Tag Archives: SAPC

Challenging the norm: GP as innovators

Cat Roberts is Clinical Lead GP involved in developing and delivering primary care services within an acute trust, including a GP-led frailty service

Following a few years of basking in the ‘delicious ambiguity of general practice we returned to the hospital wards to try to fully understand patient care pathways. Any doctor studying for membership exams will describe how the second learning cycle is so much more meaningful when digested with a wealth of clinical experience – the same is true of returning to secondary care having worked in primary care. We were stepping from a land of hypothesis into a land of diagnosis, from a world where uncertainty is used as a tool to a world where much is done to eliminate ambiguity.

The aspiration was to create a service for frail older patients. The pilot funding had been secured and we had a year in which to create a service of value. Would there be a role for GPs to work alongside gerontologists to create a Frailty Unit for these patients, focussing on key generalist principles – a holistic Comprehensive Geriatric Assessment, avoidance of over-medicalisation and aligning primary care, community services, social services and voluntary sector to facilitate this pathway?

We needed to learn another language – ‘management’ in order to communicate our understanding and to understand the ideas, concerns and expectations of managers.

The challenges that presented themselves were not clinical, in fact the familiarity of vague symptoms sets and unusual health beliefs in patients provided an anchor in a strange land. The challenges were operational, practical and political. We needed to learn another language – ‘management’ in order to communicate our understanding and to understand the ideas, concerns and expectations of managers.  In working with healthcare managers, we had to develop a new version of a shared management plan and understand each other’s agendas to improve concordance and collaboration. This was a GP consultation on a larger scale, held in an unfamiliar language, with different cultural backgrounds and with intrusive time constraint

In order to design a service for frail older patients you need to ask some fairly controversial and challenging questions of all providers, including familiar questions such as:

  • When is discharge safe?
  • When is it safe to stop a medication?
  • What if I miss something by not investigating?

However, some of the most useful questions include those not routinely asked such as:

  • When is admission safe?
  • When is it safe to start a medication?
  • What am I hoping to achieve in investigating?

Pressures, processes and clinician behaviour often means these questions do not have time to be asked, let alone answered.  And can you ask these questions unless you fully understand the alternatives?  GPs have all trained in secondary care however not all secondary care clinicians have had the opportunity to spend time in primary care – it is challenging to place trust in a system that you don’t fully understand, especially if your perception has been altered by examples of when that system has not worked well for your patients.

GPs will always be scholars – they are puzzle solvers, they delight in ambiguity and they will always seek to liberate themselves from conventions and assumptions.

So, our focus and first step was to start to develop mutual understanding with our secondary care colleagues, because those questions can only be asked and truly shared when they are perceived as a shared challenge. To start to gently challenge systems and behaviours was a fragile and privileged journey that required small tentative steps and open and constructive dialogue.

Over the course of a few blogs we would like to take you on this journey with us, to share our experiences, to explain the organic evolution of our service principles and structure, to reaffirm the notion that clinician-led service design and development can work, to celebrate in our successes and ask for your guidance with our challenges. GPs will always be scholars – they are puzzle solvers, they delight in ambiguity and they will always seek to liberate themselves from conventions and assumptions. These skills are not confined to clinical medicine.

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.