Monthly Archives: February 2016

GP Journal Club – February 2016

The February GP Journal Club is now on Storify.

The paper discussed was: Douglas IJ, Bhaskaran K, Batterham RL, Smeeth L. Bariatric Surgery in the United Kingdom: A Cohort Study of Weight Loss and Clinical Outcomes in Routine Clinical Care. PLoS Med. 2015 Dec 22;12(12):e1001925.

The next GP Journal Club will be in March – you can follow @GPjournalclub and #gpjc. Click here for the GP Journal club blogposts.

GP Journal Club 28th February 2016 – Bariatric surgery in the NHS

Paper: Douglas IJ, Bhaskaran K, Batterham RL, Smeeth L. Bariatric Surgery in the United Kingdom: A Cohort Study of Weight Loss and Clinical Outcomes in Routine Clinical Care. PLoS Med. 2015 Dec 22;12(12):e1001925.

Link: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001925

F1.largeAhmed Rashid is an academic clinical fellow in general practice at the University of Cambridge. He writes the regular monthly column “Yonder” in the BJGP and is chairing the next #gpjc. @Dr_A_Rashid

Obesity is a public health issue and not a general practice one. Right?

I’ve recently had the good fortune to have talked about obesity with two wise and experienced GPs who held quite differing opinions on this. Although they were both in agreement that it is a serious and growing problem, one felt it was predominantly a social problem with solutions in policy and government whilst the other thought it a more clinical problem with solutions in the consultation room and NHS more broadly.

Although the social causes of obesity are unquestionable and the need for policy change is clear, the already alarming rates of obesity and related diseases mean that we probably need solutions across the spectrum. Weight loss surgery is a concept that often divides opinion amongst clinicians and patients alike. However, it has become an important aspect of obesity management in recent years and is now an established discipline across various specialist centres in the UK. Although the results of bariatric surgery RCTs have been promising, we know that trial findings are not always replicated in routine clinical practice. This month’s paper is a UK observational study that investigated whether there is an association between bariatric surgery and weight, BMI, and obesity-related co-morbidities.

As well as the focus on obesity and related diseases and the relevance to GPs involved in commissioning bariatric surgery services, the paper is also of interest because of the use of the Clinical Practice Research Datalink (CPRD) – an increasingly important research service in UK primary care.

I hope you can join us for the Twitter chat at 8pm on 28th February 2016. Please don’t forget to include the #gpjc hashtag in all tweets. Below are the 5 questions that we’ll be generally basing the chat around but please feel free to raise other points that come to mind when reading the paper.

  1. Was it appropriate to use the CPRD to answer this question? (Are there other data sources that could have been used?)
  2. Were all of the clinical outcomes relevant? (Which are the most important?)
  3. Are you surprised by the speed of weight reduction?
  4. Was it acceptable to use discontinuation of medication as a definition of T2DM and HTN resolution in the absence of HbA1c and BP measurements?
  5. Should NHS thresholds for bariatric surgery be changed?

Qualitative research and the BJGP

Kath photo

Kath Checkland (@khcheck) is a GP and a Professor at the University of Manchester. She is a passionate advocate of the value of qualitative research, and is a member of the BJGP editorial board.

On Saturday, the British Medical Journal published an open letter, signed by 75 senior academics (of which I was one), calling for the journal to rethink its current stance on the publication of qualitative research. The letter was prompted by the publication on Twitter of an extract from a rejection letter stating: ‘I am sorry to say that qualitative studies are an extremely low priority for The BMJ. Our research shows that they are not as widely accessed, downloaded, or cited as other research.’

This stance represents a change in policy for the BMJ. Not only has the journal published some important and influential qualitative papers (for example see Gabbay et al 2004), but it was also at the forefront of promoting the use of qualitative methods in health research, publishing a number of highly-regarded series of ‘education and debate’ papers exploring the value of qualitative methods and providing a superb introduction to a variety of methods for the novice researcher (Pope and Mays 1995, Pope et al 2000, Pope and Mays 2009). In what would seem to represent a significant change in policy, an editorial accompanying the letter argues that: ‘qualitative studies are usually exploratory by their very nature and do not provide generalisable answers’, and puts them together with case reports, surveys of self-reported practice etc as studies less likely to ‘change clinical practice and help doctors make better decisions’.

The ‘rapid responses’ to the letter indicate the depth of support for the stance taken by the signatories. Qualitative and quantitative researchers have added their voices, highlighting the absurdity of an editorial position which selects articles by study design rather than by quality, importance of the topic or relevance of the findings. In their original claims and in their response to the letter the BMJ editorial board demonstrate a number of misunderstandings about the nature of research more generally, not only about that done using qualitative methods. These include:

  1. An apparent belief that quantitative studies can provide definitive answers to healthcare problems that will straightforwardly ‘change practice’. Some of those responding to the BMJ article have pointed out the weakness of this position. All scientific results are provisional, and clinicians changing their practice on the basis of a single randomised trial would be rightly accused of being reckless. Furthermore, the approach espoused would seem to equate statistical generalisability with real world generalisability.
  2. A failure to appreciate the complexity of service delivery. Recent MRC guidance re-emphasises the fact that even when a trial result is confirmed and replicated, many important questions still remain (Moore et al 2015). To what extent was the study population highly selected? How might the findings translate in the real world? For other study designs such as quantitative observational studies, further research is needed to explore causation and to try to delineate the relevant contexts in which particular effects might occur. Implementation research is a huge field, and it is rarely the case that the most important studies use quantitative methods. Understanding how human beings behave within healthcare organisations is vital if clinical services are to be improved, and understanding how patients appreciate and value treatments and types of services, as well as different aspects of their lives is essential if overall care is to be improved. Such research topics are not trivial or minor, and it simply is not the case that research which explores these issues can never be generalisable, of high impact or change practice. It is also not the case that BMJ readers are unlikely to find such research interesting to read or valuable in shaping their practice.
  3. A misunderstanding of the nature of qualitative evidence, confusing a method with methodology. While there is undoubtedly a place, as many responses to the letter have highlighted, for qualitative elements exploring aspects of trials of complex interventions, such research represents a tiny proportion of the possible applications of qualitative techniques. Not only does qualitative research answer different types of questions (‘how, why and in what circumstances?’ rather than ‘what?’), but it also embodies a wide range of philosophical approaches and theoretical perspectives. Just because research is not statistically generalisable does not mean that its findings cannot have wider relevance. Theoretical generalisation means that research speaks to a wider body of theory which applies beyond the immediate context, and research using qualitative methods may use theory to generate findings which are highly generalisable. For example, the work done by May and colleagues on Normalisation Process Theory (May 2009) provides a well-researched and widely applicable framework within which to think about how change occurs and how it can be supported in clinical practice. One could argue that such work is more likely to generate sustained and embedded change in clinical practice than any meta-analysis or trial.

In the 1970s and 1980s social scientists engaged in the so-called ‘paradigm wars’ in which those of different theoretical persuasions debated (sometimes hotly) their different approaches, beliefs and assumptions. In general, within social science such wars have long been over, with scholars embracing different paradigms and world views respecting one another’s work and working together without rancour. It is sad to see the BMJ apparently reopening those debates.

To suggest, as the BMJ editorial does, that qualitative work can rarely be of interest to a general medical audience, and that it represents a niche approach which should be published in ‘more specialised’ journals does a disservice to the journal’s many readers who understand and value the diverse contributions which research using qualitative methods may offer, as well as to its own honourable history.

Here at the BJGP we take a different view, and would encourage readers of the BMJ to diversify their reading to explore some of the challenging, highly pertinent and practice-changing research that we publish. In the last 6 months alone we have reported: useful evidence for GPs trying to support those bereaved by suicide ( et al 2016); recommendations as to how practices should support patients to self-monitor their anti-coagulation therapy (Tompson et al 2015); and evidence from a realist review delineating when and how digital communication methods might support access to care for marginalised patients (Huxley et al 2015). For readers, these three examples — selected at random — all address significant clinical issues, and have the potential to change important aspects of clinical care. For researchers, we offer the opportunity to have your study tested and commented on by knowledgeable reviewers skilled in a wide variety of social science disciplines and approaches, providing an invaluable service for those we reject as well as those we publish.

StarDocs: The Coffee Shop Model

PicturesJPGJim Pink (top) is a GP, father and songwriter with an interest in people, rather than patients. Jenny Coventry (right) is a fourth year medical student at Cardiff. In her free time she loves country walks and playing in the Cornish waves. Leo Duffy (left) is a fourth year medical student in Cardiff. He enjoys writing and rugby and is a full time Welshman.

The Apprentice: an assorted collection of wannabe entrepreneurs selling their souls in front of the TV cameras for the privilege of working with the self made billionaire Lord Sugar. As we sit in front of the goggle-box, unwinding from the day before, we learn about profit margins, innovation and “up-selling”. Back in the surgery, we reflect on what The Apprentice can teach us about running a GP surgery.

The economic reality that most surgeries are profit-making enterprises is lost to most patients, and indeed, some of our secondary care colleagues. There is a certain irony that whilst most GPs would resist the privatization of the NHS (to profit making organisations), those same GPs work tirelessly to maximize the profits of their own small businesses.

Up-sellling in general practice can mean two things. Even since before Stott and Davies1 described “the exceptional potential of each primary care consultation”, GPs were offering tidbits of health promotion to anyone who might listen, particularly amongst those with potential to improve their lifestyle. This practice of offering “a little extra” is now entrenched in modern UK general practice, so one can’t attend a GP with a sore throat without having a blood pressure check, and few people leave consulting rooms between October and Christmas without a flu jab, whatever they came for. Up-selling in this sense means offering a little bit more healthcare to patients for the price of one consultation, which in most cases, can be mutually beneficial to both patient and practice (not least, in terms of income).

Most will stop there, with the acceptance that if QOF points are maximized and as many people as possible are vaccinated we’ll have done the best for our patients and paid this month’s mortgage. However, what would Lord Sugar say? Perhaps he’d expect a little entrepreneurship in each surgery, particularly in a time where GPs are experiencing the double whammy of falling income and increased demand. He’d expect GPs to come up with a plan to fight back.

Over a mid morning beverage and snack, we had a brainstorm; it hit us. Why not turn the waiting room of our surgery into a coffee-shop? (Selling life insurance or funerals, although no doubt profitable, were rejected on account of insensitivity.) Imagine the scene at the front desk, “I’ll have a skinny, decaff latte with soya milk, a flapjack and a cervical smear please?”

Sadly, not all of us can always run to time, so there are often waiting rooms full of ill, tired and sometimes understandably grumpy patients. Surely a cup of something warming would help? Also, we all know of a patient or two who consider a trip to the surgery as a social outing, so why not make the environment more conducive to this, with newspapers, comfortable furniture and a selection of hot drinks and snacks. Whilst waiting for their coffee to brew, they could either have a natter with other patients, comparing the severity of their ailments, or simply just relax in a quiet corner browsing on their iPhones using the complimentary WiFi. Profits from sale of beverages could be re-invested in to the practice, to improve the service provided and employ additional staff.

Clearly, there are a few potential pitfalls with this plan (not least that not all receptionists are keen to retrain as baristas) but the change of perception of what a GP surgery should look like is worth considering. The future will tell us what role private providers will play in primary care provision, but they will surely not share most GP’s moral reservations about making money from patients.

The strength of NHS general practice is delivering personalized healthcare in the heart of a patient’s community. As such, why should the building not be a community hub? The walls could be decorated with art from the local school and sell local produce in the cafe. Charities offering support to patients such as Age Concern, Citizen’s Advice Bureau and Macmillan could be offered a platform. The building could be used in the evening for exercise classes, book clubs, stress management classes etc.

The inspirational Bromley by Bow Healthy Living Centre have adopted this holistic approach to great effect, with healthcare provision being provided alongside projects to improve skills, lifestyle and support people back into work. Not all surgeries can hope to emulate their approach, but if we strengthen the links to our communities, we may just be able to resist the private healthcare companies that are circling overhead waiting to pounce on our patient lists.

Our vision of the future of General Practice is caffeinated. Whilst patient-centred, individualized healthcare would be the base, we could also add a steamy layer of partnership and engagement with local charities and sprinkle on top the utilization of the practice premises for health improving activities out of surgery hours. And we could sell coffee. We think Lord Sugar would approve. We could call it StarDocs…..

Reference

1.     Stott NCH, Davis RH (1979).The exceptional potential of each primary care consultation. JRCGP,(29), 201-5

 

SAPC Dangerous Idea: funding research through Kickstarter

SK twitter photoSarah Knowles (@dr_know) is a Research Fellow at the University of Manchester. Her interests are mental health, applied health services research and patient and public involvement and engagement.

Since 2012, the Society for Academic Primary Care has run a competition at their Annual Conference called the Dangerous Idea Soapbox. The soapbox offers primary care clinicians and researchers a platform to share a dangerous idea that they think needs to be heard by the Academic Primary Care community. Submissions are judged prior to acceptance based on how challenging and cutting edge they are. Those chosen are presented through lightning pitches (2 minutes, 1 slide) in the Soapbox session, after which the audience can debate the ideas presented with the speakers before a final vote to decide that year’s most dangerous idea.

In 2015, I presented my idea that “Health research should be crowd funded through Kickstarter”, inspired by conversations with patients and members of the public involved in research, to challenge the audience with the idea that publicly funded research should have public backing before we’re allowed to get our hands on the money.

Kickstarter is a crowdfunding platform. You don’t have a product available which people choose and you then sell, like you would in a shop. Instead, you ask for investment up front from potential ‘backers’ and if you don’t get enough promised custom then your product does not get made. You have to make a pitch, which outlines what you intend to produce, convince people to invest in you, and you have to get the necessary number of backers within a time limit.

What if, after passing peer review, rather than being given the funds for your research, you had to make a pitch on a platform like this? What if we had to ask patients to commit to our project and only if we got enough support would the funds be released? Patients after all, as taxpayers, are paying for this research and this would give them an explicit vote with their cash

This idea is actually very consistent with current policy and with the current philosophy funders claim to have, which claims a patient driven research agenda, supporting research that reflects patient priorities, and conducting research that engages patients. So let’s put our money where our mouth is and give patients the purse strings.

Yet, despite this being a natural evolution of our claimed approach, most people I’ve mentioned it to have thought this was crazy or it sent them into palpitations – and that’s why this is a genuinely dangerous idea. This idea provokes some difficult thinking. It forces us to ask whether we really want patient-driven research – and if not, why not? Do we not trust them with the money, because we don’t trust the public to know what research is needed? Or do we not trust ourselves to communicate to the public what research is needed and justify why our studies should go ahead?

It’s also dangerous because it would carry genuine risk. If you don’t do a convincing pitch and win over sufficient patient backers, you don’t get access to the funds. But there’s a motto that’s used in Silicon Valley that I think is apt here – Fail Faster. Maybe if you can’t drum up support in advance, you need to stop and reconsider your research plans. Think about the 45% of publicly funded trials which fail to meet recruitment targets once they’re up, running, and spending public money.

This kind of patient supported research might actually help with exactly those problems of recruitment and retention. Think of platforms run by and with patients, such as PatientsLikeMe. Patients choose what they want to research, and the site has 250,000 ‘data donors’ engaged and participating in studies – how many trials can claim the same? This model would therefore not only bring to life the idea of ‘patient driven research’, it could herald a new way of working with patients, for patients, sharing ideas and sharing responsibility, with their commitment to help us see research through.

The SAPC (@sapcacuk) will be holding their 45th annual scientific meeting on the 6-8th July 2016 at Dublin Castle.

 

Have a little faith: trainee view of audit and paint-by-numbers medicine

24900_701854411339_8280213_nThuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.

The audit process is an important part of clinical governance to ensure standardised, high quality care.  It is encouraged by medical schools and a necessity of training programmes.  But for our generation of paint-by-numbers medicine and algorithm based practice, clinical audit has become another hoop to jump through for the eportfolio.  I recently completed an audit looking at the prescription of statins in patients with chronic kidney disease (CKD).  The standards were taken from the 2014 Lipid Modification NICE guidelines which advised all patients with CKD to be on atorvastatin 20mg or an equivalent regardless of age, comorbidity or qrisk.

My search revealed several high risk vasculopaths who weren’t on statins.  Yet, the largest proportion was octogenarians for whom improving 10 year survival seemed questionable.  The guidelines did not make allowances for multiple morbidity, polypharmacy or compliance in this cohort.  I marched on nevertheless as per my ARCP requirements; however, it became clear that patients are particularly astute at nuance and picking up indecision on the clinician’s part.  I found it difficult to convince those on the fence to take the statin because of my own ambivalence about its benefit.  The implementation of change was therefore weak leaving the audit suboptimal.

The need to complete an audit for the sake of it is just one facet in the NHS and its increasing ‘obsession with grip’ (as Keith McNeil, former chief executive of Addenbrookes Hospital, puts it).  The benefits of good patient care and effective training is secondary to outcomes, stringent documentation and rigorous regulation; the art and apprenticeship of medicine is being eroded.  Yes, regulation is important and safety paramount. But experience, skill and judgement – those things we only ever learn through autonomous practice and reflection – appears to have little value in the current climate.

In this context, one thing we can do to make clinical audit more relevant than just a CV exercise, is to bring a bit of ourselves into the process and have a little faith in the cycle.  Find something that piques curiosity and is not just a recent topical guideline; an idea that makes tangible sense to you as something that could actually improve practice rather than promising to do so. This belief and commitment will be visible to and appreciated by patients and other relevant stakeholders; which in turn will provide the real impetus to complete an effective audit, one that will maintain relevant clinical standards or effect real change in order to do so.

Time for a change: retired GP volunteering to treat asylum seekers

JN pictureJim Newmark is a GP who has progressed in his career from senior partnership to salaried to volunteer doctor status. He feels that his Christian faith and family make up for his abysmal memory and gross humiliation in pub quizzes.

In November 2015 I reached the first anniversary of my volunteer/honorary primary care contract that is specifically intended to help asylum seekers with complex needs. It has more than worked for me and as the months have gone by I have increasingly thought that it is an idea worth passing on.

It is clear that the NHS will never, ever fund this group of patients adequately. Yet these are human beings, just like us. The obvious differences relate to the effects of their experiences. This is the very stuff of primary care – to be an advocate, to try to make sense of an undifferentiated mass of needs, to come up with a plan, and to have the freedom to follow this up. Nowadays, who in mainstream really has the time to do this?

Hello and welcome to all those GPs who are approaching retirement, who used to love the job, who are financially secure, and who are looking round for things to do!

I loved my job – the team is fantastic, the workload was manageable, and the patients are intensely rewarding to treat. It has involved learning completely new skills as well as maintaining the old. My new expertise includes, among many others, such features as learning about the housing labyrinth, the appropriate voluntary sector to approach, and a thorough knowledge of the legal aspects of asylum claims.  Despite often feeling humbled and inadequate, I sometimes have the power to change things.  For those for whom I feel  I have contributed little, somehow my patients do not seem to think that this is the case.

What I did NOT like was the constant background turbulence of targets and finance that was increasingly stealing time from me that otherwise would have been used for this work. But I was being paid to do the job, and so I had a responsibility to conform to the will of my paymasters.

I approached my employer with a suggestion of an Honorary Contract. My idea was to leave formal employment but they would pay for my defence and reasonable CPD. In return I would maintain appropriate Clinical Governance provisions so that I could continue to use NHS resources for the treatment and care of NHS patients on a supernumerary basis. In simple terms, I was to become a volunteer doctor who adds value, but not capacity, to the service.  My manager was intrigued and happy to hear me out. As I would now be supernumerary, I suggested that my only role would be to see those patients for whom there was a shortfall in NHS provision and for which my acquired expertise would be appropriate.

After a couple of months of minor logistical juggling we have determined on long “complex consultation” appointments (30 minutes) that are booked by our experienced Nurse Practitioners at their discretion following the New Patient check , with the reviews booked by myself into the same slots.

Two distinct roles have developed – the first being to try to sort out the immediate physical and psychological needs that have been assessed as particularly complex, the other is for documentation of scarring or PTSD following torture for potential reports at the request of their solicitor.

With regard to the first, in practice, most of the complexity is psychological rather than physical and it is good to have the time available that these deserve.  It is not generally known that there is no NHS psychological provision for asylum seekers, as the basis of the treatments available is dependent on background stability.

With regard to the latter, the practice has pro-forma letters designed to invite the solicitor to request a formal report from us (with scale of charges) if we feel that this could be indicated and if the solicitor feels that such a report is appropriate. To assist them we give a very brief indication of our preliminary findings. We are careful to say that these cannot be expert witness reports but must be simple documentation of findings – such a simple, or at times complex, report falls well within any front line clinician competency.  This arrangement has been going on alongside the clinical work for some years, set up and continued by another doctor more experienced than I. However, as the “normal” workload increased it was becoming much more difficult to continue this “non NHS” work in the same way. The difference it made to me personally was that I could exclusively concentrate on this role and take some of the pressure from the rest of the team, especially as this service was felt to be part of the ethos of the practice.  The reports also bring in income to help offset my defence and CPD costs.

It seems to have worked. As it is a particularly “specialist” GP function the demand is not overwhelming. In addition, in my voluntary and supernumerary role I feel that I have control over my workload and this is good for my morale. True,  I sometimes have to suppress my conscience when I see how busy my colleagues are and occasionally, when a client does not attend or when I have time for any other reason, I am very happy to help out and take a few patients from them. In truth I need to see a reasonable number of such patients for my appraisal validation, and I supplement the numbers by occasional locums in the same practice.

So, anybody else want to join me? It is a niche market and certain prerequisites are required –  a general practice that sees a lot of asylum seekers, an ongoing licence to practice, and clear boundaries spring to mind (I am treated and behave as any other locum when in that role) . Both in finance and time, it costs me, which causes some puzzlement around – but when I equate it to other voluntary roles outside medicine that most retired GPs take on then there is a degree of understanding.  There is a desperate need that is likely to increase dramatically over the next few years – with the current state of the world, how can it not?