#OPAL2018: Identifying and addressing shared challenges in conducting health and social care research for older people
By Nathan Davies, on 2 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).
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.
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!
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!
By Nathan Davies, on 22 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.
Are we dancing with the devil? Thoughts on academics working with private companies in the digital health field
By Nathan Davies, on 20 March 2018
In this post Julia Bailey from the eHealth Unit discusses collaborating with the private sector with particular reference to digital health.
Digital health is booming. In this article I stereotype ‘the commercial sector’ and ‘the public sector’ to illustrate important inherent tensions between the approaches, assumptions, interests and motivations of different players in the digital health field.
Digital innovations can empower patients, improve health, and potentially save health service resources. There are innovation success stories such as Nervecentre clinical records software which is saving lives and NHS resources by alerting clinicians to patient sepsis. Another success story is the Sleepio cognitive behavioural therapy app for insomnia which has been commissioned in many NHS localities. Digital health is fertile ground for the commercial sector, and there is excited talk about how to ‘monetise’ healthcare, and ‘disrupt’ existing NHS systems.
Tech companies are stereotypically innovative and dynamic. Small companies can be flexible and responsive, and the short timescales from idea to product can be very impressive. However, digital health innovation can sometimes be characterised by technology in search of a health problem rather than health problems which need innovative solutions, and the vast majority of health apps and websites have not been evaluated to see whether they have health benefits or whether they cause harm.
Academics and clinicians can offer clinically relevant, evidence-based design, and rigorous evaluation. Ethical review, data monitoring and regulatory protocols allow for patient wellbeing and safety to be carefully considered. However, while academic research can be thorough and insightful, the timescales of research and development within the NHS are stifling innovation – it can take 5 years or more from applying for a grant to publishing the results, at costs running to hundreds of thousands of pounds. Public sector funding does not support continuous iteration, or a willingness to spend on ideas which might not work. Innovations are implemented in a piecemeal way, and dropping digital innovations into an inefficient organisation such as the NHS without a whole-system review is unlikely to be successful.
NHS staff may feel wary of private sector motivation and conduct. For example, the Reed Elsevier group (who publish the Lancet) was involved in organising arms trade fairs until public pressure forced a stop. Pharmaceutical companies invest hugely in advertising and sponsorship which influences doctors’ prescribing habits, and pharmaceutical company research tends to produce favourable results. Patient groups supported by pharma may increase pressure to endorse particular treatments. Public trust has been eroded regarding the handling of sensitive data: for example Care.data was designed to take data from GP records and to combine it with hospital records to find better ways to prevent, monitor or manage illness, but the programme was dropped after public outrage over the sharing of sensitive medical information with commercial entities without explicit consent. In 2015, 1.6 million NHS records were unlawfully shared with the Google’s Deepmind Health machine learning research group. Some mechanisms for app monetisation may engender distrust, for example advertising or selling data.
There is a risk that digital innovation is used as a pretext to reduce face-to-face health services. For example, sexual health services in England have been heavily cut with the expectation that 30% of London’s patients will go online to request tests instead of attending clinics. However, the new online system has not been evaluated in terms of its impact on health, workload, inequalities or cost-effectiveness, and clinics have been reduced or closed before the online service was ready to roll out.
*Stereotypes for illustration. There are many exceptions to these characterisations…
There is an important tension between ‘profit’ and ‘better health’ as the criteria for success of an innovation. It is tempting to judge the success of a product by how popular (or profitable) it is rather than its impact on health. Both popularity and health benefit are necessary, since an intervention needs to be attractive and engaging to have optimum impact on health. Digital health interventions need technical and clinical updating, which means that an income stream is necessary, but it is essential to enshrine health benefit to ensure that innovations are ethical and beneficial.
Collaboration between sectors can play to different strengths to develop high quality, sustainable innovations within reasonable timescales, but all parties need to be aware of any conflicting assumptions, priorities and interests. We need productive cross-sector collaboration (including patients/users) to develop effective, attractive and engaging interventions underpinned by the best available evidence.
- There are important inherent tensions when academics, clinicians and health service commissioners collaborate with the private sector
- Collaboration between sectors can make the most of different strengths and is likely to lead to better interventions
- Health benefit should be enshrined in all digital health innovations
- Rigorous evaluation is needed to make sure that money is well spent, and that digital innovation leads to better health (or at least no harm)
Acknowledgements: Grateful thanks to colleagues who have commented on drafts of this blog.
By Lorraine McDonagh, on 19 February 2018
In this post, Kingshuk Pal discusses his experiences of moving from qualitative research to quantitative research.
So I’m between research methodologies. It’s a bit awkward as you might imagine. Bumbling my way through a no-man’s land between two opposing paradigms – the self-conscious embarrassment of adolescence an unwelcome companion once more. I question myself constantly. Was I truly unhappy being where I was? Is the promise of happiness at the other end of the rainbow just a fairy tale?
Should I seek to define myself as a qualitative researcher or a quantitative researcher? Can I meaningfully be both? Am I method-fluid, mixed-methods or just mixed-up?
The transition is certainly not an easy process. Language acquisition skills apparently peak by age 7, so the evidence-based solution for learning Stata would be to find a time machine that can transport me back in time 30 years or so. But as my time-machine building efforts are short a DeLorean and flux-capacitor or two, having a study group and working through a short introduction to Stata for biostatistics with my colleague Tom Hartney has certainly proved a remarkably helpful alternative. Amazing what you can learn from copying the homework of someone way smarter than yourself. Sadly my attempts to learn about medical statistics and epidemiology have not gone quite so well. My textbooks are currently gazing down at me judgementally from a shelf where they are gainfully employed as bookends… Maybe I can start a book club… targeting anyone suffering from insomnia. For any readers still awake – thanks – and please let me know if you’ve got any good suggestions for epidemiology or stats courses…
There may be some people curious about what tempted me over to what my qualitative friends suspiciously view as the “dark side”. I’m exploring the links between diabetes and depression by looking at routinely collected primary care data (from the THIN database). Poorly controlled diabetes increases the risk of heart attacks, strokes, amputation, blindness and renal failure (National Collaborating Centre for Chronic Conditions, 2008). The presence of depression increases the risk of poorer outcomes in diabetes as it is associated with poor glycaemic control and increased rates of complications (de Groot et al. 2001; Lustman et al. 2000). Depression has also been found to double the likelihood of being diagnosed with diabetes (Eaton et al. 1996; Kawakami et al. 1999). The relationship between the two might be partly due to shared underlying pathophysiology driven by changes in stress hormones in the hypothalamus-pituitary-adrenal cortex axis and sympathetic nervous system (Renn et al., 2011; Snoek et al., 2015). Both conditions are also associated with subclinical inflammation (Tabák et al., 2014). There are also behavioural factors and complications associated with these conditions that link them through poorer self-care due to raised BMI, reduced physical activity etc. (Lin et al., 2004). The net result is a shared increase in vulnerability to these common chronic conditions and poorer outcomes (including increased mortality) where they co-exist (Park et al., 2013). My area of interest is the use and impact of anti-depressants in people with type 2 diabetes and seeing how that reflects the interactions described above.
In contrast, part of my doctoral work on the HeLP-Diabetes project was qualitative research that touched on the negative emotional burden (diabetes related distress) that was placed on people living with type 2 diabetes (Kingshuk et al., 2018). And now I sometimes think about which might be more helpful for me as a doctor – to understand or measure the impact of depression and distress in people living with type 2 diabetes? Clearly I need to be able to do both. If I don’t understand what it means to be depressed with diabetes, it’s harder for me to engage with patients and frame my advice in terms that are meaningful and relevant for them. But when time and resources are increasingly limited, I need evidence to help guide me as to how hard I look for depression, who I should focus on and what the best treatment option might be.
So as a clinician, I need both. But as a researcher can I do both? There is often debate in the medical profession about the merits of generalists Vs specialists. And most GPs would unsurprisingly mount a passionate case for the role of the generalist providing holistic care and continuity over time which is different to the focused care provided by specialists. So I hope the same is true with research – and maybe somewhere there’s a place for a mixed-up researcher like me…
By Lorraine McDonagh, on 23 January 2018
In this post Fabian Sailer discusses using Google Trends and the current flu season
Google Flu Trends (GFT) was a project which aimed to predict flu outbreaks based on web searches of google users. The project was launched in 2008 but abandoned in 2015. Why did this happen? Mainly because the predictions were not accurate enough; disease models based on surveillance data, e.g. of the Centre for Disease Control (CDC), have shown higher accuracy. GFT also did not predict the non-seasonal 2009 H1N1 pandemic, and from 2011 until 2013 the flu prevalence predicted by GFT was wrong in 100 out of 108 weeks. Approaches to estimate flu epidemics of another independent research team based on google trends showed a better accuracy then GFT.
There was enough reason to cancel this project, many also say it was cancelled because it was able to predict the past better than the future. The promising results of Yang et al. motivated me to have a look at trends.google.com, a web page which allows users to analyse the popularity of search terms over time.
I was interested in the current flu season which is why I started to look at the term “flu”.
This figure (Graph 1) shows that “flu” searches on Google started to increase at the beginning of September 2017, which is also the beginning of the vaccination period. The terms “vaccine” and “flu vaccine” have been searched more frequently in this period as well. In December the number of searches rose faster and peaked on the 09.01.2018. I compared the shape of this graph with the surveillance data provided by Public Health England (PHE) in their weekly national influenza report. PHE documents that the flu season picked up speed in December and peaked in the first week of January.
Due to this similarity between the PHE data and the graph obtained from google trends I decided to have a little play around with trends.google.com.
As a next step, I wanted to know whether I could also recognize the “flu” pattern from the first figure for searches for flu symptoms. Therefore, I took the first 5 symptoms listed on nhs.uk/conditions/flu.
Generally this chart (Graph 2) does not indicate a clear trend as observed in the flu chart. But the searches for some symptoms (“fever”, “cough”, and “sore throat”) seem to rise in line with the general “flu” trend. On the other hand, other more unspecific symptoms like “aching” and “tired” did not show this trend at all.
Looking at other generic terms (Graph 3 – “sick”, “ill”, and “healthy”) I could not observe the “flu” trend. On a side note, I could also see that during Christmas people are searching less frequently for “healthy”. But presumably the New Year’s resolutions overcompensate this drop-off with searches for “healthy” peaking in the first week of January.
I wanted to know whether these observed “flu” trend connects to current news.
It was reported that the National Health Service (NHS) is currently working at a 100% capacity. This maximum workload is partially due to the flu season. Therefore, I wanted to see whether the “flu” pattern can be observed in search terms looking for the NHS or health care in general as well.
Interestingly, there is a completely different pattern in this data. First of all, the three curves displayed here do not start rising between October and December. But all of them show a weekly repeated pattern. Most searches for “nhs”, “gp”, or “hospital” happen on Mondays/Tuesdays. Over the week there is a slight slope until Friday before the number of searches drop to their lowest value of the week on Saturday/Sunday (Graph 4).
There might be lots of reasons for this pattern. My first theory was that employees might need to get a doctor’s certificate on these days to call in sick for work.
But this pattern cannot be observed within the search terms for sick notes (Graph 5).
A similar weekly pattern can be observed if we examine the searches for other working places like a “bank”. Even the searches for “flu” and the symptoms for the flu seem to follow this weekly repetition to a certain extent. But none of these patterns is as distinct as the one for “nhs” and “hospital”. I was not able to find the one reason for this pattern, and I guess it is a combination of factors which result in this unique shape.
As all of this data is freely available I invite you to have a play with google trends and see which interesting bits and pieces you might discover.
By Nathan Davies, on 20 December 2017
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
By Nathan Davies, on 10 November 2017
In this post Nikki Newhouse discusses a very successful 2017 for the UCL TechSharing Seminar Series. Not sure what they are or want to become involved?? Have a read!
The TechSharing Seminar Series is organised by a group of early career researchers from UCL Interaction Centre, the Research Department of Primary Care and Population Health (eHealth Unit), the Department of Clinical, Educational and Health Psychology and the Department of Behavioural Science and Health. The aim of the seminar series is to foster knowledge exchange and future collaboration between researchers, practitioners, policy-makers and industry professionals working within or at the boundaries of health technologies and digital behaviour change interventions.
The series has been active since 2014 and has brought together a wide audience around key topics in digital health research and practice including creativity, communication, methodology and policy impact. Led by early career researchers, the seminar series places UCL students and the UCL community at its heart, and sees an audience drawn from across multiple UCL departments and academic disciplines. The series’ healthy reputation means that the audience is enriched by contributors and audience members from outside UCL: students from other academic institutions, technology developers, clinicians and policy-makers.
The most recent iteration of the series was funded by a UCL Policy Challenge Award. Three interlinked seminars explored the practice and process of embedding technology within the NHS.
Seminar 1 – Bridging the interdisciplinary gap
The first seminar in May 2017 interrogated multidisciplinary teamwork within the context of digital health technologies. The day started with a thought provoking talk by Carmelo Velardo, Senior researcher in Digital Health at the Institute of Biomedical Engineering and Departmental Lecturer at the Department of Engineering Science, University of Oxford. Carmelo’s research focuses on the use of technology solutions to support patients suffering from chronic conditions.
Carmelo was followed by coffee fuelled small group discussions during which attendees critically examined the meaning of key terms, such as engagement, co-design, evidence, implementation and impact/effectiveness. The lively audience was comprised of computer scientists, health professionals, human-computer interaction researchers, psychologists and industry professionals including those from software development, media and banking. This was then followed by a panel discussion with participants drawn from academia, industry and health policy and facilitated by Dr Henry Potts, deputy director of CHIME, UCL’s Centre for Health Informatics & Multiprofessional Education.
Seminar 2 – Co-designing for health
The second seminar in June 2017 focused on the principles of co-design in the context of digital health and provided a practical introduction to the topic. The session was led by Dr Victoria Betton, Founder & Director of mHabitat. Co-design activities included understanding and creating personas, user stories and translating these into design solutions.
Dr Roisin McNaney, Human Computer Interaction Lecturer at Lancaster University then presented a case study on co-designing and enacting tools to support young people’s engagement with people with dementia. We closed the session with a panel discussion facilitated by Dr Julia Bailey, Clinical Senior Lecturer in Primary Care with UCL’s eHealth Unit and a Speciality Doctor in Community Sexual Health.
Seminar 3 – Is it worth it? Getting your digital product into NHS (or choosing not to)
The third and final seminar of the 2017 series saw academics, policy-makers and developers come together in October to debate pressing issues facing those attempting to embed health technology within UK’s healthcare system. The seminar also served as an introduction to the key rules, regulations and realities of getting health tech adopted by the NHS.
The audience enjoyed presentations from Yinka Makinde (DigitalHealth.London), Professor Elizabeth Murray (UCL eHealth Unit) and Dr. Anne Bruinvels (Px HealthCare) before engaging with the lively panel discussion, moderated by Professor Ann Blandford (UCL Interaction Centre & IDH) which included our speakers as well as Indra Joshi (NHS England) and Susannah Robinson (Public Health England).
The series website hosts a collection of blog posts that have been widely disseminated using social media (https://ucltechsharingseminars.wordpress.com/). Planning for the 2018 series is under way and the organising committee is keen to hear from anyone who would like to be involved, either as a speaker or as part of the planning team. Please get in touch with Nikki Newhouse for further information (email@example.com)
ECL TechSharing Team
PhD student – Department of Computer Science (UCL Interaction Centre) and the Department of Population Health and Population Health Research (eHealth Unit)
PhD student – Department of Clinical, Educational and Health Psychology
PhD student – Department of Behavioural Science and Health
PhD student – Department of Population Health and Population Health Research (eHealth Unit)
Dr Aneesha Singh
Postdoctoral researcher – Department of Computer Science (UCL Interaction Centre)
By Nathan Davies, on 5 October 2017
“We trained hard—but it seemed that every time we were beginning to form up into teams we were reorganised. I was to learn later in life that we tend to meet any new situation by reorganising, and what a wonderful method it can be for creating the illusion of progress while actually producing confusion, inefficiency, and demoralisation.” (Petronius Arbiter 27-66 AD)
As a member of the Improvement Science team (ISL) for the past few months I’ve been evaluating the delivery of integrated care in East London. Integrated care refers to care that is person-centred and co-ordinated across health and social care, so providers, commissioners and local authorities need to work together to deliver the different elements of care that a person needs. In 2013 WEL (Waltham Forest and East London) was launched as one of the 14 Pioneer Programmes of Integrated Care bringing together commissioners, providers and local authorities covering the area served by Barts Health NHS Trust.
When I started this job last May, the ISL team had already carried out a two-year evaluation of WEL, which highlighted a disconnect between strategic thinking and service design on the one hand, and the delivery of integrated care on the other hand. This is hardly surprising. We know as many as 70 percent of change programmes do not achieve their intended outcomes. A lack of commitment (patience?) to see a programme through to the end and high turnover of management might be part of the problem.
Very soon I realised that WEL no longer enjoyed much attention. There were new programmes, new acronyms, new objectives, and with them different pressures, different actors, and different priorities: TST (Transforming Services Together), STP (Sustainability and Transformation Partnerships), ACS (Accountability care Systems)… Petronius Arbiter’s quote came to mind, “it seemed that every time we were beginning to form up into teams we were reorganised…” (The fact that this quote might have been misattributed doesn’t make it less painfully relevant).
Where do we look to see organisation change?
Within a very crowded policy context, I faced a dilemma: how could I build on the findings of the previous phase of the WEL evaluation if WEL was no longer a priority? It felt important to look at the impact that all this change at the strategic level is actually having on frontline work, to unpick the gap that my predecessor identified between strategic thinking and operational delivery. It is at the frontline level, after all, that change is meaningful, when it happens. But how does it happen?
The literature on organisational management is quite clear on the matter: change is often evolutionary rather than the result of radical restructuring (Hodgson, G, 2008). Organisation-level change is hardly ever linear and often has an emergent element (Dawson 1996). It tends to happen by ‘drift’ rather than by design. By looking at organisational routines we might then have a chance at unpacking the grammar of organisation change, so to speak. Routines are recurrent, collective, and interactive behaviour patterns, which help coordinate work (Becker 2004). This new phase of the WEL evaluation will then focus on frontline professionals’ routines in the three WEL boroughs and look at how health and social services staff work together to deliver more coordinated care. The aim is to shed some light on patterns of resistance to change and sustainability of change towards integrated care and understand the impact of organisational development on the ground.
I am a researcher-in-residence, which in practical terms means that I’m embedded in the organisations I’m evaluating. I work closely with stakeholders across three boroughs with the aim to coproduce learning that is relevant and timely, and so increase the chances that evidence might inform programme developments. This role raises a number of challenges, including maintaining objectivity, but it also gives me regular access to management and frontline professionals, as well as key operational meetings. This gives me a vantage point to understand better their organisational routines, how these professionals work with colleagues across different organisations, and what challenges they face on a day-to-day basis.
Based on my initial scoping work, it is clear that the rhetoric on integrated care is powerful, but so are the blockers on the ground, namely a lack of staff and resources (particularly within social services) and an increased fragmentation of services, after the separation of commissioner and provider functions.
For all the rhetoric, is care really more integrated or actually more fragmented? I hope that my work in the next few months can contribute to finding some answers.
Becker MC (2004) Organizational routines: a review of the literature. Industrial and Corporate Change 13:643-77.
Dawson, S. J. N. D. (1996) Analysing Organisations. Hampshire: Macmillan
Hodgson, Geoffrey M. (2008). ‘An Institutional and Evolutionary Perspective on Health Economics’, Cambridge Journal of Economics, 32(2): 235-56.
By Nathan Davies, on 27 September 2017
In this post, Daniel Aggio, a PhD student at PCPH, discusses some of his PhD work that was recently published in BMJ Open and has had widespread media coverage in the UK and across the pond in America.
There is a considerable body of research suggesting that physical activity tracks from childhood into adulthood. In other words, being an active child means you are more likely to be active as an adult. Something that has been less explored is how physical activity tracks during the transition to old age, an important period when many major life events are likely to occur.
This study utilises data from the British Regional Heart Study, a prospective cohort study involving over 7000 middle-aged men recruited between 1978 and 1980 from 24 towns across Britain. One of the main assets of the British Regional Heart study is the lengthy follow up data, including measures of physical activity throughout the transition to old age. By exploiting these data, we were able to explore how physical activity tracks during this period and identify the types of activity in midlife that are most likely to predict an active lifestyle in later life.
It did not come as much of a surprise to find that being active in midlife more than doubled the odds of being active in old age, but we were struck by how strongly midlife sport participation, and particularly if it was initiated earlier in life, predicted being active in old age. For example, men who had played sports for 25 years or more were nearly 5 times as likely to be physically active in later life compared with men who did not play sports. But even taking up sport relatively late in midlife (i.e. less than 4 years ago) significantly increased the odds of being active in old age. Higher levels of walking and recreational activity in midlife also increased the odds of being active in later life, but they were not as strongly associated as sport participation. Until we carry out more research we can only speculate as to why this is the case. Plausibly, people who keep up sport may simply do so because they enjoy it. We also suspect that sport plays a pivotal role in the development and maintenance of key motor skills, which may prove vital in later life.
Although sport participation may be more stable and more likely to predict activity in later life than other types of activity, walking was the most likely to increase during later life, possibly because retirement might free up more time and functional declines may limit capability for more intense activities. From a public health perspective, promoting walking may be more feasible in later life as we show that many older adults are already increasing their walking during the transition to old age.
Being active in midlife, particularly playing sport, is important for maintaining an active lifestyle into old age. Sport participation may be crucial for establishing lifelong physical activity and should be promoted throughout the lifecourse, especially in early life. Strategies to increase physical activity in later life may also need to target other forms of activity that can be widely adopted, such as walking.
Click here to read the full published article.
By Nathan Davies, on 22 September 2017
Very topical in the news right now are the recruitment rates of trainees into the specialties of general practice and psychiatry. In the post Amber Appleton Amber an NIHR Academic Clinical Fellow and GPST4 talks about her experience of choosing general practice and the experiences of other trainees.
When I began as a GP Academic Clinical Fellow (ACF), I wanted to do something different and was keen to conduct my own research project. I had the idea for it not that long ago when I applied for my current GP training post, and at the same time I also applied for psychiatry training. I struggled to choose between these two specialties, and although I did not choose psychiatry my interest has never dwindled. I still remember the day I became interested in psychiatry as a medical student when I was taught by an inspiring psychiatrist. Because of this, I wanted to find out what made others choose psychiatry and to explore whether it was also related to their medical school teaching experiences.
By designing and seeing through my own project, the research, teamwork, organisation and communication skills I have gained from the experience have been profound. Marta Buszewicz has supervised me along with Surinder Singh, both of whom have provided invaluable support and guidance throughout the project, which has really nurtured my learning throughout my ACF post.
So, to give a bit of background to the rationale behind the project…
One in four people in the UK will experience a mental health problem each year. The first person they may talk to is their GP who sees most of the people with mental health problems in the community, and then those with the most complex or severe cases may be referred to a psychiatrist if indicated. The overlap between psychiatry and general practice is especially significant as approximately a third of GP consultations are for mental health problems.
As a result, both GP and psychiatry are essential for ensuring good patient care and there is an on going need to recruit competent doctors into these specialties – throughout the UK. Unfortunately, both psychiatry and general practice have been experiencing real recruitment problems with one in three training posts in both GP and psychiatry currently left vacant.
I was interested in exploring some of the factors before, during and after medical school, which ultimately result in trainees choosing a career in psychiatry. I was hoping that this information might help to improve the way these specialties are taught at medical school, which could encourage more doctors to sign up to this important specialty and also potentially improve attitudes amongst all future doctors towards mental health problems.
I designed a web-based survey to explore the views of psychiatry trainees nationally, followed by conducting qualitative in-depth interviews with a group of 21 purposively sampled London psychiatry trainees. The whole research team analyzed the interview findings.
Many trainees said their attitudes had changed after being taught psychiatry at medical school and that the placement influenced their career choice, although the quality of the teaching was very important and some people had not had such good experiences. A significant number of those interviewed described how doing a Foundation job in psychiatry (a 4 month post in the first two years after graduating from medical school) had had a significant impact on their career choice. Currently only around half of junior doctors do a Foundation year post in psychiatry, but this is under review. Most trainees felt positive about the idea of teaching about physical and mental health problems together during the curriculum, rather than separately (as has quite recently been introduced at UCL Medical School), but it was thought very important that this shouldn’t dilute the amount of psychiatry teaching overall.
One of the main barriers trainees described that they had to overcome when choosing psychiatry was stigma from colleagues/peers and family members. One respondent described the response she received when speaking openly about considering applying for a career in psychiatry.
P5 Female ST7:
I said: “I’m thinking of actually applying for psychiatry as well as general practice.” And she (Foundation year two supervisor) said: “What a shame.”
The “badmouthing of general practice and psychiatry” has been highlighted in a recent BJGP paper (1) as a subtle but important factor influencing graduates’ career choices: quite simply why would a junior doctor choose a specialty looked down upon by other members of their profession?
The psychiatry trainees interviewed had attended a range of UK medical schools and provided a range of recommendations for improving the way psychiatry is taught at medical school, as well as suggesting other strategies to improve recruitment to the specialty.
Summary of the key findings:
- Medical school placements in psychiatry should be introduced early and integrated throughout the curriculum to help prevent negative attitudes developing.
- Positive role models and mentors were described as key and there should be greater visibility of prominent psychiatrists within medical schools.
- Barriers to choosing psychiatry that were described included: the stigma still associated with mental illness and feeling ‘not a proper doctor’, as well as the emotional stress and responsibility involved with decision making in psychiatry.
- Outreach projects into secondary schools
- Buddy schemes and mentors should be offered widely
- Negative attitudes at medical school towards specialties such as psychiatry and general practice need to be challenged
- More Foundation posts should be offered in psychiatry
Recruitment into the twin specialties of psychiatry and GP continues to be problematic and the key messages from this paper suggest that appropriate interventions are needed at all stages, i.e. before, during and after students’ time in medical school.
The full published paper is now available from BMC Psychiatry
- Baker, M., Wessely, S., & Openshaw, D. (2016). Not such friendly banter? GPs and psychiatrists against the systematic denigration of their specialties. Br J Gen Pract 2016; 66 (651): 508-509.