method of teaching medical students and doctors about clinical nutrition, and is endorsed by chefs and celebrities

With thanks to Dr Sara Thompson for her input in writing this blog post.

Covid 19: Adapting to new realities and ensuring well-being

Nathan Davies21 September 2020

By Dr Patricia Schartau

The Covid 19 pandemic is likely one of the most consequential global challenges of this generation. Individually, it impacts on all aspects of our lives including our health, finances, relationships, wellbeing and sense of self. Globally, it has far reaching consequences by affecting our healthcare systems, the economy and the way our world functions on an everyday level.

While this is a new type of ‘disaster’, for decades researchers have mapped the phases of emotional response to crisis, such as natural catastrophes and terrorism1: The initial ‘heroic’ phase2 is characterised by high levels of activity and a surge in altruistic behaviours (e.g. volunteering, healthcare workers stepping up).  The ‘honeymoon’ phase which followed through April3 comprised a sense of collective optimism and virtual community bonding. In May the ‘disillusionment phase’ started, probably the most challenging phase characterised by a heightened sense of discouragement and stress. This phase is associated with negative emotions, such as anxiety and sadness, and physiological upsets such as insomnia, dream disturbances and hyperarousal. Eventually, we will progress into a calmer yet similarly challenging phase, the ‘reconstruction’ phase. Whilst some of the phase headings seem somewhat misleading given the gravity of the situation and it is important to recognise the fluidity of the phases, they provide a good framework in order to describe human emotions and behaviours in response to crisis.

The ‘disillusionment’ phase, our current phase, exposes our vulnerabilities- our respective roles amongst family and friends, in employment and the wider society have been shaken up. The fragility of our health, wellbeing and socio-economic security have been exposed. What seemed relatively untouchable (e.g. freedom of movement, supply chains of medications and food) suddenly collapsed. Whilst the world around us moved and reformed on a daily basis, our own personal tsunamis (in my case primarily the unexpected loss of a close family member and losing some of my patients to Covid 19) create even more instability, with the usual safety nets, such as social activities and work routine, having become disabled.

Over the past months, most of us will have felt at least intermittently overwhelmed and asked ourselves- how can I make sense of this situation let alone get through it?  Personally, I reflected on my PhD in emotion regulation and assimilated the public advice from former psychology colleagues, such as Willem Kuyken from Oxford University. He highlighted4 a few simple mechanisms to help cope with this challenging situation:

Focussing our attention: We naturally focus our attention to threats in order to protect ourselves. Attending to the 24/7 Covid news is cognitively and emotionally exhausting. Whilst most of us are feeling a sense of loss of control, training ourselves to re-focus (e.g. by using mindfulness techniques5) and by choosing carefully what to attend to is a way to regain it. One practical example is to limit the number of times per day we read the news and/or Covid related WhatsApp threads.

Changing how we relate to the crisis: Us humans naturally enjoy to ‘time travel’- switching from past, to present, and to the future with an incredible speed and fluidity. Making future plans keeps us goal-orientated, grounded and emotionally stable. However, during the pandemic, trying to make plans has been an additional source of distress, unsettlement and anxiety. In my experience, digesting the world in smaller bites, with a sense of calmness and patience whilst not reacting to every change around us (including one’s own emotions), helps enormously. The notion that one can change thoughts and emotions in this situation by shifting focus, and choosing personal ways to relate to the crisis, is immensely empowering and somewhat reassuring. Whilst the world out there continues to change ever so quickly, it allows to regain some much needed stability.

Taking care of ourselves and having meaningful relationships with others: This is not rocket science, but wellbeing is supported by a healthy diet, plenty of exercise, a good sleep hygiene, good hydration, keeping some kind of routine and doing things that we enjoy and that give us meaning.  The latter includes social interactions with, for example, friends and family.

As Kuyken highlighted, ‘psychology offers ways for us to meet such crisis with courage, clarity and wisdom’. It also offers us alternative interpretations: For example, to value the opportunity that has arisen from the quarantine to re-evaluate personal goals and priorities:

 

References:

  1. Carson, J., Eyre, H. & Lavretsky, H. (2020). Dear Mental Health Innovators: The Covid-19 honeymoon is over. Letter in: MJH Life Sciences and Psychiatric Times.
  2. DeWolfe, D.J. (2000). Training manual for mental health and human service workers in major disasters. US Department of Health and Human Services. Substance Abuse and Mental Health Services Administration: Center for Mental Health Services.
  3. Washington, E. (2020). Phases of Disaster. https://www.samhsa.gov/dtac/recovering-disasters/phases-disaster
  4. Kuyken, W. (2020). Waking up in the time of Corona: four insights from Psychology.
  5. Kuyken, W. (2020). Keeping a cool head and warm heart in challenging times. https://www.oxfordmindfulness.org/news/keeping-a-cool-head-and-warm-heart-in-challenging-times-by-willem-kuyken/

Supporting carers of someone living with dementia during the coronavirus pandemic

Nathan Davies28 July 2020

In this post Dr Kirsten Moore, Marie Curie Palliative Care Research Department, UCL talks about dementia and supporting those living with demenita during the coronavirus pandemic.

Who is dying with Covid-19?

In April this year Covid-19 (coronavirus) became the most common cause of death in the UK. Office for National Statistics data showed that most deaths caused by the virus in England and Wales were among older people and those with underlying health conditions.

One fifth of people dying with coronavirus had dementia, making it the most common pre-existing condition. Also, the death rate from dementia was significantly higher in April than the previous five-year average.

How is COVID-19 impacting family and carers?

In the UK 700,000 family members and friends support someone living with dementia, providing 44% of the cost of care for people living with dementia1. Being a carer can negatively impact finances, stress and physical and emotional health. In our recent publication   we highlight some of the end of life care challenges that coronavirus has created for families caring for a frail older person or someone with dementia.

A diagnosis of dementia often leads to reduced social interaction for both the person with dementia and their family carer. Social distancing and lockdown measures are increasing this isolation and loneliness. Carers may have additional worries supporting the person with dementia who may not understand the importance of shielding and keeping socially distant from others.

End of life discussions and planning

When a person with dementia lacks capacity to make decisions, families may be faced with difficult decisions about whether to send their relative with dementia to hospital or a care home for care, or whether to provide end of life care at home where they can be present with their relative. Alternatively, they may have these decisions taken out of their hands due to procedures and guidelines adopted to contain the spread and impact of coronavirus.

In advanced dementia communication may be limited for many months. Having discussions in the early stages of dementia gives someone with the condition an opportunity to express their preferences about end of life care.

There are many benefits to discussing our end of life wishes with our family and those who are important to us. They allow us to share how we want to be cared for and who we want involved in decision making if we can no longer make or communicate decisions.

These discussions can also help family feel more confident in making decisions if the person living with dementia lacks capacity. When family members are unsure what a person wanted at the end of life, they may worry they have made the wrong decisions or feel guilty if the person had an uncomfortable death.

However, these conversations are not easy. Discussing end of life is something most of us tend to avoid. It is difficult to face our own mortality. These conversations are also difficult because we don’t know what is likely to happen or what sort of decisions we, or our families, may be faced with. Often discussions tend to focus on resuscitation status, place of death or whether someone should be taken to hospital.

People who have dementia may find it difficult to imagine situations that they have not yet faced, such as difficulties swallowing and talking.

How can we support carers?

Simply keeping family carers involved and informed is an important way healthcare professionals, hospitals and care homes can support family carers. This may involve having conversations about place of care and end of life care.

There are numerous guides about difficult conversations, such as this Marie Curie blog. There is no one-size-fits-all approach, but the most difficult part is often starting the conversation. Healthcare professionals may be worried about raising end of life topics, that they may not have all the answers or that the family may not want to have these discussions. Carers, however, usually prefer an open and honest conversation, including being told that there may be uncertainty or no clear answers.

Being responsive to whether the carer is ready to have a conversation is important. There may be a pressing need for a conversation, but if discussions are raised at an earlier point in the dementia trajectory then it can give the carer more time to prepare themselves for discussing end of life.

What can carers do?

Family and carers may feel that if a conversation about end of life is needed, it will be raised by healthcare professionals. However, this may not always happen. Carers should feel reassured that if they have questions about the care of their friend or relative, that they should feel able to ask healthcare professionals for information and advice.

You may find it helpful to talk decisions out loud or write down a list of pros and cons. These simple strategies can help you clarify what is important or where you need more information or advice. It is important to get information from reliable and trusted sources. Make use of helplines such as the Marie Curie, Dementia UK or Alzheimer’s Society helplines.

Having a family member who understands how dementia progresses has been linked to a more comfortable death for care home residents. Keep in mind the best interests of the person with dementia if they lack capacity to make their own decisions. Think about their values and what would be important to them. It may not be realistic to follow all their wishes, so do not feel guilty if this cannot be achieved.

Developing a decision aid

To help guide families and carers in making some of the complex and challenging decisions raised here, our team at the Marie Curie Palliative Care Research Department at University College London are developing a decision aid.
We will be exploring the questions that people are asking Marie Curie and the Alzheimer’s Society to work out the biggest challenges facing people with dementia and their families during the pandemic.

We will then work with family carers, healthcare professionals and use existing research to develop a decision aid. The decision aid will help carers think about their current circumstances and provide relevant information to help inform their decision making.

Sources

1. Prince, M., Knapp, M., et.al. (2014). Dementia UK Update (2nd edition).

 

This blog was originally posted on the Marie Curie website, taken with permission from Marie Curie and Kirsten Moore. https://www.mariecurie.org.uk/blog/supporting-carers-dementia/277479

Signposting patients to sexual health online – don’t forget the health (or the sex)

Nathan Davies22 May 2020

In this post Julia Bailey discusses the impact of Covid-19 on sexual health services and discusses sexual health online. 

The Covid-19 pandemic has prompted an unprecedented shift to remote health services as a response to social distancing for patient and practitioner safety. Sexual health clinic capacity has been cut as staff have been deployed to other parts of the health service, and patients are now asked to contact health services by phone or video-link, with clinic visits reserved for a small proportion of people who need to be seen (FSRH guidance). People can also access online sexual health services for STI testing (+/- contraception), in areas where this service is provided.

The shift to remote consultations is likely to make it more difficult to offer holistic healthcare and health promotion. For example, patients welcome opportunities to discuss sexual wellbeing beyond physical health (e.g. sexuality, sexual difficulties, sexual pleasure), but picking up on this will be more challenging with less opportunity to notice non-verbal cues and to establish trust (e.g. whilst examining).

Resources via the Internet and mobile phone can offer private, convenient access to information, which may be particularly welcome for topics which can be difficult to discuss (e.g. sex, sexuality, sexual difficulties). Online sexual health services can offer efficient STI testing and treatment, but do not usually offer evidence-based sexual health promotion. Interactive (i.e. tailored) digital interventions are effective for learning and sexual behaviour change, and could be incorporated into online sexual health pathways.

There is no nationally commissioned digital sexual health programme, and digital innovation varies widely across the UK. There are thousands of health apps and websites, but only a tiny minority have been rigorously evaluated and it is difficult to know which to recommend – the NHS apps library curates trustworthy resources.

Digital sexual health resources for patients – some suggestions:

Before (or instead of) appointments:

After a diagnosis/ongoing support:

Tips for writing patient materials

  • Don’t reinvent the wheel! Check what’s already available
  • Involve target users to make sure material meet their needs, priorities and preferences
  • Draw on principles of evidence-based sexual health promotion
  • Address barriers to access, e.g. audio and video formats; material in first languages
  • Address groups whose needs are often overlooked (e.g. women who have sex with women, trans, non-binary, intersex, and disabled people).

Summary

The post-pandemic ‘new normal’ will include digital health. There are some excellent online sexual health information resources available, and there is currently an unprecedented opportunity to offer evidence-based, tailored sexual health promotion to complement online and clinician-delivered sexual health services.

 

(This post was originally posted on the BMJ Sexual and Reproductive Health website who have provided permission to repost)

Dementia research behind the Scenes: Experience of an A-level student in an academic department

Nathan Davies27 September 2019

Vennie working with Nathan Davies learning about our dementia projects

We have a fantastic post below from Vennie an A-level student aspiring to study Medicine at university. She visited the department and shadowed some of our academics in their various projects in July. In this post talks about her experience and what she took away from it. 

Dementia is an increasing problem especially with the growing older population in the UK. The awareness of dementia is rising, especially through the use of media and organised events such as Memory Walks. However, how much do we know about dementia?

Well, in simple words, dementia is the ongoing decline in the brain. This is only an umbrella term for 200+ different sub-types of dementia that exists, some of which you may have heard off. For example the most common two are Alzheimer’s disease and vascular dementia.

During my placement in the Research Department of Primary Care and Population Health at the Royal Free Hospital, I was able to shadow members of the team that are involved at different levels of research projects.

I discovered that there are many stages which make up the process of a research project. Starting with the planning and design of the research project, ethics, and recruitment through to finally analysing and presenting the results produced. Alongside all this and integrated throughout are processes to ensure the results are implemented into clinical practice and policy, to make a difference. I learnt about the different types of studies such as qualitative studies and large clinical trials. Due to the involvement of human participants including often patients from the NHS in the studies the department runs, a major part of the research process is the ethical application and review. The purpose of the review is to establish if the project has more benefit than risk to the person and their family as well as is the project being conducted sensitively. For all of this to happen, it may take 5 to 20 years to see a difference in practice and policy.

In order for, this project to be successful, a range of people are required to take part, which in turns bring a variety of skills into the mix. These individuals may include designers, programmers, clinicians, psychologists, sociologists, statisticians, qualitative researchers, and importantly patients and their family themselves. A few of the most prominent skills are communication, teamwork, determination and resilience. For example, a project with Dr Davies and Prof Rait I observed on producing a support package for people with dementia and their families, communication has a massive role to play. The project uses workshops with people with dementia, their family and professionals to develop the support package. There is a need for clear communication between the ranges of people for this project to progress smoothly. The communication may come in the form of discussion-based in meetings, emails and many other ways. Therefore, teamwork is essential as each person will have a special role in the project. Finally, determination and resilience are required from every member of the team as there will be challenges along the way, which could be out of your control that must be overcome. For example, if the project does not meet the criteria of the ethics committee it may be returned to the researcher, and his or her team must go back and amend the plan.

In conclusion, research of any kind similar to this project requires a range of people to be involved with a variety of skills that are vital for the research to work. This work experience has been a fascinating and exciting opportunity for me to experience what goes on behind the scenes of a research project.

Accessing GP appointments- a disaster waiting to happen or hope on the horizon?

Nathan Davies16 May 2019

In this post Ruth Abrams and Sophie Park reflect on the current pressures facing GPs and NHS today.

In a recent expose called ‘GPs: Why Can’t I Get an Appointment?’, a Panorama documentary, which aired on BBC1 on Wednesday 8th May, emphasised the current limits of and pressures on the NHS system. The programme featured interviews with overworked GPs and allied healthcare professionals, painting a rather bleak picture. Practices are merging and closing at an ever increasing rate. Patient loads increase as patient lists are subsumed. Patient multi-morbidities have increased the need for chronic conditions to be monitored with regular GP appointments. Yet on average patients wait a minimum of two weeks for a routine appointment. Early retirement and a limited flow of trainees into General Practice also contribute to the strain, making practice sustainability difficult to envisage. Inevitably, pressure and frustration are being felt amongst both patient groups and the primary care workforce.

Whilst those researching, working in and experiencing primary care within the UK will already be familiar with these factors, what has become a pressing concern since the 2015 publication of the BMA’s, National survey of GPs: The future of General Practice, is patient safety. At present only the most urgent of cases are seen quickly in General Practice. Yet still an unsafe number of patients are seen by any one GP in a day. This high demand placed upon GPs makes for little time to reflect on cases.

Enter- the release of the new GP contract and the NHS long term plan which intend to employ a multi-disciplinary army of healthcare professionals. Within this new way of working, workloads will be shared amongst staff, with greater efforts being made for both integration and collaboration. A typical GP’s day will begin to look very different. Micro-teams will have time to discuss patient cases, a GP’s time can once again be focused on the professional tasks only they can undertake and overall there begins to be a healthier outlook to teamwork.

Some promote this utopian vision of General Practice working unquestioningly. Pots of money, such as those made available through the Prime Minister’s Fund, have encouraged new ways of working with very limited evidence base. Yet one aspect seemingly unaddressed within the new plans is the disparity across patient access and levels of deprivation within the UK. In a recent report by the Health Foundation, GPs working in higher deprived areas see more patients compared to their counterparts. These are areas where recruitment of this new workforce will inevitably be harder. This raises questions about how best to incentivise recruitment so that patient access to care remains equal for all.

There is also a certain feel that these plans are being done to, rather than with GPs. We need only reflect back a few short years to the junior doctor protests to recall that in order for patient safety to happen, workforce perspectives must be accounted for. In order for the NHS to remain as successful as it has been and for the principles of Astana declaration to be realised, GP engagement rather than negation needs to remain central to all future planning activities.

Unequal access to care and a disruption to professional identities present major issues. But doing nothing is no longer an option. At a time when the NHS is so often synonymous with the words crisis and strain rather than success, a Utopian vision for both staff and patients may be both timely and necessary. Reifying this however, becomes a different matter all together.

Can a self-management intervention facilitated by peer support workers reduce readmission rates to acute care for people discharged from crisis resolution teams

Nathan Davies23 August 2018

In this post Louise Marston talks about their recent study published in The Lancet on peer support for reducing readmission among people to acute care for people discharged from crisis resolution teams, which provide intensive home treatment following a crisis.

CORE (CRT Optimisation and RElapse prevention) has been a big part of my working life for a number of years.  It was an NIHR funded programme grant from 2011 to 2017.  One of the work packages was an individually randomised controlled trial supported by Priment Clinical Trials Unit.  The results were published in The Lancet recently.

Why did we do this study?

Crisis resolution teams work in the community to help prevent admission to acute care at times of mental health crisis.  Nationally, they have not resulted in a decrease in bed use.

Self-management is a way for people to actively manage a condition; recognising the signs of crisis and knowing how to manage symptoms and other aspects of their life.  Interventions may aid self-management, but might be more effective when facilitated and motivated by someone else.  Peer support workers have had similar experiences to the people they are supporting, so are able to be a role model for recovery.

Who did we enrol in the study?

We recruited people who had been on the caseload of mental health crisis resolution teams, been discharged from the crisis resolution team in the previous month and had capacity to consent to taking part.  We did not recruit those who were deemed to be high risk to them or others, were discharged out of the area or who could not understand English.

What was the intervention?

This was a self-management workbook, which was adapted from other resources in an earlier CORE work package, which was facilitated by a peer support worker in up to 10 sessions.  In these sessions, peer support workers were encouraged to help participants complete the workbook and to reflect and discuss their recovery plans.  Peer support workers were also employed to provide supportive listening and instil hope of recovery, through sharing strategies to aid recovery learnt through their own recovery journey.

What was the comparison?

Participants in the control group were sent the workbook in the post, but did not have access to a peer support worker and were not given further guidance on how to use the workbook.  They could also access usual care.

What did we find?

We found that those randomised to the peer support worker group were less likely to be readmitted to acute care in the year after they enrolled in the study compared with those who were randomised to the workbook alone (29% versus 38% respectively).  Time to admission was also significantly longer in the intervention group, as was satisfaction with mental health care and self-rated recovery at 4 month follow-up.

What does this mean?

The rate of readmissions was lower than expected overall.  However, peer support workers have the potential to help reduce readmissions further in people who have had a mental health crisis, giving them the opportunity for a sustained recovery.  It also means that the burden on acute services will be less; potentially giving savings to the NHS.

Satisfaction with care related to all mental health services; even so as this was statistically significant at four month follow-up suggesting that participants liked having a peer support worker, and uptake of the peer support worker intervention was good.  If peer support workers after mental health crisis were more widely available, this may go some way to improving Trust satisfaction ratings.

 

Johnson S, Lamb D, Marston L, Osborn D, Mason O, Henderson C, Ambler G, Milton A, Davidson M, Christoforou M, Sullivan S, Hunter R, Hindle D, Paterson B,  Leverton M, Piotrowski J, Forsyth R, Mosse L, Goater N, Kelly K, Lean M, Pilling S, Morant N, Lloyd-Evans B (2018) Peer-supported self-management for people discharged from a mental health crisis team: a randomised controlled trial Lancet 392 409-428 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31470-3/fulltext

#OPAL2018: Identifying and addressing shared challenges in conducting health and social care research for older people

Nathan Davies2 July 2018

In this post Rachael Frost from the Centre for Ageing and Population Studies discusses the fantastic achievement of being awarded a place on an international early career researcher workshop in Brazil.

I was recently lucky enough to be awarded a place on a Brazil-UK Researcher Links workshop: Identifying and addressing shared challenges in conducting health and social care research for older people (OPAL) in June 2018. Funded by the British Council, the Newton Fund and Sao Paolo Research Foundation (FAPESP), the workshop aimed to encourage collaboration among UK and Brazilian early career researchers and to develop joint research proposals to address some of the major challenges facing ageing research in both countries. As an early career researcher in the Centre for Ageing and Population Studies in PCPH, I was really excited about the opportunity to meet other early career researchers and share our experiences.

Brazil’s population is ageing rapidly, and in a much shorter time frame than many European countries. Whilst France had 150 years to adjust to a doubling in the proportion of the population aged over 60, Brazil has just 20 years. Dementia and frailty are on the rise in both Brazil and the UK. However, Brazil is approximately 35 times the size of the UK, and faces extra challenges in access to healthcare, particularly in rural areas (e.g. despite the size difference, the UK has almost ten times more GPs).

  Outside the Sao Paolo State University Faculdade de Medicina

The workshop was organised by Dr Kathryn Hinchliff-Smith, Dr Reena Devi and Associate Professors Adam Gordon and Alessandro Jacinto with teams from both the University of Nottingham and Sao Paolo State University. It brought together 13 UK early career researchers from a range of UK universities and 18 Brazilian early career researchers, in the small Brazilian city of Botucatu at the Sao Paulo State University School of Medicine. It was a long flight over (not helped by Adam telling us everything that went wrong with the plane the last time they flew out…), but well worth it when we got there!

As well as serving us copious amounts of tasty Brazilian food, the five day workshop included a talk each day from the workshop mentors. They discussed the context of ageing research in Brazil and the UK and the key challenges for each country. The early career researchers presented posters on current projects and future research interests, and took part in larger discussions of how the academic research context works in Brazil and the UK. We were also given a lunchtime tour of Botucatu’s hospital.

In addition to this, one of the main workshop aims was to develop international research ideas and grant proposals.

Our final day presentation

We were put in small groups, and spent a couple of days discussing our interests and ideas. It was sometimes a difficult balance trying to find a project that was both feasible and interesting to everyone in the group, however by the last day each group had formed clear plans for projects. We presented these ideas around dementia, frailty and palliative care to the rest of the group.

In addition to lots of hard work, we also made the most of fantastic opportunities to see round Botucatu. Although it was technically winter in Brazil, it was the same weather as an English summer. An enthusiastic group of us got up at 6am two days running to see the ‘base of the clouds’ (a beautiful sunrise view of miles of wilderness) and to have an early morning dip in a waterfall! We also managed to fit in evening piano concerts, coffee museum visits, acai berry ice cream and a fair few caiprinhas. Our Brazilian colleagues were fantastic and welcoming and showed us how to dance Brazilian style!

A pre-workshop waterfall visit

It was an amazing opportunity, and all our groups are planning to take our ideas forward with support from the workshop mentors. In addition to new proposals and collaborations, we also learnt a lot about each other’s countries (including a smattering of Portugese), and made new friends and colleagues in both Brazil and the UK. Obrigada, Brasil and hope to see you again soon!

 

A morning visit to the ‘base of the clouds’

Even modest amounts of activity from midlife are associated with significant health benefits

Nathan Davies22 June 2018

In this post Daniel Aggio talks about his recent trip to the American Heart Association’s conference in New Orleans, and the exciting findings on the effects of physical activity and risk factors for cardiovascular disease. 

In March this year, I was fortunate enough to attend the annual American Heart Association’s conference on Epidemiology and Prevention (EPI Lifestyle) in New Orleans. The overarching goal of the conference is to promote development and application of translational and population science to prevent heart disease and stroke. The conference theme this year was health promotion: risk prediction to risk prevention, with a large focus on behavioural strategies to promote and sustain healthy lifestyles. This conference was highly recommended by my supervisors and it turned out to be a fantastic experience. There were some inspirational speakers from the field of physical activity, such as Professor Andrea LaCroix, who presented her work on American older women showing that light physical activity is associated with a reduced risk of cardiovascular events in later life. This was particularly encouraging given that a recent paper from the British Regional Heart Study (BRHS) mirrored these findings in older men.

On the first day of the conference, I was presenting in one of the moderated poster sessions and what a lively session it turned out to be. The poster I was presenting was from my PhD work utilising 20-years of physical activity data from the BRHS, a prospective cohort study of middle-aged men transitioning into old age. In this study I used group-based trajectory modelling, a form of latent class growth analysis, to plot trajectories of physical activity and examine their associations with a range of cardiovascular risk factors in old age. The take home message was that although sustained high levels of activity proved optimal, in fact sustaining more modest amounts of activity from midlife was also associated with significant health benefits. The session was well attended and I received some tips and advice from one of the first researchers to utilise group-based trajectory modelling in physical activity research, Dr Tracie Barnett. Since returning to UCL, I entered this poster into the Faculty poster competition in which I was awarded the runner up spot. It was amazing to see my work being recognised with so much other great research going on in the Faculty.

EPI Lifestyle also had a strong programme of events for early career researchers, including a three-minute thesis competition and a session on identifying your niche in academic research. I was also invited to participate in a round table discussion on forging International Collaboration, where I represented the BRHS. Representatives from cohort studies from around the world were in attendance along with early career researchers looking to find out more about these studies and opportunities for collaborations. This was a great opportunity to learn about other cohorts, many of which I hadn’t come across before, and also to network with some of the leading investigators of these studies. More information about these cohorts can be found here.

Overall, EPI Lifestyle was an amazing experience where I learned some great science, but the highlight for me was the networking opportunity. I made some valuable contacts that gave me some great advice and will no doubt be useful connections in my future career.