Category Archives: Research

BJGP Open: adapting primary care for migrants

Photo by shawn at Morguefile.com

The aim of this paper was to provide some insight into how primary care is managing to offer care to migrants. In particular they were interested in looking at the challenges and the ways in which practices and practitioners were adapting to meet this need.

The first phase was an online survey. During this they surveyed 70 primary care practitioners. They then used responses to select eight case studies for a further qualitative phase. They had a mix of mainstream GP practices as well as specialist services that offered tailored services to refugees, asylum seekers and other migrants. There was one group interview (with three GPs from the same city) and seven further in-depth interviews. The descriptive analysis was structured around the principles of equitable care that drew on the framework from Browne et al.

They found that practitioners tended to focus on working with community and external agencies and adapted their own processes in order to avoid care. This was particularly evident in areas such as screening, vaccination, and health checks. The biggest barrier was the lack of funding and this was cited in 73% of cases. The organisation and partnerships were regarded as particularly important to ensure there is an awareness of wider social determinants, the impacts of trauma and violence, and all this had to be wrapped up into culturally-competent care.

Opinion: There is a small section in this paper that caught my eye in relation to burnout. Just over one-third (34%) cited personal fatigue/burnout/capacity as a barrier to developing services. The additional workload ramped up the stress for some healthcare professionals and in one of the services they had introduced life coaching. In another they had adopted debriefings that are similar to those used in conflict areas.

“I think in terms of values, everyone sees the work that we do in serving vulnerable groups as a privilege.”

I’d put a positive spin on the burnout angle – it can be enormously re-invigorating to get involved with marginalised groups. As one ‘mainstream’ GP stated: “I think in terms of values, everyone sees the work that we do in serving vulnerable groups as a privilege.”

There are some fine examples in this paper on how primary care can be developed to give a more “equity-oriented service”. It showcases how, despite all the appalling strain on the system, there are still ways for primary care to innovate to reduce health inequalities. More than anything we should be driven by the principle that we need to reduce health inequalities to improve our societies. And sometimes we need to hunt these people down. Whether it is people with learning disabilities, or the mentally ill, or people who inject drugs, the homeless or as in this case migrants and refugees – these are the groups of people that need our attention.

ResearchBlogging.orgSuch, E., Walton, E., Delaney, B., Harris, J., & Salway, S. (2017). Adapting primary care for new migrants: a formative assessment BJGP Open DOI: 10.3399/bjgpopen17X100701

GP partnerships – sinking into obscurity or sailing into the future?

Johanna Spiers

Johanna Spiers

Johanna Spiers is a qualitative health researcher working at the University of Bristol. She uses a range of methods to investigate different health psychology topics. Her current work explores the experiences of GPs who are in need of support.
Johanna Spiers

vmrmyolqzwo-andreas-ronningenThis post was co-authored with Ruth Riley. Ruth is a medical sociologist and qualitative health researcher with an interest in the mental health and wellbeing of NHS healthcare professionals. She is Principal Investigator of a NIHR SPCR funded study: Exploring the barriers and facilitators to help-seeking amongst GPs: Improving Access to Support.

In the past, the huge majority of GPs were partners, with partnership seen as the obvious career pathway. Partnerships consist of groups of general practitioners who own and run their practices, meaning they are in some regards their own bosses. However, the numbers of salaried GPs (employed by the partners) and locum doctors have been soaring in recent years. Many younger doctors and GP students are now deterred from seeking partnerships, seeing them as unattractive or even risky.

As a researcher looking into the mental wellbeing of GPs, I have found myself inclined to agree. I have spent the past 12 months of my working life interviewing distressed and anxious GPs who are working in a context of increasing workloads and financial pressures, and analysing those interviews. So many of those GPs have spoken to me and the project’s PI Ruth Riley about the difficulties of partnerships that it’s been hard to see what the advantages might be.

When more and more partners resign, it can become a sickening game of tag to find out who is the last doc standing.

It won’t be news to any readers of this blog that there is a recruitment crisis in general practice. GPs are retiring, resigning and relocating in droves, meaning those remaining are hideously, heart-breakingly overworked. And they don’t have the option to leave at the end of their shift and sign the work over to the next doctor; a GP partner’s shift starts and ends with her or him.

Being small business owners, GP partners are financially responsible for their practices, meaning that when more and more partners resign, it can become a sickening game of tag to find out who is the last doc standing – and who is therefore personally responsible for the masses of debt a forsaken GP practice will have built up.

GP partners are also expected to act as managers, running the books, organising human resources for staff members and disciplining wayward employees. Medical school doesn’t currently offer much in the way of management training (although there is a move towards introducing this), meaning these roles can be extremely stressful for GPs and are sometimes very badly handled, resulting in stress for the whole practice.

Add to this a total absence of formal occupational health protection during periods of ill health, no guaranteed maternity leave and having to juggle the potentially fragile and fraying egos of your colleagues every week in a partnership meeting, and it becomes resoundingly clear why partnership feels like a poisoned chalice to so many.

To counter this gloomy picture, I have heard some arguments in favour of the partnership model. Some of the doctors I interviewed spoke glowingly of the team work, trust and mutual support within their partnerships. One participant in particular worked at a surgery which is a shining example of good practice, with all members chipping in to fund a therapist to come in twice a month and provide supervision. If more partnerships were able to run this way, how much better could things be?

A recent debate (2016) in the BMJ argued that maintaining semi-autonomous employment will save GPs from a similar stand off to the one in which the junior doctors continue to find themselves. However, I wonder if this is true? The department of health and the NHS seem entirely capable of imposing changes and demands on GPs within the current model, so I find this doubtful.

The partnership model works well for some; merged super-practices with all salaried GPs may be best for others.

There is no one model which will suit all doctors; and there is no one way of working which will suit every team of doctors. Some partnerships are small and supportive, some are large and lonely. And the reverse can also be true. The dynamics of each group will depend on so many factors: the personalities of the doctors involved, their experience, the socio-economic status of the area and much more besides. The partnership model works well for some; merged super-practices with all salaried GPs may be best for others. This is a complex debate and there is no easy answer.

However, there is one thing which would help towards solving these problems, and that’s a genuine increase in funding to general practice from the government. More money could mean more doctors, more capable managers, more training and more occupational health support, all of which could make the partnership model more sustainable, or allow thinking space for a viable alternative. The GP Forward View promises this cash, but will it arrive in time? Critics have said the promised money isn’t in addition to existing funds, but is just rebranded existing funds. Without that extra money, the future of GP partnerships seems in danger of sinking.

References

Majeed, A. & Buckman, L. (2016). Should all GPs become NHS employees? BMJ. 355:i5064

 

 

 

Top 10 most read BJGP research articles published in 2016

16Jan_Top10_research_2015_BJGP_smThese are the top 10 most read research articles based on full text downloads from bjgp.org in 2016.

1. Overdiagnosis of asthma in children in primary care: a retrospective analysis. 
http://bjgp.org/content/66/644/e152

Overdiagnosis of childhood asthma is common in primary care, leading to unnecessary treatment, disease burden, and impact on quality of life. However, only in a small percentage of children is a diagnosis of asthma confirmed by lung function tests.

2. Telephone triage systems in UK general practice: analysis of consultation duration during the index day in a pragmatic randomised controlled trial. 
http://bjgp.org/content/66/644/e214

Telephone triage is not associated with a reduction in overall clinician contact time during the index day. Nurse-led triage is associated with a reduction in GP contact time but with an overall increase in clinician contact time. Individual practices may wish to interpret the findings in the context of the available skill mix of clinicians.

3. Primary care clinician antibiotic prescribing decisions in consultations for children with RTIs: a qualitative interview study.
http://bjgp.org/content/66/644/e207

Prognostic uncertainty remains an important driver of health care professionals’ antibiotic prescribing. Experience and training in recognising severe respiratory tract infections (RTIs), together with more evidence to help professionals identify the children at risk of future illness deterioration, may support identification of the children most and least likely to benefit from antibiotics.

4. Continuity of care in primary care and association with survival in older people: a 17-year prospective cohort study.
http://bjgp.org/content/66/649/e531

This study demonstrates that low continuity of care in general practice is associated with a higher risk of mortality, strengthening the case for encouragement of continuity of care.

5. Nursery sickness policies and their influence on prescribing for conjunctivitis: audit and questionnaire survey.
http://bjgp.org/content/66/650/e674

Most of the childcare providers’ sickness policies contain requirements that are inconsistent with Public Health England guidance. The requirements of childcare sickness policies are likely to be resulting in unnecessary primary care consultations and thousands of prescriptions for antibiotics with little demonstrable clinical or public health benefit.

6. Unrecognised bipolar disorder among UK primary care patients prescribed antidepressants: an observational study.
http://bjgp.org/content/66/643/e71

Among people aged 16–40 years prescribed antidepressants in primary care for depression or anxiety, there is a substantial proportion with unrecognised bipolar disorder. When seeing patients with depression or anxiety disorder, particularly when they are young or not doing well, clinicians should review the life history for evidence of unrecognised bipolar disorder. Some clinicians might find the Mood Disorder Questionnaire to be a useful supplement to non-standardised questioning.

7. Identifying depression among adolescents using three key questions: a validation study in primary care.
http://bjgp.org/content/66/643/e65

Depression in teenagers can have serious consequences and the incidence seems to be increasing. Three short questions, suitable for use in general practice, are useful for identifying depression in adolescents in primary health care.

8. Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review.
http://bjgp.org/content/66/643/e114

Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than ‘one size fits all’ approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians’ skills and emotions around treatment intensification and facilitation of patient behaviour change.

9. Comparison of brief interventions in primary care on smoking and excessive alcohol consumption: a population survey in England.
http://bjgp.org/content/66/642/e1

Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, less than 10% of those who drink excessively report having received advice on their alcohol consumption.

10. Molluscum contagiosum and associations with atopic eczema in children: a retrospective longitudinal study in primary care.
http://bjgp.org/content/66/642/e53

Consultations for molluscum contagiosum in primary care are common, especially in 1–9-year-olds, but they declined significantly during the decade under study. A primary care diagnosis of atopic eczema is associated with an increased risk of a subsequent primary care diagnosis of molluscum contagiosum.

 

Happy birthday to the NSPCR

Roger Jones

Roger Jones

Roger Jones is Emeritus Professor of General Practice at King's College, London and is the Editor of the British Journal of General Practice.
Roger Jones

The NIHR School for Primary Care research has celebrated its 10th anniversary.

Photo by MichelleBulgaria at Morguefile.com

Photo by MichelleBulgaria at Morguefile.com

Shortly after the National Institute of Health Care Research was established in 2006, with the aim of supporting applied health research for patient benefit, one of the first research Schools to be established was the National School for Primary Care Research, in 2006. The School initially consisted of the five top-scoring University Department of general practice in the most recent Research Assessment Exercise: the composition of the School has changed over the intervening years, so that it now consists of the primary care departments from Bristol, Cambridge, Keele, Manchester, Newcastle, Nottingham, Oxford, Southampton and University College London.

The school has just celebrated its 10th birthday by holding a showcase conference in the Wellcome Collection, London – not a bad choice of venue, because of the history of discovery and innovation embodied by the Wellcome Trust and also the Trust’s generous contributions to applied medical research funding over the years. Writing in the introduction to the conference programme, the Schools Director, Professor Richard Hobbs from Oxford, says that “The school was established by the NIHR in 2006 to increase the evidence-base for primary care practice. The school’s reputation to produce evidence with a patient-centred approach has influenced the development of policy, general practice, patient and public involvement and academic endeavour. Sound partnerships have strengthened the School over the years and collectively we offer a wealth of experience from a wide range of specialties and disciplines.” The School certainly has been a powerhouse of primary care research with a distinctly practical, clinical focus and a strong patient-centred ethos. It has made particularly strong recent contributions to the problems of antibiotic prescribing and resistance, and the management of atrial fibrillation and the use of prophylactic anticoagulation.

The introductory presentation to the conference was given by Professor Martin Roland, University of Cambridge, who was the first Director of the newly-founded School. Martin surveyed the key milestones in primary care research, beginning with the appointment at the University of Edinburgh of Richard Scott to the first chair of general practice in the world. Before running through the pantheon of the heroes of academic general practice, Martin paused to reflect on the malignant influence of one of the great villains of the piece, Lord Moran. He might have been Churchill’s physician, but he absolutely had it in for general practice. Famously, when he was giving evidence to the Doctors’ and Dentists’ Remuneration Committee of the BMA on the subject of merit awards, he was asked whether he agreed with the proposition that the two branches of the medical profession, general practice and consultancy, were not senior or junior to each other, but were on a level. Moran replied “I say emphatically no! Could anything be more absurd? I was Dean of St Mary’s Hospital Medical School for 25 years, and all the people of outstanding merit, with very few exceptions, aimed to get on the staff. There was no other aim, and it was a ladder off which some of them fell. How can you say that the people who fell off the ladder are the same as those who got to the top of it? It seems to me so ludicrous”.

Martin went on to describe the contributions of David Morrell, my own predecessor in the chair of general practice at Guy’s and St Thomas’s, and John Fry, the legendary single-handed GP from Beckenham, who laid the descriptive basis for clinical practice in primary care in the UK – two great founding fathers of general practice research. He explained how John Howie , Richard Scott’s successor in Edinburgh, negotiated for over 12 years to bring the Service Increment for Teaching funding out of the hospitals into general practice to support undergraduate medical education, how David Mant’s 1997 report on R& D in primary care exposed the order of magnitude under-funding and under-staffing of academic general practice and set a target for the proportion of R&D spend on primary care research, and how the Medical Research Council Topic Review, in the same year, led by Nigel Stott, focused the attention of the Council on research in general practice for the first time.

A previous director of the Wellcome Trust, Sir Mark Walport, produced his report in 2005 which transformed clinical academic training and in the same year the NIHR was established. The success and influence of academic general practice continued to increase, although it now may well have plateaued: only last year it was thought necessary to write an editorial for the BMJ entitled “Academic general practice: Visible? Viable? Invaluable”, and nothing can be taken for granted about the way in which general practice is viewed by the hospital specialties. In her recently-published report for Medical Education England “By choice – not by chance” Professor Val Wass reports on a “very powerful anti-GP rhetoric” in the medical schools and “an unpleasant cultural lack of care and respect for general practice”. Moran’s ladder casts a long shadow.

Looking ahead, Martin Roland thought that we should give some consideration to three questions. Are we, and do we want to be, the same as or different from academic colleagues in other disciplines? On the whole academic primary care leaders have thought it more appropriate, with more to gain, if we complete on an even playing field, but we must ensure that the playing field truly is even. Second, we should look inwards, and ensure that we are focusing on doing work of the highest international quality, likely to bring in the best Research Excellence Framework returns, which is genuinely useful to clinical practice in primary care. Finally we must think about ways of engaging across the NHS with other professionals, once again to ensure that research remains relevant to the needs of a rapidly changing health service.

A discussion session after the presentation touched on the relevance of academic primary care research to “real” GPs, their involvement in research networks and research projects, and their need for evidence-based practice. It is likely that proportionately more general practitioners are involved in research networks and in primary care research in the UK than almost anywhere else in the world, and by and large clinicians and primary care teams welcome the expanding evidence base for patient care in general practice. The NIHR School for Primary Care Research has achieved much already, and is likely to make a strong contribution in the years ahead.

How research is helping with GP wellbeing and informing performance at Feel It Festival

Johanna Spiers

Johanna Spiers

Johanna Spiers is a qualitative health researcher working at the University of Bristol. She uses a range of methods to investigate different health psychology topics. Her current work explores the experiences of GPs who are in need of support.
Johanna Spiers

file0001634469948GPs work back-breaking hours, often in isolation. They make hundreds of decisions every day, sometimes without time to eat, drink or breathe. The fear of making a mistake or receiving a complaint is ever present.  GPs feel constantly under threat, overly scrutinised, under pressure, disillusioned, demoralised by the battering they receive at the hands of the press. Many GPs love their jobs, yet find themselves crumbling in the face of ever increasing workloads, a constantly changing system which seems almost designed to trip them up, and the pressure of running a small business with ever decreasing funds.

I am a qualitative health psychologist based at the University of Bristol. Our team (from Bristol, UCL, Keele and the Practitioner Health Programme) are conducting a qualitative study exploring the experiences of GPs living with depression, anxiety, stress and/or burnout. We are hoping that our findings will help define the barriers and facilitators to help seeking for this group, as well as illuminating participants’ experiences of mental illness in a resonant manner.

Our analysis is ongoing, and of course we hope to publish our findings in several high impact journals. However, we wanted to communicate our research findings to a wider audience and engage the public with this topic area using a more dynamic and creative approach.

In collaboration with The Elizabeth Blackwell Institute at the University of Bristol, the study team have commissioned Viv Gordon, an innovative and talented dance artist with lived experience of mental illness to communicate the findings of our study. Viv has used anonymised transcripts as a source material to create a performance piece called Pre Scribed (a life written for me), which will be performed at the opening night of the Feel It Festival (http://www.bristol.ac.uk/blackwell/public-engagement/feel-it/).  Having seen a preview of the script, Ruth Riley, the Principal Investigator of the study, said that “Viv has crafted a sensitive and imaginative tragi-comic performance piece based on a doctor’s life script while examining and engaging with some of the paradoxes of being a doctor-patient.  This is an unforgettable, emotive and hard-hitting piece, not to be missed.”

Viv says of the experience:

The research transcripts offer such rich stories, such important stories, that it feels a great privilege and also a great responsibility to translate them into a performance that captures the complexity of the GP experience. The challenge for me is to offer something that illuminates the research without telling the audience what to think or how to feel but instead raises questions, curiosity and dialogue. My own experience of having what I call a “high functioning breakdown” a few years ago is helping me connect with the internal tug of war that goes on for people who are genuinely doing their very best under unmanageable circumstances. It’s important to me that I’m coming at the subject with that personal understanding and I hope that can add weight and authenticity to the performance work.

As an academic, it can be discouraging to feel that no matter how important and insightful the findings of a research project may be, they are likely to have a pretty limited audience. Most researchers will talk about wanting to do work that makes the mystical and revered ‘Real Life Difference’, but the reality can often be more about inciting the same half dozen people one sees at every conference to a lukewarm discussion before heading off to the buffet. It is therefore really refreshing to see our findings turned into something with genuine emotional power, and the potential to reach a diverse audience.

I would love to feel that our work had the potential to influence governmental policies on support for GPs, and who knows, maybe it does. What I am sure of, though, is that Viv’s piece will engage members of the public, who may then approach their GPs with more empathy, and read their Red Tops with more skepticism. And of that, I feel truly proud.

Altmetrics at the BJGP: a beginner’s guide


Unsure about altmetrics? Check out this video, less than three minutes long, that will give you an introduction.

We’ve been using altmetrics at the BJGP for a while now. You can see them for each individual article by clicking on the ‘Info’ tab (as shown below).

Screen Shot 2016-05-17 at 14.32.16

At the bottom of the Info tab is the altmetric information where the wider impact, beyond that of simple citations, of the article is represented in graphical form. For instance, here is the ‘donut’ for the article shown and you can click on it to visit its own Altmetric page.

Screen Shot 2016-05-17 at 14.37.48

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.

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.

 

Top 10 most read BJGP research articles published in 2015

16Jan_Top10_research_2015_BJGP_smThese are the top 10 most read research articles based on full text downloads from bjgp.org.

1. Child obesity cut-offs as derived from parental perceptions: cross-sectional questionnaire.
http://bjgp.org/content/65/633/e234

Parental perceptions and clinical definitions of child obesity are known to diverge; however, the extent of the discrepancy has not been documented. This study characterises parental classifications of obesity and identifies sociodemographic characteristics that predict misclassification. Also, BMI centile cut-offs for weight status are established as derived from parental perceptions.

2. Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis.
http://bjgp.org/content/65/635/e387.full

This current review looks at management of non-malignant chronic pain as a whole, includes only randomised controlled trials, and uniquely focuses on humanistic outcomes such as pain acceptance and perceived pain control. These are of particular relevance with this self-help technique, as well as clinical and economic outcomes.

3. Help seeking for cancer ‘alarm’ symptoms: a qualitative interview study of primary care patients in the UK.
http://bjgp.org/content/65/631/e96.full

The Model of Pathways to Treatment highlights the importance of understanding patient appraisal and decision-to-consult processes for improving earlier diagnosis. Little is known about how people make decisions about visiting their GP for potential cancer symptoms in everyday life, without a researcher-imposed cancer perspective. This is the first qualitative, community-based study to assess how people respond to cancer ‘alarm’ symptoms outside of the cancer context. The results not only highlighted the importance of people’s interpretations of symptoms, but also their sense that they had to limit their demands for GP advice, both to preserve their self-image and to avoid uncomfortable interactions with the GP if they were seen as time wasters. The findings highlight potential avenues to promote prompt help seeking.

4. Simplified sleep restriction for insomnia in general practice: a randomised controlled trial.
http://bjgp.org/content/65/637/e508.full

Insomnia is a common health problem seen in general practice. Cognitive behavioural therapy for insomnia (CBT-I) is effective but its use has been limited by the time and expense required for delivery. Sleep restriction, or restricting the time in bed, is one component of CBT-I. This trial found that simplified sleep restriction advice, delivered in two GP consultations, is a practical, effective intervention for chronic primary insomnia.

5. Cannabis, tobacco smoking, and lung function: a cross-sectional observational study in a general practice population.
http://bjgp.org/content/65/631/e89.full

Cannabis smoking is associated with increased respiratory symptoms, but evidence of adverse effects on lung function is sparse. This study provides the first UK data on the impact of cannabis smoking on the prevalence of respiratory symptoms and chronic obstructive pulmonary disease in a general practice population. Although many adverse effects appeared attributable to tobacco, evidence of some additional adverse effects of cannabis was found.

6. Physician associates and GPs in primary care: a comparison.
http://bjgp.org/content/65/634/e344.full

Physician associates (previously known as physician assistants) are a new professional group in UK general practice, and evidence is required on their outcomes and costs. For patients attending for same-day or urgent appointments, PAs attended a younger patient group who present with less medically acute problems and fewer long-term conditions, compared to those attended by GPs. After adjusting for case-mix, there was no difference between PA and GP consultations in the rate of investigations, referral to secondary care, prescriptions issued, or the rate of patient re-consultation for the same or a closely related problem within 14 days. Patients report high levels of satisfaction with PA and GP consultations. The average PA consultation was longer than with a GP, although costs per consultation with a PA were lower.

7. Reduction in self-monitoring of blood glucose in type 2 diabetes: an observational controlled study in east London.
http://bjgp.org/content/65/633/e256.full

In many people who have type 2 diabetes but are not treated with insulin, self-monitoring of blood glucose (SMBG) is an often unnecessary task that confers no benefit, while being at very high, and increasing, cost. This is the first study to describe a systematic and major reduction in unnecessary use of SMBG. In people on metformin or no treatment, SMBG use was reduced from 29.6% to 6.0%; in all non-insulin users the rate fell from 42.8% to 16.5%. If replicated nationally, this would avoid unnecessary testing in 340 000 people and save £21.8 million that is currently spent on diabetes prescribing.

8. Patients’ online access to their electronic health records and linked online services: a systematic review in primary care.
http://bjgp.org/content/65/632/e141

Online services have been successfully piloted by large American organisations (such as Kaiser Permanente) but this success has not been replicated in the UK. This study found that patient satisfaction improved through enabling better self-care. Clinicians had concerns about the additional burden and workload from online access but evidence found their fears were only partly realised. There is a lack of good quality research in these areas in the UK; especially research that measures impact (such as health outcomes).

9. Patient information materials in general practices and promotion of health literacy: an observational study of their effectiveness.
http://bjgp.org/content/65/632/e192.full

Patient information leaflets (PILs) provide information to patients to encourage participation in their health care. Research evidence has variously concluded that PILs do affect patient health outcomes, but that many are poorly written. This study shows that less than 25% of PILs in general practice meet recommended reading-level guidance, and that most would be too complex for 43% of the English population. Less than 10% of the PILs covered managing illness or health promotion.

10. Provision of medical student teaching in UK general practices: a cross-sectional questionnaire study.
http://bjgp.org/content/65/635/e409.full

Demand for GP care is rapidly increasing, but the supply of GPs is problematic. Currently, the number of GPs going into training is also problematic. Plans to expand GP training to 50% of medical graduates have been proposed. Teaching medical students in general practice increases the probability that they will opt for a career in general practice and so appropriate undergraduate experience will be important for workforce planning. Since the late 1960s GP teaching of medical students has increased to occupy 13% of the clinical teaching in UK medical schools. This study suggests that this growth has stopped, and may be in decline. Effective financial mechanisms may help to alleviate this, but central intervention may be required to deliver it.

Acute primary care in an integrated NHS

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

The tsunami of chronic disease management – the ageing population, rocketing rates of non-communicable diseases, and increasing complexity – have dominated much of the debate about the future of general practice and of the NHS. The crucial function of general practitioners in making accurate, timely diagnoses in patients presenting with acute symptoms is easily overlooked, yet is at the very core of primary care. The implications of this for mending the fractures in the system and for the design of integrated models of care came home to me in the course of three conferences over the last couple of weeks.

The first was a European meeting on screening for colorectal cancer, held in the Czech Republic, involving European Commission and Parliament policy-makers, as well as clinicians and epidemiologists. The focus was on increasing the momentum in member states of the EU to develop and extend screening programmes for colon cancer, which is an enormous health problem in Europe. However, the flip side of this debate is the fact that the huge majority of bowel cancers are diagnosed outside screening programs, either in patients presenting in general practice with suspicious symptoms or, in a substantial minority, in emergency hospital admissions for the complications of advanced disease.

The next was a conference summarising the achievements of the Discovery programme, a large, NIHR and charity funded research programme of research aimed at collecting evidence to support early cancer diagnosis in general practice (http://discovery-programme.org). One of many important messages for primary care was the need to be prepared to investigate patients with potential cancer symptoms much more promptly than we do at present, and the consequent requirement for better investigative services that can be readily accessed by general practitioners. Discovery investigators presented new data to show that many of the “typical” symptoms associated with cancer presentations are, in fact, much less common than more general,  often vague, complaints, such as fatigue and “feeling different”. They have also demonstrated that patients presented with vignettes of possible cancer scenarios are much more willing to undergo investigations at an earlier stage than previously recognised.

The third meeting was the Annual Conference of the South London Faculty of the RCGP which took as this year’s theme “Early diagnosis in general practice”. I presented some recently-published data, including the important recent BMJ Open paper from Peter Rose and a number of European colleagues which shows that GPs in England, Wales and Northern Ireland are much less likely to request investigations for potentially worrying symptoms then their general practice colleagues in most of the eight other European countries taking part in the study. Given the relatively poor cancer outcomes in the UK (and, for some reason, in Denmark), this is an important finding, adding weight to the need for speed and accuracy in investigations for suspected cancer.

Taken together, these studies and observations are powerful ammunition for the commissioning of better access to investigations, and for careful review of two-week wait criteria. They do, I think, mean more than this, and have major implications for the kind of integration between primary and secondary care that should develop within the NHS in the near to medium term future. In his Five Year Forward View, Simon Stevens, the NHS Chief Executive, describes two possible models of integration – the so-called Multi-speciality Community Provider (MCP) model and the Primary and Acute Care Systems (PACS) model. The first of these is a more horizontal integrative approach to community-based services, including of course general practice, whilst in the PACS model there is scope for a single provider organisation to deliver both primary and secondary care services, with no pre-defined requirement for this to be general practice-led or hospital-led.

The RCGP has, understandably, focused on developing the MCP model, which is probably more likely to keep general practice in the “driving seat”, and meets the five College criteria for an acceptable approach to integration. However, it seems to me that much might be gained by looking more positively at the PACS model, within which investigative pathways for patients with potentially serious conditions – and this of course doesn’t just apply to cancer, but to a host of potentially serious clinical problems – could be developed jointly between generalists and specialists. This approach could, I believe, lead to the creation of much less delay and misunderstanding by removing many of the barriers to speedy diagnosis and swift intervention that presently exist at the primary: secondary care interface. It would be simplistic to suggest that the MCP model is better suited to chronic disease management and the PACS to acute presentations and treatment, but that may not be far from the truth.

It is also possible to see other potential advantages of the PACS system, in locations where it would provide the most clinical benefit. A single employing organisation could provide economies of scale that the small-business model of general practice simply cannot achieve. Making use of joint infrastructures, including finance, HR, and procurement is likely to have significant cost benefits. Beyond this, the possibility that primary care specialists might be employed under similar contractual arrangements to hospital specialists, with benefits for continuing professional development,  career structure and work force planning, and with potential positive spin-offs for recruitment and retention, should not be underestimated or discounted.

When Simon Stevens spoke on the BBC’s, Andrew Marr show recently, he was candid in saying that general practice has suffered from 10 years of under-investment. The RCGP has done a terrific job in making this argument and articulating a strong case for substantially increased investment in the infrastructure and in the general practice workforce. Whilst the burden of an elderly, co-morbid and increasingly dependent population is undoubtedly making general practice creak at the seams, it will be important in the future – in the very near future, given the shortage of doctors wishing to become general practitioners – to look at how other professions can support the central role of GPs in delivering primary medical care. It will also be crucial for general practice to forge alliances with other parts of the health service and, when this is in the best interests of patient care, to collaborate, as well as lead, in new systems of integrated care likely to provide the best clinical outcomes.