In this post Dr Catherine Jackman an ST6 inGeriatrics and General Medicine talks about the bed blocking we saw in the 1960s through to modern day ‘delayed transfer of care’ or becoming known once again as ‘bed blocking’. 

“NHS bed-blocking rises 42% in a year…”

“NHS ‘bed-blocking’ rises for sixth month in a row”

“’Bed-blocking’ patient left waiting three and a half years to be discharged…”

At a time when the NHS faces unprecedented change and challenges there is barely a day which passes when the media doesn’t comment on bed blocking (or as it is called today – Delayed Transfer of Care) and the huge number of older patients unnecessarily ‘stuck’ in hospital.

Delayed transfer of care (DToC) refers to the long term occupation of hospital beds, often by older patients, who are medically fit to be discharged but are unable to leave due to a shortage of available care options elsewhere.  The consequences of this are significant; there is a huge added cost to the NHS, beds are not appropriately utilised and many other patients may wait long hours in A&E for a free bed on the ward.  DToC patients suffer physically, in terms of hospital acquired infections, and psychologically.  They are at risk of becoming institutionalised and, in addition to this, staff morale takes a hit.

Evidence would suggest however that this has been a problem the NHS has had to deal with for many years.  Geriatric medicine has evolved over the past 60 years and the provision of care available to our older population has changed, but bed blocking and DToC continues.

Departmental reports from the geriatric medicine department in Stoke in the 1960s-1970s comment on the challenge of patient demand exceeding the facilities available to provide adequate care.  At that time there were, on average, 700 long stay beds for elderly patients in the Stoke area.  They functioned as the equivalent of today’s care homes but often without recreational or rehabilitative facilities.  Patients would also be admitted for “holiday respite” so that their family could have “a well-earned rest”.  Despite requesting relatives sign a “contract” to state they would take the patients back home this often did not happen.  One report is of an 87 year old widow who was admitted as a “holiday spell” and a form guaranteeing re-acceptance was signed by a son.  After admission the patient was found to be active, alert and continent.  After a month long admission the family refused to accept her home and involved a solicitor.  The patient then had to join a long waiting list for local authority provided accommodation instead.

Another patient report from the long stay facility is of a 76 year old woman whose son wrote “mother and I have not got on very well for years.  She has led a very useless life…Naturally, I feel very bitter about this…As you are aware the proper authorities will provide for her if you will only apply to them.  I cannot do anything more in this matter.”  This patient again joined the waiting list, “blocking” the hospital bed in the meantime.

The length of stay of these patients on the wards could often exceed 1 year.  And, as is the case today, many died or deteriorated whilst awaiting local authority funded welfare housing or placements.

Fast forward 20 years to 1986, a BMJ paper entitled “Bed blocking in Bromley” reported that more than 1 in 10 of all acute patients were classified as bed blockers – rising to 1 in 5 of medical patients.   The authors commented “bed blocking seems inevitable in wards attempting to cope with the steadily increasing proportion of elderly patients”.   They defined bed blocking as patients who remained in hospital for 4 weeks or longer, and in the opinion of the medical staff, no longer required the facilities provided there.  Reasons suggested in this study were similar to those of the earlier reports i.e. social and administrative problems as well as relatives refusing to have patients home.

After the 1980s there was a change away from long stay geriatric wards and care of our older population is now integrated into the acute hospital setting.  Additionally there has been far more emphasis on social care with social workers very much integrated into the hospital teams.  Since 2003 local authorities have been fined if they fail to organise care in a timely fashion.

The late 1990s and early 2000s was a golden period when the government tried to transfer the focus of care into the community and social care expanded.  However, following the financial crisis of 2008, in 2010 the government introduced a period of austerity and the rate support grant to local authorities has been reduced every year.  So, with cuts to their budget, there has been less social care spend despite an increasing demand exacerbated by steadily rising patient numbers and a declining number of beds.  Inevitably this has increased pressure on hospitals to provide the necessary care and resulted in the return of “bed blocking”.

A solution to the recurring problem of bed blocking, or DToC, has not been developed by any government as yet.  A proper integration of Health and Social Care would seem to be needed with joint funding.  This would involve a major upheaval/reorganisation which, as the King’s fund reports, is extremely difficult in a time of decreasing budgets.

Dr Catherine Jackman

catherine.jackman@nhs.net

In this post Surinder Singh, Course Director for the iBSc in Primary Health Care gives us na update with some great feedback from past and present students.

We have just just “graduated” the twentieth cohort of students undertaking the Department’s integrated BSc in Primary Health Care (iBSc).  After their first two years at UCL  all medical students  undertake an iBSC year  which allows them to pursue an individual subject, of their choice, in considerable depth, with a strong emphasis on undertaking an extended research study.  This is a fundamental element of the medical school’s  mission to produce  “scientifically-literate” clinicians. (http://www.ucl.ac.uk/medicalschool/staff-students/course-information/year-3).

Ever since 1997 one of the iBSc options at UCL has been the iBSc in Primary Health Care.  This was the first primary care iBSc in the UK and each year we recruit a small but dynamic cohort of usually 10-14 students.

Over the last twenty years we have produced almost two hundred graduates, most of whom are now practising clinicians throughout the UK and abroad. The original Course Director was Melvyn Jones who subsequently handed over to current lead Surinder Singh.

The iBSc consists of six modules encompassing individual patient care, the consultation in primary care as well as health of the population and critical appraisal – now jointly taught with the iBSc in Paediatrics. The single largest module is Research* – led by Richard Meakin. This is a module which students find sometimes challenging, usually fascinating and always rewarding.   It is also the component where we are particularly keen to involve PCPH researchers and research students as project supervisors.  So please contact Surinder or Richard if you would like to get involved or have a small project in which you think a bright and well-motivated student could contribute in return for your supervision.

A short video about the iBSc and a list of all projects and abstracts/scientific papers are on the iBSc website.

Two recent graduates have kindly sent us  the following comments about their experiences of the iBSc in Primary Health Care for this blog:

Student Rajit  Randhawa writes:

“As far as I am aware primary healthcare is only amongst a few iBScs to offer patient contact – one day a week throughout the year.  Not only does this help tie in the theoretical learning about consultation models and patient-belief systems, it most definitely prepares us for the 4^th year clinics and in my opinion, is a truer placement than the 5^th year GP placement because we actually see continuity of care over a prolonged period.  In my time at my medical practice I clerked and examined many patients, performed basic procedures such as flu jabs, and even had the opportunity to write up an inquest into a patient’s death in addition to doing more routine tasks such as home and hospital visits”

 And of the teaching during the year:

“I cannot think of a single session where I thought the teaching was overbearing or too complex. Tutorials can be up to three hours but it’s not as bad as that since the format lends itself to promoting healthy and productive discussion between different groups of students.  As someone who was often happy to sit silently I now appreciate being driven out of my comfort zone, and it has helped to develop my confidence speaking to larger groups”

Another graduate of the course, Joht Chanda– now a junior doctor wrote:

 “I am currently finishing my Foundation Year 1 in the West Midlands. During medical school at UCL I was fortunate to get onto the iBSc in primary care and population health after my pre-clinical years.  I wasn’t sure what to expect before starting the course, however the lessons I went onto learn, were extremely positive in shaping where my career is currently going.

 The iBSc was the first opportunity I ever had to try taking part in research. Academia was not something I had ever considered before, as in my head I thought it usually consisted of lab work and being told what to do (two things I can’t stand!).

 However, in comparison to the other courses available, this iBSc was one of few to give you an opportunity to run a research project from start to finish, even applying for our own ethics (I can say happily now, but not so much back then!).  Although seemingly daunting at the time, the task of designing my own project was possibly one of the most useful I was able to complete during medical school.  It meant that in the proceeding clinical years, I had a solid grounding in research methods and was able to start taking on work myself that others in my year group wouldn’t have the knowledge of where to start.  

 Being self-sufficient meant I was able to strengthen my application for foundation years without having to rely on others for opportunities.  Instead this self-sufficiency taught in the iBSc meant I was the person responsible for creating the opportunities. The iBSc supervisory team were extremely supportive and even helped me publish my project and present it at conferences; these were great stepping stones for the future as most career paths usually prefer some level of academic engagement.

 I cannot explain quite how useful doing the course was for me and how thankful I am to have got on it, thinking back”.

Joht wrote a paper with Richard Meakin for BMJ Open and Rajit has produced a poster for a conference in 2017.

• J S Chandan & R Meakin: Do special constables in London feel that they are adequately prepared to meet their first aid responsibilities? A qualitative study 
•  Randhawa, J S Chandan, T Thomas, S Singh. Investigating the attitudes and views of general practitioners on the use of video consultations in primary health care. Poster accepted for conference on Telemedicine (UCL)

PLEASE DO GET IN TOUCH IF YOU WOULD LIKE TO GET INVOLVED

We are currently recruiting projects supervisors for the new cohort of eleven  iBSc students starting in September 2017.  If you are a PhD student/post doc and would like to get involved  please do contact  Surinder Singh or Richard Meakin

In this post Nathan Davies talks about his recent oversees visit and the importance of developing international collaborations. 

Working as a researcher in academia, one of the great benefits we have is the ability to work with others from across the globe and travel to visit them; sharing our ideas, results and enthusiasm for the work that we do. And this is exactly what I have done recently in Hong Kong and Australia. But importantly it is not just a benefit but I think a vital part of academia, learning from other leading academics and health care systems.

In 2011 I started working on a European Commission funded study whic

Learning about Traditional Chinese Medicine

h had a whole host of leading academics in both dementia and palliative care not just from Europe but even from Australia. It was at this point I met Prof Wendy Moyle from Griffith University, Brisbane, Australia who invited me to visit her and the team at Griffith. I did so back in 2015 and have just returned from my second visit.

On the way to Australia I made a quick but exciting pit-stop at Hong Kong Polytechnic University, where I was hosted by Prof Wai Tong Chien at the School of Nursing. In addition to presenting the work I have been doing as part of my NIHR School of Primary Care Research Fellowship, I met with members of the team to understand how cultural variations affect the provision of end of life care, for example a hot topic was the use of feeding tubes in people with dementia. But, it was also fantastic to see how Hong Kong uses the latest technology to train their new generation of aged care nurses, with specifically designed teaching labs.

Following Hong Kong I was in Australia for just over four weeks – although, I must admit it wasn’t all work and I did take a bit of time to have a holiday out there too. For the first part of the trip I was in Sydney and I met with various academics from three different universities; University of New South Wales, University of Sydney, and University of Technology Sydney. I presented some of the exciting work that we have been doing here in the UK, including my work on developing an online support tool for family carers of people with dementia, as part of my SPCR Fellowship. In Sydney I was particularly keen to hear about the digital interventions and trials which are currently underway which focus on supporting families and people with dementia. At UNSW I met with Prof Henry Brodaty and Dr Megan Heffernan who went through their Maintain Your Brain project which is about developing a website for use by teaching people how to manage modifiable risk factors for dementia. We were able to have a lengthy discussion regarding the design of websites but also the challenges of eHealth interventions in academic research, learning some valuable lessons for my own eHealth research. I was also able to meet with Associate Prof Lee-Fay Low who discussed her trial of CareToons which is an online program on management of behaviour changes for carers of people with dementia. These were great learning opportunities to bring back to my own work here in the UK.

Moving up the coast to Brisbane, I spent a week with Prof Moyle and her team meeting and learning a lot from different academics and clinical staff, including Prof Elizabeth Beattie, the Director for the Dementia Collaborative Research Centre: Carers and Consumers. I also visited a long term care facility Jeta Gardens. This was a great opportunity to learn not just about aged care in Australia but also to learn about the architectural design of aged care facilities.

Jeta Gardens tour

Prof Moyle has a large group of PhD students from across Australia and the rest of the world. I was asked to provide a qualitative methods workshop to get the students thinking about what qualitative research is and how it can work with and alongside quantitative research. This was a great chance to learn about the PhD students’ work and to understand how they could see qualitative methods working within their work, much of which was clinical trials.

I can definitely say this was a fantastic opportunity to have early on in my research career and I left having developed some fantastic connections and learnt a lot not only about research methods and topics, but also about how aged care works in different countries. As part of this trip I am also now supervising a new PhD student studying at Griffith University, conducting a qualitative study exploring end of life care for older adults in Ghana. I will remain in contact with Prof Moyle who is now also a mentor in my future work and new fellowship.

I 100% encourage everyone especially early career researchers to think about who they want to work with outside of the department, not just nationally but also internationally, and don’t be afraid to go for it!

On the 21st July Dr Lee-Fay Low will be visiting us from Sydney giving a talk for our seminar series about her work on CareToons and several other projects she has been involved in, please do come along.

Dr Hazel Gilbert and her team have today had their start2quit trial findings published in The Lancet. Read the official press release from The Lancet below.

Smokers underestimate their personal risk of illness, and a key aim of the study was to try and persuade them that these risks are personally relevant.

Offering smokers a taster session at an NHS Stop Smoking Service and explaining their personal risk of developing smoking-related diseases doubles their likelihood of attending a stop smoking course, according to a study in The Lancet.

Smoking is the leading cause of preventable ill health worldwide. Although smoking rates in England have halved since 1974, this decrease has slowed since 2007, and the total cost for the National Health Service to treat smoking-related disease was estimated at £5.2 billion in 2005-06.

NHS Stop Smoking Services combine specialist support with prescribed medication, and are an effective way of helping people to stop smoking.  However, attendance is low and only around one in 20 (less than 5%) smokers use the service each year.

In the trial, 4384 smokers from 18 service areas across England were either given a routine referral letter (1748 people) or a new personalised letter explaining their individual risk of smoking-related diseases and offering them a stop smoking taster session (2636 people).

The personalised letter included the person’s individual risk of serious illness if they continued to smoke, rating them as being at high, very high or extremely high risk compared to people who used to or never smoked. It also included information about how much their risk would reduce if they quit smoking immediately. The calculations were based on information from the person’s medical records. For example:

“Based on your smoking habits and your personal health, your current risk of developing a serious illness and suffering an early death is very high compared to a non-smoker or ex-smoker of your  age… Even by smoking 12 cigarettes per day you are seriously increasing your risk of developing one of these major diseases and dying sooner than you need to… The good news is that if you quit now, at 45, you can halve your additional risk of contracting these diseases, or of suffering any other conditions such as a stroke and osteoporosis…”

The trial found that 17% (458) of those who received the personalised letter attended the first session of a Stop Smoking Service course within six months of receiving the letter, compared with 9% (158) of those who had the routine referral letter – meaning the personalised letter doubled the likelihood that a person would attend. It also doubled the likelihood of people completing the full six-week course (15% (382) vs 7% (123)).

Six months after receiving the letter, those who had the personalised letter were more than 1.5 times more likely to have gone without a cigarette for a week (9% compared with 5.5% [2]). Those who didn’t attend the Stop Smoking Service were least likely to have quit for a week (4.4% of those who received the personalised letter and 4.9% of those who had the routine letter).

Of those who took up the offer and attended the taster session, and also subsequently attended the Stop Smoking Service, 28.7% achieved 7-day abstinence. 

“Smokers underestimate their own personal risk of illness, so a key aim in motivating them to try to quit is to persuade them that these risks are personally relevant. Individual risk information can also arouse fear or concern, which might prompt them to quit, particularly when combined with a reassuring message that doing so would be effective and that help is available,” said lead author Dr Hazel Gilbert, University College Medical School, UK. “The combination of hard-hitting “why quit” messages about the consequences of tobacco use, and supportive and positive “how to quit” messages, emphasising quitting resources, has been shown to be effective in some mass media campaigns. In our study, we found that this combination of personalised risk and easy access to a session doubled smokers’ likelihood of attending and increased their chances of quitting.” [1]

Overall smokers found the taster sessions helpful and interesting. Two-thirds of participants (66%) found the letter useful and very few found it antagonistic, depressing or anxiety-inducing, suggesting that using risk information while offering support was an appropriate way to target smokers.

The researchers estimate that the intervention would be a cost-effective use of NHS resources. While the intervention is more costly than the usual treatment in the short term, the authors say that it is likely to be cost-effective in the longer-term because of health-care cost savings and health benefits attributable to the reduced risk of smoking-related diseases.

Limitations of the study are that only 18 of 151 Stop Smoking Services in England participated, and that the proportion of potentially eligible smokers recruited was low. The average age of smokers involved in the trial was 49 years-old meaning the results may not be representative of a younger age group.  More research is needed to confirm how this intervention would apply in practice.

Writing in a linked Comment, Dr K Michael Cummings, Medical University of South Carolina, USA, said: “Most people who have smoked for any significant length of time would like to stop smoking. Findings from prospective studies examining the natural history of efforts to stop smoking show that smokers often make frequent efforts to stop smoking or reduce their consumption, with little long-term success… Low attendance at Stop Smoking Services is a concern because evidence shows that these services are not only a highly cost-effective medical intervention producing higher quit rates than other approaches, but are also effective in reaching smokers from disadvantaged communities… Government authorities should resist any cost-cutting suggestions to decrease support for the Stop Smoking Services on the basis of the obvious and well documented benefits achieved when smokers are enrolled in these services.”

NOTES TO EDITORS

The study was funded by the National Institutes of Health Research Health Technology Assessment. It was conducted by scientists from UCL, the University of Cambridge, Smokefree Camden, and the University of York.

[1] Quote direct from author and cannot be found in the text of the Article.

[2] 9% of all people who received the personalised letter and invitation to a taster session (236 of 2636 people; ie. Including people who did not attend the services) and 5.5% (97 of 1748 people) of all people who received the routine referral letter.

 For interviews with author, Dr Hazel Gilbert, University College Medical School, Royal Free Campus, UK, please contact: E) hazel.gilbert@ucl.ac.uk T) +44 (0) 1635 203484 / +44 (0) 788 4121630

 For interviews with Comment author, Dr K Michael Cummings, Medical University of South Carolina, USA, please contact E) cummingk@musc.edu / carpente@musc.edu T) +1 843 876 2429 / +1 843 876 2436

This month Nathan Davies talks for the NIHR School for Primary Care Research about the news that dementia is now the leading cause fo death in England and Wales, and explains about some of the factors which may be underlying this revelation.

Last week we saw the Office for National Statistics announce that Alzheimer’s Disease and other dementias have become the leading cause of death in England and Wales. It has replaced heart disease, with 61,686 out of 529,655 recorded deaths last year in England and Wales. Now this sounds all very alarming, but actually we know from recent studies that the incidence of dementia is falling. However, our population is ageing and therefore the prevalence of dementia is increasing. All a bit muddy.

But, why are we seeing dementia now as the leading cause of death? There are many reasons as to why this number has increased. We have seen an improvement in the diagnosis of dementia across the country, including the inclusion of dementia diagnosis in Local Enhanced Services in Primary Care. In addition to this doctors are now much more likely to record dementia as an underlying cause of death on death certificates and not simply record pneumonia for example.

Regardless of all the factors which lie behind this news, dementia is one of the biggest health concerns facing older people, and the health and social care systems. There is no cure or disease modifying treatment for dementia as yet and only this week we saw that a drug (solanezumab) which sounded promising last year, has been reported as unsuccessful in delaying or slowing down the progression of Alzheimer’s Disease.

With no known cure it is vital that not only does research into treatment, cure and prevention continue, but also that care based research continues. As a School the NIHR School for Primary Care Research currently funds many dementia care pieces of research, and I am fortunate enough to receive some of this funding.

My work at UCL focusses on end of life care for people with dementia. As part of this work I  am exploring the support and challenges that family carers of people with dementia face at the end of life. Families provide the majority of support to people with dementia and it is vital that they are supported too. Our study CADRE is developing a website to provide support for family carers when caring for someone with dementia at the end of life. We are still in the development stages of our study and building our prototype website, but keep an eye out as we will soon report what we think a website needs to include and how this should look! Initial suggestions include elements of networking and social interaction, including a function to identify other carers in the local area.

Our other study ‘After the Liverpool Care Pathway: What next for people with dementia?’, which has recently come to an end has developed a series of rules-of-thumb for practitioners providing end-of-life care for people with dementia. Our rules-of-thumb cover the core and most difficult decisions facing a practitioner at the end-of-life: eating/swallowing difficulties, providing routine care, reviewing treatment and interventions, and agitation and restlessness. The rules-of-thumb provide a practical toolkit for making decisions and make the implicit knowledge which has been built up over a number of years explicit. Potentially, this is a great method for training junior staff and those less experienced who work with people with dementia at the end-of-life, but it also provides practical and on-the-job assistance. The toolkit has been taken up by the Alzheimer’s Society who are currently looking at ways to implement it in their training packages.

Although the prevalence of dementia is increasing, and it is now the leading cause of death, it is important to realise, as a research community particularly within primary care and the School, that we are conducting timely studies in an effort to help health and social care practitioners, carers and those affected by dementia.

Marta Buszewicz discusses the primary care mental health research project, exploring the mental health of general practitioners, which  is an NIHR School of Primary Care (SPCR) funded study which is still underway.

There has been a great deal written in the press about the considerable and increasing work pressures which general practitioners (GPs) in the UK are currently under, along with  significant financial constraints and difficulties recruiting sufficient new GPs to replace those who are leaving or retiring. Something which has been explored less are the emotional and mental health difficulties experienced by many GPs, which they are often reluctant to disclose or may feel unable to seek appropriate help for. There is evidence that doctors, including GPs, are more likely than the general population to experience mental health symptoms such as anxiety, depression, stress and burnout.

This qualitative study involved 47 interviews with a wide range of GPs recruited from a variety of locations and including the following groups: those currently living with anxiety, depression, stress and/or burnout; those returning to work following treatment for such conditions; those off sick or retired early due to mental health problems and those who have not personally experienced mental health problems but were interested in the project. The study proved quite easy to recruit to, with so many GPs approaching us wanting to take part that we had to turn quite a few away after interviewing more than the initial recruitment target of 40 participants. I think this indicates how many practitioners are likely to be suffering in silence, and who welcomed the opportunity to speak in confidence to an empathic researcher about the problems which they were experiencing.

The research team were struck by the very high levels of stress, depression and anxiety experienced by many of those interviewed. It was also clear that many felt quite isolated, and that it was difficult for participants to acknowledge their difficulties within the practices they work in for fear of burdening the other doctors working there. It is also very difficult for many GPs to seek professional help for their psychological problems, as they often have concerns about confidentiality if the GP they are registered with is someone who they know locally in a professional context. Many GPs are reluctant to take time off sick because of the impact this is likely to have on their colleagues’ workload, as well as difficulty getting appropriately qualified locums in the current climate.

We have now finished interviewing all the participants and the analysis is underway. Preliminary results were outlined in a recent British Journal of General Practice (BJGP) editorial. Which you can download here.

An innovative component of our research project is that it has also informed two performances in November at an Arts Festival in Bristol . Which we have discussed in a recent BJGP blog.

In writing up the final results from this project and describing and discussing the various issues involved, we aim to highlight the emotional component of most GPs’ workload and encourage the primary care community to openly recognise this and be more supportive of each other. We also plan to make recommendations which can inform the provision of appropriate services for distressed GPs and which they can access without necessarily going through their GP if confidentiality is an issue.

I will give further details when the results of the study have been published.  It is being led from Bristol – more details of the project and the study team are available on the Bristol website.

This blog describes independent research funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). The views expressed are those of the author(s) and not necessarily those of the NIHR, the NHS or the Department of Health.

In this post Dr Surinder Singh talks about his interest in HIV and a recent campaign around HIV in primary care. 

I have a long interest in HIV – I’m not entirely sure why but I know it started when two jobs were advertised many years ago (I really do mean many) aiming to “facilitate the care of people with HIV/AIDS in the community”.  At the time I had just completed an excellent general practitioner (GP) vocational training scheme in London and was in the middle of a community paediatric job in South London – interesting and hard but it was never going to be a long-term career move.

Thus, my first role on the unit for people affected by HIV was at the old the St. Stephen’s hospital – the ward was invariably busy since this was very much pre-retroviral therapy and individuals would often be admitted in the terminal stages of the conditions which make up AIDS. I then went on to be the Principal Medical Officer at London Lighthouse – in a great airy building in Ladbroke Grove, London W11.

Ever since I have maintained that interest in HIV and working in a borough of London with one of the highest prevalence rates made this particularly relevant and tangible.  And, over the years though my interest in HIV/AIDS has never disappeared – my involvement dropped, largely because the other pressures within general practice took over (those of you in general practice will know what I mean – finance, staffing, management, performance levels, the care quality commission).

It was therefore with great timing that over the past year or so – several HIV-related projects presented themselves to me; the chance to update the Medfash* book [HIV in Primary Care: an essential guide for GPs, practice nurses and other members of the primary care health team) and an opportunity to work with the British HIV Association (BHIVA) on attempting to “define and explore the role of primary care in the provision of quality healthcare for people living with HIV”.

Along the way I’ve also been working with the Royal College of General Practitioners (RCGP) and ViiV looking at ways of optimising HIV-testing; the latest figures from public health suggest that there are around 18,000 people in the UK with HIV infection but who are, as yet, unidentified.  While it is easy to point fingers at primary care, it is clear that HIV is being missed within hospital departments, including casualty and out-patients. Thus a new campaign has recently launched encouraging all clinicians – general practitioners included – to focus on patients presenting in primary care with what could be symptoms of HIV. The imperative is, quite simply, to test (www.changethefaceofHIV.co.uk).   Just so that you know the campaign is being promoted through a series of online banner advertising slots running across GP Online, Pulse and BMJ.com, directing people to the HIV awareness in primary care – website (www.changethefaceofHIV.co.uk) where the Change the Face of HIV film can be viewed.

So, it’s been a busy year – several HIV-projects coming together in a synthesis which is both systematic and, hopefully, can change lead to practical change.  If after viewing any of the campaign material, clinicians convert their thinking to testing for HIV it will have done its job.

If there are questions or queries I’d be happy to try and answer them? If you have specific comments about the film – do forward them to me in the first instance

*MEDFASH (Medical Foundation for HIV & Sexual Health) is is an independent charity dedicated to quality in HIV and sexual healthcare. It has published HIV in Primary Care: an essential guide for GPs, practice nurses and other members of the primary healthcare team. 3^rd Ed. P. Matthews, S. Madge, S. Singh & N. Theobald. The booklet can be ordered by contacting enquiries@medfash.bma.org.uk or the pdf purchased directly at: www.medfash.org.uk

Post-script: Medfash has recently announced that it will cease to function after December 2016 (please visit Medfash for more details).

In this post originally written for the BMJ and posted on blogs.bmj.com/ce, Prof Elizabeth Murray talks about digital health interventions in the NHS.

Digitising the NHS is back in the news with the publication of the Wachter report on using IT in the NHS to achieve healthcare’s triple aim of better health, better healthcare and lower cost. As Wachter says, not “giving highest priority to digitisation would be a costly and painful mistake”.[1] 

Although the report focuses on digitising secondary care, many of the recommendations are equally applicable to digital health interventions (DHI). DHI are interventions delivered on a digital platform, such as the web or mobile phones, which aim to deliver health care or health promotion, including behaviour change,[2][3] self-management support,[4] or treatments such as Internet Cognitive Behavioural Therapy (ICBT). Because of their potential to combine personalisation with scalability, they hold out real hope for delivering better health, better healthcare and lower costs, but the potential has yet to be realised, despite the millions of commercial “health apps” available.

Achieving the potential of DHI will require investment, research and development. Wachter recommends the NHS “digitise for the correct reasons” – for DHI this means identifying a clear clinical need, where a treatment or education programme is known to improve health, and where the treatment or education can be delivered effectively and at lower cost, on a digital platform compared to face to face. For the benefits of scalability to be realised, DHI must reach large sections of the population, but at present, low engagement by users often limits effectiveness. As Wachter says “it is better to get digitisation right than to do it quickly” and “health IT Systems must embrace user-centered design”. Developing DHI that are effective, acceptable to patients and health care professionals and that fit with NHS workflows takes time, effort and substantive user design. Our self-management programme for people with type 2 diabetes (HeLP-Diabetes) took 2 years to develop, and involved a multi-disciplinary team of patients, clinicians, behavioural scientists, health service researchers, software and web-designers. It was developed around user requirements, had a strong theoretical underpinning, and all content was evidence-based. We believe that this extensive input was essential for achieving the high levels of acceptability to patients and health care professionals, as well as the effectiveness and cost-effectiveness demonstrated in an RCT (submitted for publication).

Wachter also emphasises the importance of investing in effective implementation of digital resources, advising that benefit realisation requires ongoing investment, workforce development, and adaptive, as well as technical, change. Our work with HeLP-Diabetes reinforces this advice. We showed that if health professionals invested a small amount of time (less than 5 minutes) in promoting the programme and encouraging patients to use it, uptake was significantly increased, and the digital divide was overcome. However, many general practices struggled to invest even this small amount of time.

Are DHI worth the investment in research and implementation? For answer, I’d like to quote Wachter again:

“To those who wonder whether the NHS can afford an ambitious effort to digitise in today’s environment of austerity and a myriad of ongoing challenges, we believe the answer is clear: the one thing that NHS cannot afford to do is to remain a largely non-digital system. It is time to get on with IT.”

In this post Marie-Laure from the eHealth Unit talks about her experiences of entering the scary world of academia. A very funny post which I am sure many of us can relate to in one way or another. 

Visions

I always enjoyed research as an undergraduate and was thirsty for some time to gain in-depth knowledge of one particular field. A two-year part-time academic clinical fellowship (ACF) sounded perfect: I could balance my time between being a GP Registrar and a researcher. The eHealth Unit immediately caught my attention – I had seen what a difference technology could make in a hospital setting and wanted to know all about primary care and public health applications. I was hooked by the dream of developing an app that would save billions of pounds for the NHS, educate people by the millions and save thousands of lives! I let my imagination run away. When I pictured the eHealth Unit at UCL, I saw what I imagine a tech start-up in Silicon Valley to look like: people riding down corridors on segways, ordering their morning coffee from the full-time barista on site, free massage twice a day etc. I stayed up until the early hours completing my ACF application form powered by the thought of the free Coco Pops and Nobel Peace Prizes that would surely come my way. ·

Reservations

Application form submitted: tick. Interview granted: tick. Interview preparation: HELP? Clearly I couldn’t mention the peace prizes and segways in the interview. Yes I enjoyed research as a medical student, but I only had two mediocre publications. Plus, did I really want to be an academic? Would I have to start wearing glasses and spraying Eau de Old Library Book every day? ‘Research’ sounds very nice. But what is it exactly? How were the other ACFs I spoke to so certain of their chosen path in life? Had the Academia Fairy visited them in their sleep?

Enter Professor Murray, who just said: calm down, and be honest. I couldn’t say for sure that I wanted to do a PhD and pursue a career in academic general practice because I didn’t have any real experience of research. And that’s exactly what I told the interview panel. So yes, I was surprised when I was offered the fellowship.

Reality

First day at the eHealth Unit. Free coffee! (Who cares that it’s instant?) My first few weeks were spent familiarising myself with the Unit’s existing work, especially HeLP- Diabetes, the impressive NIHR-funded type 2 diabetes self-management programme, and getting a real sense for what research should look like.

Time to get to grips with my own project. I had exchanged a number of emails with Professor Murray before my start date, and had chosen diabetes prevention as my research topic. I spent at least a month reading and thinking (a true pleasure compared to the pace of seeing patients in general practice). I refined my research questions: what is the evidence that diabetes is preventable? What is the evidence that lifestyle modifications can help to prevent or delay the onset of diabetes in high risk populations? Which components of lifestyle interventions are effective and how do these work? Most importantly: can digital interventions help with these effective components?

With a good grasp of the current literature, I set about planning my research project. The eventual aim might be to develop a complex (digital) intervention so I familiarised myself with the MRC guidance. The first step in any complex intervention is to carry out a thorough ‘Needs and Wants’ assessment, i.e. qualitative work that would be used together with existing frameworks and literature reviews to inform an eventual digital intervention.

It was soon clear that I would need to apply for some funding for this and I put together a rough draft for the SPCR FR11 Grant. This was my first grant proposal. The first time I designed a study protocol. The first time I costed a study and recruited PPI input. The first time I provided the scientific rationale for a study. Does this officially make me a researcher now? I think so. With the help of two brilliant PPI and a very experienced team I put together a grant application. I was over the moon – on a Segway Rocket with a personalized PR0F3SS0R number plate – when I was told it had been successful.

Since the funding was granted I’ve been finding out about ethics and R&D approvals, and exactly why everyone sighs and looks at me pitifully when I say what stage I’m at. Yes, it’s a slow process. But I feel like a real researcher. And I know all the acronyms so feel like I’m part of the gang now. IRAS, HRA, REC, NoCLOR, CRN, PAF, DRN, DSH: no problem.

Reflections

So while free massages and Coco Pops haven’t featured thus far, I can’t say I’m disappointed. I’ve discovered what it’s like to conceive and own a research project and to feel like I have in-depth knowledge of a particular field (no matter how niche digital diabetes prevention may be). I can now say with confidence that I like research. Plus there are many other perks. I’ve attended a number of useful courses and I’ve had to think and learn about marketing strategies, social media and coordinating efforts across the team; skills that are rarely developed at this stage of GP training. And the work environment is incredibly supportive. I feel like I am part of a wider network, with many opportunities.

I also love the mix between clinical work and research. It’s easy to feel frantic and overworked in general practice. The two and half days I spend on my research offer an antidote to this. I’ve found the research has kept me interested in the wider picture too; the background and the many ‘why?s’ that crop up during my consultations. It’s sometimes difficult to balance the two, but none of it is insurmountable.

So, do I want to do a PhD? I can’t say for sure yet. But I wouldn’t be disappointed if the Academia Fairy visited me in my sleep now.