PCPH eMagazine Summer 2020

Summer 2020 Department of Primary Care & Public Health NHS must fix its poor record on staff health, for the sake of patients as well as workers Girl with a Pearl Earring - Johannes Vermeer - Montage by Ian Burt – Creative Commons

Summer 2020 During the spring and summer of 2020, we have continued with our academic work despite the difficulties caused by the lockdown implemented to help control the Covid-19 pandemic. Members of the department have played important roles in the local, national and international response to Covid-19, in addition to their usual work. Many thanks to the many individuals who have helped with this work. Congratulations also to Nina Dutta for her Imperial College President’s Award. As we move into autumn, we are looking to start a gradual move back to more normal modes of working. This transition will depend on factors such as how well Covid-19 is controlled and whether we will have an effective vaccine soon. We will Professor Azeem Majeed continue to make the health of our staff and students our number one priority. Head of Department of Primary Care and Public Health Imperial College London Follow Prof Majeed on Twitter We welcome feedback on the ARCHIVE PRIVACY NOTICE newsletter and are taking submissions for future issues. Email your news, events, achievements and stories to us. [email protected] PCPH eMagazine Team Subscribe Unsubscribe Javier Gallego Mehrosa Memood Copyright © 2020 Department of Primary Care & Public Health, Imperial College London

Image © freepik.com PREVALENCE OF FAMILIAL HYPERCHOLESTEROLEMIA AMONG THE GENERAL POPULATION AND PATIENTS WITH ATHEROSCLEROTIC CARDIOVASCULAR DISEASE A Systematic Review and Meta-Analysis Familial hypercholesterolemia (FH) is an inherited disease that affects how the body breaks down LDL-cholesterol. But it is unclear how many people live with the condition without knowing. A team led by Professor Kausik Ray people could be affected worldwide, carried out the largest meta-analysis to increasing their risk of cardiovascular date to estimate the global prevalence disease’’. of FH. Their findings, published in June, reveal the condition is more prevalent Professor Ray adds: “Identifying than previously thought. patients with FH offers the opportunity to screen their relatives to identify Dr Antonio Vallejo-Vaz, study author, new cases in the family, before they said: “The number of reported cases is have suffered any cardiovascular low. But we found that as many as 1 in disease, and where needed, potentially every 311 people in the general get them on preventative treatments, population could have FH overall, such as statins”. which means that around 25 million Read article in Circulation

DEPARTMENT NEWS REASSURING STUDY ABOUT COVID- As part of his project, ‘Impact of RELATED DELAYS IN CHILDREN Health-Related Twitter Messages on ATTENDING A&E DEPARTMENTS Rates of Diabetes Screening in the Saudi Arabian Population’, Dr Dougal Hargreaves was part of a Alakhrass successfully conducted a national team that prospectively health promotion campaign on assessed 1349 A&E attendances for Twitter, encouraging undiagnosed children and young people across 7 Type II diabetics in Saudi Arabia to hospitals during the lockdown period. undergo diagnostic screening. As part There were low rates of delay due to of his project, he analyzed data from parent factors (N=40 (3.0%)) and the Saudi Arabia Ministry of Health, health service factors (N=11 (0.8%)). conducted a survey of Twitter No children experienced any significant followers, and interviewed clinical and harm from these delays. The article governmental stakeholders in Saudi has been accepted for publication in Arabia. Dr. Alakhrass found that over the Lancet Child & Adolescent Health. 90% of the people surveyed indicated that they chose to undergo Type II These data are reassuring that the diabetes screening as a result of impact of Covid-19 restrictions on information they read in the delayed presentations of acute campaign's tweets. Dr. Alakhrass' problems may be less than originally thesis represents a comprehensive feared. However, there remain serious case study in the optimal use of concerns about the longer-term effects Twitter for health promotion in Saudi of covid-19 restrictions on children’s Arabia. mental and physical health. We are currently involved in a number of studies to investigate these effects further. DR HOSSAM ALAKHRASS ACHIEVES HIS DOCTORATE Dr. Hossam Alakhrass (pictured) has achieved his Doctorate of Philosophy in Public Health from Imperial College London as a result of passing his viva on 27 April 2020. He graduates under advisor Professor Azeem Majeed (Committee: Dr Nikolas Mastellos and Dr John O'Donoghue).

UNIVERSAL WEEKLY TESTING AS ONGOING WORK LOOKING AT THE UK COVID-19 LOCKDOWN EXIT CHILDREN WITH COMPLEX NEEDS STRATEGY BY NWLARC CHILD HEALTH Three SPH academics Sonia Saxena, There is growing concern that both Ceire Costelloe and Elio Riboli wrote to clinical outcomes and healthcare the Prime Minister and Dominic Raab experience are often poor for children asking for a testing strategy in May - and young people (CYP) with complex published in The Lancet in June 2020. needs. Research in this area has been limited by lack of commonly agreed PROF MAJEED ON NEWSNIGHT definitions that can be used to identify this group and understand their needs. Professor Azeem Majeed was on BBC As part of the NWL ARC child health Newsnight where he spoke about the workstream, we are combining three importance of having a good contact different approaches to identifying and tracing system in place for Covid-19. characterising this group. FOCUS ON INEQUALITIES IN  Through review of clinical notes HOSPITALS’ COVID RESPONSE and discussion with GPs and paediatricians (see recently Researchers in PCPH published a published article which was a health policy analysis paper focussing collaboration with clinical teams on the potential for NHS trusts’ in NWL) response to COVID-19 to exacerbate health inequalities. Writing in the  Through analysis of CYP who Journal of the Royal Society of account for high levels of NHS Medicine, Prof Azeem Majeed, Sophie spending 'High Cost High Need Coronini-Cronberg and Ed Maile Children and Young People' highlighted issues including restricted accepted for presentation to access to non-urgent clinical services, HSR UK July 2020. Collaboration unreliable NHS ethnicity data and the with the analytics team at the precipitous decline in Emergency Health Foundation. Department attendances, a setting which marginalised groups  Through segmentation analysis disproportionately use to access of CYP data within the Whole routine care. The paper was Systems Integrated Care dataset subsequently covered by several (ongoing work led by Thomas outlets, including the World Economic Beaney). Forum.

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Globally, 6.3 million children under the age of 5 years die every year, while 200 million don’t achieve their full developmental potential, according to the World Health Organization .

With the growing recognition that health in individuals’ early years lays the groundwork for their lifelong well-being, policies and programmes aimed at improving children’s health have become more important. The existing child primary healthcare models are usually based on generic family doctors or paediatricians. However, there is no consensus on the best way of providing such services that vary widely across Europe. The EU-funded MOCHA (Models Of Child Health Appraised) project has been addressing this challenge by analysing various aspects of primary care for children in 30 EU and European Economic Area countries. It covers various disciplines, including medicine, nursing, economics, informatics, sociology and policy management. The researchers led by PI Professor The MOCHA project was set up to Mitch Blair, reviewed the current obtain and analyse key information on standards and published their findings a range of child primary care topics in the journal The Lancet Child & across Europe. These covered the Adolescent Health. They have outlined delivery of care across organisational a set of essential principles and boundaries, such as primary and requirements for optimum healthcare secondary care, social care and following “an analysis of data gathered education. MOCHA’s assessment also on several areas, including the included complex care as well as integration of care for the child at the school health and adolescent health acute–community interface, the services. In addition, MOCHA looked at referral–discharge interface, the social issues regarding equity of provision care interface, nursing preparedness and delivery for all children and use of for practice, and experiences of the electronic record systems in child child and family”. healthcare. It also developed measures of quality, outcome, cost and In the same article, the researchers workforce. The MOCHA project said: “The three main principles, focuses on prevention and wellness. As underpinned by a child-centric stated on CORDIS: “There is a need for approach, are access to care, co- focus on preventive care and on creation of care, and effective fostering good health in a population integrated governance”. They added: that is largely well, and can develop “Collectively, the principles and good habits that can lead to a healthy standards offer a means to benchmark adulthood and old age, particularly at a existing services for children living with time when several new Member States complex care needs, to influence are reviewing and developing their policy in relation to service delivery for health systems”. Partners have made these children, and to provide a suite evidence-based recommendations for of indicators with which to assess optimal child healthcare models and future service developments in this suggest how countries might adopt area”. Best practice. them.

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Dr Nina Dutta scoops coveted President’s Award We are delighted that Dr Nina Dutta is the recipient of this year’s Imperial President’s Award for Excellence in Teaching. Her commitment to promoting excellence, diversity and inclusion has driven her outstanding work in education. She has taken core values of education and social justice into the very heart of how she provides leadership, promoting an inclusive culture for students, faculty, patients and wider community. Nina is the Lead for the Year 3 interested in healthcare. She also undergraduate Medicine in the continues to work clinically as a GP Community (MICA) course, Diversity in London and applies this and Inclusion lead for MEdIC experience to all her educational (Medical Education Innovation and roles. Research Centre), Deputy Lead for Faculty Development, and Lead for Nina’s leadership of MICA has the team’s Widening Access to transformed the experience for Community Careers in Healthcare Imperial students, faculty and our (WATCCH) programme, which is wider local community, and the open to all year-12 secondary course receives outstanding student school students from diverse and feedback every year. She has challenging backgrounds who are developed teaching materials to

support community GPs with It is of no surprise that she has also innovative tutorials and support been nominated by her students for students to learn about patients’ this year’s Imperial College Student holistic health needs. She has also Union ‘Student Choice’ awards. led on developing on-campus and community tutorials for her year 3 Nina has led development of the students. Nina has developed a Community Action Project that all unique suite of trans-disciplinary year 3 students undertake to specialty choice options within identify and address a community MICA, so students can experience need. Examples have included cutting-edge aspects of medicine projects to increase access to including Medicine in the Media, healthcare for people who are Digital Health Futures, Health homeless as well as people from Coaching, Yoga and Mindfulness, Black and Minority Ethnic preparing our future doctors to communities and to co-create navigate the evolving and broad video-based resources with healthcare landscape. members of the Arab community aimed at raising awareness within Her students clearly value her work, this community of mental health and as one student comments: conditions and reducing the stigma associated with these. Through “I think Dr Dutta has delivered Nina’s exemplary mentorship, to us some of the best teaching we’ve received at students have presented at Imperial. She’s an incredibly conferences and published engaging teacher and always in peer-reviewed gives us highly relevant publications, winning teaching sessions. She also numerous awards offered makes a lot of effort to build relationships with by the RJGP, all her students, which we all notice”

The King’s Fund and Royal Society of mentorship for tutors. She also Medicine. applies her ability to develop robust and inclusive education by As Faculty Development Deputy delivering regular teacher training Lead, Nina directly influences the RCGP accredited courses (TACTIC teaching practices of hundreds of and ASTIC), contributing to our GP tutors. She and her team have student’s positive student developed robust quality assurance experience whilst they are on methods to provide support and community placements. Nina’s President’s Award is richly deserved and we are grateful for all her work in supporting and inspiring students, tutors and colleagues, developing innovative curricula and promoting a diverse, inclusive workforce. Images by macrovector_official @ freepik.com

There is already a lot of evidence that shows that self-care is effective for non-communicable diseases (NCDs) such as type-2- diabetes (T2D), obesity & cardiovascular disease - or so called ‘lifestyle diseases’ - which are the main cause for deaths globally. We also know the personal and intermediate risk factors associated with NCDs. For example, personal risk factors (e.g. unhealthy diet, physical inactivity, tobacco use and excess alcohol) and intermediate risk factors (e.g. raised blood glucose, hypercholesterolaemia, high blood pressure and obesity) render individuals at increased risk of the developing T2D, hypertension, stroke, kidney disease, lung disease and some types of cancers. Controlling or eliminating these shared risk factors through lifestyle behaviour modification & ‘self-care’ can delay or even prevent the appearance of NCDs. Last year, in 2019, the WHO published their first Guideline on Self- Care. This was a signal moment for governments & commissioners of health & wellbeing to refocus effort on supporting individuals and societies to feel more empowered and to take back control of, or become more participatory, in affecting their own health and wellbeing. In 2020, the case is also being made for the singular importance of practicing self-care to tackle communicable diseases. Nothing has brought this closer to home than the COVID-19 pandemic.

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Flattening the Curve with Self-Care The importance of self-care has never been more evident as health systems around the world reposition to address the rising threat of the COVID-19 pandemic whilst trying to remain solvent. When we physically distance and wear masks (i.e. risk avoidance) and wash our hands (i.e. good hygiene practices) we are in effect practicing self-care. Governments and policy makers are also promoting self-care when they provide us with self-diagnosis guidelines to check if our symptoms match that of COVID-19 symptoms. Practicing good self-care guidelines for coronavirus shows how individuals can become active and empowered agents in their own health. Without a doubt, self-care is particularly effective in preventing the spread of communicable diseases including COVID-19, and this rationale is the basis behind contact tracing initiatives for SARS.

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A message from Oz Self-Care: Central to effective COVID-19 suppression strategies Maria Dugan, Mitchell Institute for Education and Health Policy, Australia Public messaging from Australian governments in response to the COVID-19 pandemic has emphasised the importance of self-care. Self-caring activities such as social distancing, wearing face masks and other preventative hygiene measures have been pivotal to the response to the disease by Australian governments and many others worldwide. The national campaign to tackle the virus with social measures, deployed by citizens as well as the use of traditional public health interventions such as testing and contact tracing, has been supported vigorously by a range of government, organisations, NGOs, media outlets and influencers in many sectors. The key message is that staying home and observing government guidelines is ‘doing your bit’ for others as well as yourself. At the same time, healthcare systems and individuals and professionals and organisations have undergone achieving greater personalisation of self- extraordinary and rapid transformation, management of established health implementing with speed, and at a scale conditions. that was unimaginable a few months ago, a range of changes including telemedicine, Some have argued that the public digital triage, integrated care systems to messaging has shunted the responsibility assist in the management of caseloads for managing the risks of the pandemic and new workforce models involving away from governments and onto multidisciplinary teamwork and role individuals. Others suggest that the flexibility. These changes have the emphasis on personal responsibility in the potential to address a range of long- context of the pandemic ignores or denies standing inefficiencies and inequities in the vast body of evidence that health is current operational models, provided affected, for better or for worse, by a efforts are made to mitigate any more wide range of social factors, which may be negative consequences. There is some more influential than individual evidence that people became afraid to characteristics in creating and managing seek help from health services from fear certain health risks. Whilst both critiques of exposing themselves to COVID-19 may have some validity, they do not tell infection. Some measures have acted as the whole story. Three important obstacles to patients accessing healthcare, observations emerge from the experience putting their health at risk and there may of the pandemic. be quality and safety risks from the development of an unregulated Firstly, it is now clear that the marketplace in digital health services, management of health risks arising from including telemedicine. However, many of infectious diseases necessarily involves these disruptions to traditional models actions by individuals as well as by health also have the potential to support self- services and governments. care and deliver better prevention of both communicable and chronic diseases by Secondly, health services have enhancing direct interactions between demonstrated through changed processes

Image: Information for Aboriginal and Torres Strait Islander people and communities about coronavirus © Australian Government

and practices that that they have a role in Thirdly, the recognition at policy level that helping people to prevent communicable self-care happens in a social context and disease and to remain healthy during a that the benefits of good self-care reach public health crisis, and that they can far beyond the individual to society at apply the evidence emerging from these large has clear implications for the ethos innovations to work differently to prevent and priories of future health policy. The and manage both communicable and lessons of the pandemic must include a chronic disease and support better self- new direction for health policy, care and self-management by individuals emphasising and investing in prevention and communities. and strengthening the health resilience of the population by enabling better self- care by all. The World Health Organization (WHO) and Self-Care David Webber, President International Self-Care Foundation Over the years WHO has had various engagements with self-care, without having a strong focus on the subject. Most significantly, in 2019 a major programme of work on self-care was initiated by the WHO: WHO launched its first guideline on self- serve greater numbers of people and use care interventions for health, with a focus their skills where greatest need exists. on sexual and reproductive health and According to WHO the guidelines will be rights. These guidelines look at the expanded to include other self-care scientific evidence for health benefits of interventions, including for prevention certain interventions that can be done and treatment of noncommunicable outside the conventional health sector, diseases. ISF President David Webber & although sometimes with the support of a Austen El-Osta are acknowledged as health-care provider. Evidence suggests external partners in the guidelines. that self-care allows health providers to “Achieving health for all includes empowering and educating people to become active decision-makers in their own health. That’s what self-care is all about. Many health issues can be dealt with through self-care. People have been practising self-care for millennia…” WHO DG Dr Tedros on the launch of the first WHO guideline on self-care interventions WHO Self-Care Month (June 24 – July 24) WHO launched the Self-Care Guidelines during the World Health Assembly on June 24, and announced that there would be a Self-Care Month ending on International Self-Care Day (24 July). The purpose of ‘Self Care Month’ is to raise awareness about the importance of self-care and to promote research and dialogue across Regions and with partners as WHO establishes a community of practice for self-care.

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STAFF SUCCESS This page: Arti Maini - Opposite page. Left to right: Camille Gajria, Nichola Hawkins, Nina Dutta & Bethany Golding

IMPERIAL COLLEGE UNION STUDENT CHOICE AWARDS Congratulations to several members of the Undergraduate Primary Care Education team who were nominated by students for the 2020 Imperial College Union Student Choice Awards. Dr Arti Maini, Deputy Director of the knowledge as a GP to help her students. Undergraduate Primary Care Education She was recognised particularly for her Team, received the Award for Outstanding engagement and student-centred Student Partnership. This award is given approach with the Imperial GP Society. to an individual with a student-centred mind-set who embraces all aspects of Dr Nichola Hawkins and Dr Nina Dutta student-staff collaboration from co- were nominated for Student Choice creation to co-evaluation. The students Awards for Outstanding Teaching. Nichola who nominated Arti commented that she is an out of programme GP trainee in the demonstrates ‘’a true understanding of department and Dr Nina Dutta leads the the student perspective and goes above Year 3 MICA course. and beyond to create space for them to express their opinions. She is able to Bethany Golding, community create a symbiosis between staff and collaborations lead, was nominated for an students’’. Arti is an inspiration for all who award for Outstanding Student she works with and this award is Partnership. This is particularly impressive appropriate recognition of her hard work as Beth joined the department in January. and dedication to students and faculty. In the few months she has been here, she has been able to forge important Dr Camille Gajria, Teaching Fellow within collaborative relationships with students the Undergraduate Primary Care and community to develop our Education Team, was shortlisted for the undergraduate courses such that they are Award for ‘Outstanding Professional better able to target the assets and needs Support Staff’. The panel were impressed of our local community. with how Camille was able to apply her Thank you to all our students for their nominations and we look forward to continuing these hugely valuable collaborative relationships. See Arti collect her award

RESEARCH TOP PAPER FOR 2019 Jonny Blackwell’s paper, ‘The impact of smoking and smoking cessation on disease outcomes in ulcerative colitis: a nationwide population‐ based study’, was one of the top downloaded papers in Alimentary pharmacology & Therapeutics in 2018/9. Congratulations to Jonny and his co-authors! WHAT DO EPIDEMIOLOGISTS DO – AND WHY ARE THEY CRUCIAL TO INDIA’S FIGHT AGAINST COVID-19? Congratulations to PhD student Tishya Venkatraman on her article in Scroll.in: ‘Who are epidemiologists & why they are crucial to India’s fight against Covid-19?’ She explains why building a strong epidemiological system will be the cornerstone in reducing the impact of the next inevitable pandemic in India. Well done, Tishya! FREQUENT ATTENDANCES AT EMERGENCY DEPARTMENTS IN ENGLAND Geva Greenfield and colleagues recently published a paper in BMJ Emergency Medical Journal about frequent attendances at emergency departments in England. The conclusions from their article were that one in 10 patients attending the ED are frequent attenders and account for over a quarter of attendances. Emergency care systems should consider better ways of reorganising health services to meet the needs of patients who attend EDs frequently. READ FULL PAPER

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‘You’re on an OOPE? What’s that?’ We were frequently asked this question over the past 12 months by colleagues, students, family and friends, occasionally it has been all too easy for us to fall back on the automated response – ‘we’re taking a year out of GP training to work in medical education’, and leave it at that.

In reality, the insights gained and lessons learned over this past year have formed a significant part of our postgraduate training in themselves. Here we expand and reflect on our Out Of Programme Experience (OOPE); a year-long full-time post as Medical Education Fellows within the Undergraduate Primary Care Education Team at Imperial College London.

By Medical Education Fellows Felicity Lalloo and Nichola Hawkins Generally granted for a period of up to 12 months, an OOPE does not count towards the Certificate of Completion of Training (CCT) but provides a valuable opportunity for postgraduate trainees to gain experience in areas outside the curriculum of their chosen specialty. In 2019, as GP-trainees fast approaching CCT, we were keen to build on previous extra-curricular teaching and learning experience and further develop skills that could be applied to our future careers; with primary care a prime environment from which to facilitate authentic undergraduate learning experiences, there is a demand for community clinicians that are willing and able to actively engage in medical education. Despite this, little (if any) formal training exists within the postgraduate GP curriculum. We therefore sought to temporarily pause our GP training and apply for this post, enabling us to pursue these interests further. Fully immersed within the Primary Care assessment and feedback practice, course department, we have been involved in a evaluation, curriculum development and wide range of educational activities medical education research, (Figure 1). Alongside the regular delivery simultaneously undertaking postgraduate of departmental teaching sessions across qualifications in teaching and learning all years of the MBBS, we have engaged in ourselves.

We feel lucky to have been supported by Year 3 Community Action Project a dynamic team that is passionate about response to COVID-19. general practice, continually striving to deliver meaningful undergraduate Taking a step back from the demands of learning experiences. Beyond developing clinical work and focussing on medical practical skills in teaching and learning, we education in this way, we have gained have gained insight into the value of true valuable perspective on the symbiotic collaborative working – between students, relationship that exists between the two faculty and the community and across areas of practice – core knowledge and different courses and institutions both skills acquired from each one enhancing nationally and internationally. Building on everyday practice in the other. As we this, it has been exciting to be part of prepare to return to our final year of GP innovative departmental projects that are training, we feel empowered to actively underpinned by socially accountable seek and maintain a balance between the values and evidence-based practice; two fields in our future careers. The OOPE amongst others, specific examples include year has been invaluable in our two pilot Longitudinal Integrated development as general practitioners, Clerkships (Year 5 Longitudinal looking to guide and inspire the next Community Clerkship and Year 6 F-Zero), generation of tomorrow’s doctors. To all the Widening Access to Careers in of you that have guided and inspired us Community Healthcare scheme, and the over the past 12 months – thank you. Figure 1: Areas of activity during our OOPE as Medical Education Fellows

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IMPERIAL COLLEGE SCHOOL OF MEDICINE – VOLUNTEERING IN THE COMMUNITY As the COVID 19 pandemic unfolded in early March it became clear that our medical students could form a key role in providing support to local communities via volunteering their services to GP Practices across North West London. The Undergraduate Primary Care Education Team set up an innovative new medical student volunteering scheme, which has to date allocated 70 individual students to 45 GP Practices who expressed the need for volunteers to help during the COVID 19 pandemic. Students from across the MBBS The scheme is still running for years came forward to be part of medical students in years 1-3 who the scheme, many of whom were can continue to volunteer until still carrying out their studies and nearer to the start of the new preparing for their end of year academic year, and we are still exams, but were keen to find the finding that new recruits are coming time to devote some hours each forward to help. week to support GP Practices across North West London. Medical students have commented on how much they have learnt from The medical students undertook a the experience, how they have felt variety of activities whilst in the able to contribute towards the practices, ranging from manning the national emergency efforts and practice telephones in reception, importantly how much of an impact processing repeat prescriptions and they were able to make to the lives delivering medications, telephone of vulnerable and isolated patients triage of patients, calling vulnerable during the COVID 19 pandemic. and isolated patients plus working with practice-based link workers in the community.

The NW London ARC Child Population Health study team have just completed the largest and most up-to-date population-based cohort study examining children’s health care use across the whole health system in England in the period following changes in financial incentive schemes and primary care reforms. We followed 1.4 million children aged less young children. These trends raise a concern, than 15 years registered to general practices particularly amidst the current COVID for every year between 2007-17, studying 7.6 pandemic, about preserving access and million GP consultations and 3.9 million quality of routine NHS care for children, whilst hospital contacts including emergency NHS efforts are diverted to an adult department visits and outpatient attendances population prone to COVID risk. and admissions. Children’s use of hospital emergency services Our findings suggest large year on year rising is generally sensitive to access and availability demand for NHS health care particularly from of primary care. However, general practice is families with children under 5, over the past open, and we want children to continue to decade since National Health Service primary receive preventive care including vaccinations care reforms. Despite falls for older children, and development checks as well as first GP consultations for infants have risen by 1% contact care for acute problems, so it will be each year such that nearly 7/ 10 consult their important to monitor what happens to GP each year. Children’s use of hospital children’s consulting in coming months. It is urgent and outpatient care has risen in all crucial to ensure that child health is not ages, especially infants. compromised and consequently manifests with potential future measles outbreaks, long These changes signify the need for better term conditions such as asthma deteriorating access and provision of specialist and and poor mental health among children. community- based support for families with What’s new about this study: • This is the largest nationally representative population-based study to date examining trends in children’s healthcare use in the National Health Service in England. • The cohort design using individual-level linked data from primary care and hospitals enabled an analysis of children’s healthcare use across the whole system. • Improvements in data quality have enabled analysis of children’s emergency department and outpatient visits.

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Lessons learned during the COVID-19 pandemic The Undergraduate Primary Care Education Team leads on the delivery of a wide range of courses across the six years of the Imperial MBBS programme. On March 14, 2020, the medical school announced the suspension of all face-to-face undergraduate clinical placements in light of the COVID-19 pandemic. With major implications for two of our key primary care courses – Year 3 Medicine In the Community Apprenticeship (MICA) and Year 5 General Practice and Primary Healthcare (GPPHC) – we were tasked with the rapid conversion of these face- to-face clinical attachments into courses that could be developed and delivered entirely remotely. Traditionally, both MICA and GPPHC are centred on medical students observing and assisting doctors in an authentic clinical environment, regularly engaging in meaningful interactions with patients themselves. The team therefore sought to capture the complexities of this learning environment, ensuring that we were adequately addressing the educational needs of our students. Here we describe and reflect on selected key components of the digital MICA and GPPHC courses, sharing some of the lessons learned from our students along the way.

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Large group live webinars interaction, and a platform to Alongside other webinars, both actively promote development of MICA and GPPHC digital courses students’ consultation skills, both incorporated weekly live ‘Case MICA and GPPHC held history taking Rounds’; webinars centred on sessions using Zoom’s breakout clinical cases and questions, which room function to facilitate were circulated to students in interactive small-group work. This advance. Attended by up to 140 enabled role-play of a range of students, interactivity was integral primary care scenarios. Students to these webinars and maintained rated the session highly, by actively encouraging students to commenting on the value of real- submit questions and answers via time personalised feedback from the ‘chat’ and utilising real-time both tutors and their peers. voting applications such as Mentimeter. Student feedback on “It was a good opportunity to live webinars in general was socially connect with colleagues overwhelmingly positive. It was remotely and undertake some interesting to hear them repeatedly peer-to-peer learning”. Year 5 describe feeling liberated to interact GPPHC student more freely, due to the anonymity of the online format; it appeared to Self-study e-learning resources create a more inclusive Alongside timetables of live environment for students whilst sessions, an online package of retaining engagement and learning learning materials mapped to core value. curriculum content was made available to both MICA and GPPHC “I like this format because I feel cohorts, combining internally more comfortable to engage and created resources and external interact compared to face to face. resources that had been quality Makes it feel safe knowing that we assured by the team. Well received can contribute without other by students, this was available to students knowing it’s me giving access remotely in their own time, that answer…I felt more engaged at their own pace, promoting and switched off less. I think it’s a asynchronous online learning. good idea which should be incorporated more for future “[Good] to have flexibility and years”. Year 3 MICA student ability to go back to the resources”. Year 5 GPPHC student Small-group history taking sessions Recognising the need for peer-peer

As a team, we have rapidly upskilled Drawing on the valuable lessons in our digital capabilities to deliver learned, we are looking to develop innovative online learning across a these digital course components range of formats. It is exciting to further as we approach the start of pause and reflect on what has been the new academic year. Although achieved in such a short space of students will be returning to clinical time. We have also had the placements, it is clear there will opportunity to collaborate with remain an important role for digital colleagues in Melbourne University learning strategies alongside more who have been leading a similar traditional placement teaching. radical change to digital delivery of medical education. This Dr Nicky Hawkins (Medical Education collaboration has enabled shared Fellow), Dr Neepa Thacker (GPPHC course learning and innovation, which has lead), Dr Nina Dutta (MICA course lead), led to acceptance of a joint Dr Arti Maini (Deputy Director of the publication in The Clinical Teacher. Undergraduate Primary Care Education Team) Image by pikisuperstar – freepik.com



Medical students and community leaders work together to make a difference Third-year medical students partnered with community, voluntary, health & social care leaders to respond to local needs in the era of COVID-19 25 third-year medical students volunteered to Students taking part in the project also had take part in the normally compulsory part of the opportunity to discuss their plans with their degree. All have worked with their international thought leaders, and West partner organisations remotely via London Health Partnership has funded some videoconferencing. Faculty connected early of the promising projects. on with healthcare commissioners and community leaders to identify needs and Nafsika Thalassis, the Director of the BME assets, meaning that our students were well- Health Forum, reflected: “The best thing placed to get involved and bring innovative about it was how you found out what was ideas to important initiatives. important to the community leaders. As a Dr Nina Dutta said: “Medical students across result, we were doing a project that we the world have been able to come together thought genuinely mattered”. and work with community leaders to address pressing local needs”. Student Shaper Ray Wang added: “What I think makes this type of work more The seven different projects were ongoing meaningful for the local people and the over a period of ten weeks, and range from people involved, is to have a problem and partners as varied as Queens Park Rangers then have some sort of open-ended (QPR) in the Community Trust to local discussion around how do you go about community groups and voluntary solving that problem in a way that works for organisations such as the Community you rather than an idea that works for people Champions, Sobus, Healthy W12, the BME that might be sitting in the office suite”. Health Forum and Healthwatch CWL. Photo © by Nikolay Romensky – Creative Commons

Communities and medical students tackle health inequalities together Dr Nina Dutta, course lead in the School of the Barbara Shelton, Project Manager at Addison Public Health, said: \"Our students have Community Champions , said: \"This is my third admirably risen to the challenge of identifying year of being involved with Imperial and addressing the needs of the College's community projects. The students were local community. Although this term, wonderful. Many have never set foot in a currently a voluntary part of their programme, community centre before and don't we've had a great response to the project. necessarily recognise what they're there for, The undergraduate medicine MBBS course so that learning experience is always useful. has had to shift to delivering education online Especially in times like these the medical response to the pandemic. This has posed profession needs to recognise that community challenges due to the inherent hands-on leaders are an asset. If students can have nature of healthcare, however the digital those interactions at this early stage of their community action project has been a career, it will change the way they view their successful example of this transition. Here communities forever. For our part as medical students across the world have been community partners, one of the biggest able to come together and work with lessons we learn from the students is how to community leader to address pressing local better showcase the work we do and how we needs. We're looking forward to learning can tackle social inequalities together\". lessons from this experience, and hopefully being able to see all our students and Another student group, working with the BME community partners in person again soon\". Health Forum Director and West London CCG, created accessible, captioned videos in Presenting their projects remotely to their multiple languages (English, Farsi, Sylheti, peers on 6 May, one student group's Kurdish, Somali, and Arabic) to reassure 'Community Action Project' (CAP) has built on communities in North West London that NHS past work by the Community Champions services continue to be safe to use during the Programme and QPR in the Community Trust . pandemic. Targeted specially to meet the The need for the project was identified by the needs of BAME communities, the videos will Champions and the Trust early on, with their be shared via community leaders and social respective profiles, community and social media platforms, particularly on WhatsApp media reach being key to the project’s and Facebook. sustainability. Student Abi Mahendran said: \"With A&E The Addison Community Champions and attendance 30% lower than in normal times, representatives from QPR in the Community and with 4% of Londoners not speaking Trust are now preparing to create and deliver English well, we knew this might be a useful resource packs for one hundred vulnerable project. We originally had a shortlist of families living in the London borough of languages we wanted our videos to be Hammersmith and Fulham. The packs will translated into, but we've found the provide items to support children and young communities we're working with are even people’s creativity and emotional well-being more diverse and require additional during the COVID-19 pandemic, including translations. Hopefully we'll have the recipe books and exercise ideas, mental opportunity to put plans in place to publish health support, mood journals, arts and crafts even more videos\". materials, and signposting flyers designed by Imperial students. VIEW CAPTIONED VIDEO

Educational empowerment in London my whole life, doing this research made me more aware of how social All seven projects were taken forward owing determinants of health can impact on to the College's commitment to continue residents’ quality of life in different boroughs. delivering on its educational mission during I learnt the importance of community the social distancing measures introduced in a collaboration and how great work can be number of other countries across the world. done when communities and organisations come together with the common goal of Bethany Golding, Community Collaborations changing lives for the better”. Lead in the School of Public Health, said: \"It has been really impressive to see how Kim noted how the CAP had affected him on students and community leaders have come both a professional and personal level: together under challenging circumstances to “Participating in the CAP has shown to me the work on targeted projects that could make a affirmative and inclusive aspects of engaging real difference. It was great to work with West with the community, where anyone and London Health Partnership in bringing down everyone can thrive by working together to funding for these projects where needed, and achieve common aspirations. Everything I I am grateful to our inspiring community have learnt throughout this project, I will take partners who worked so hard to connect our away and keep close to my heart not only as a students with the voices of communities, and medical student, but as a person as well”. are now taking the projects forward. As a Faculty we should be very proud of our The CAP module is just one of a number of students' engagement with community needs learning experiences created by Imperial's at a very challenging time\". Undergraduate Primary Care Team in the School of Public Health that are intended to Third-year medical students Nadia Zaman and encourage students to collaborate, engage Kim Alipio undertook a CAP exploring how with the communities in which they're living global examples of asset-based community and working, studying and working in, and development (ABCD) could help to proliferate gain an authentic understanding of what it community-led COVID-19 related initiatives in means to be a medic in the modern world. Hammersmith and Fulham, Hounslow and Ealing. Nadia said: “Undertaking the Community Action Project opened my eyes to the challenges faced by different groups in society. Having grown up Image by gstudioimagen at freepik.com

By Paquita de Zulueta In June I led a BACP webinar discussion with best selling author (Grief Works) and grief counsellor Julia Samuels and the clinical director of the charity CRUSE Andy Langford on ‘Working with bereavement and complex grief in the time of COVID-19’. This well received event had 3,100 delegates signed up for the webinar and 1,800 participants on the day. Complex or complicated grief (CG) is People are deprived of the social a more intense, disabling and support they would normally persistent grief than normal grief receive. Traditional cultural and and normally present in only 10- religious practices and rituals are 15% of bereaved people. Risk forfeited or pared down leading to factors to CG include personal disenfranchised grief, heightened by antecedents such as attachment the media representing the loss of style, coping strategies and the their loved as a ‘mere statistic’, with nature of the relationship to the no public mourning to provide person, but contextual factors are validation and solace. There may also very relevant. also be guilt associated with inadvertently infecting the loved CG is more likely because of the one. All these combine to make CG nature of deaths from COVID-19: more likely. I also stressed the these may be sudden, unexpected impact on health care providers and and in an alien, dehumanised the moral distress they may hospital setting and often combined experience in this context. I with constraints on normal human provided slides with references for interactions before and after death. further learning.

Photo: Grief © Tom Bell - CC

Aso Alaa, Immy Webber & Austen El-Osta Social isolation may affect people of all ages, but it does not equate to loneliness and vice versa. Although acknowledged to be different concepts, social isolation and loneliness (SI&L) are often considered together. Social isolation & loneliness are a rising problem in society and have negative impacts to individual health as well as wider economic and societal impacts. The public health implications of SI&L are well documented, and although there have been numerous attempts in the literature to identify predictors of loneliness, this subjective phenomenon remains difficult to measure, and its prevalence is thought to be significantly under-represented. Known predictors of loneliness include living alone, living in rented accommodation (instead of being a homeowner), having poor health or poor functional status etc. Successful interventions aimed at tackling SI&L include befriending schemes, skill development strategies and psychological therapies. The UK government published its first Loneliness Strategy in October 2018, signalling the first important step in the DH’s long-term commitment to combat SI&L. Investigating the impact of school closures on the mental health & wellbeing of parents & their schoolchildren (SOLO) The COVID-19 pandemic has affected educational systems worldwide, leading to the near-total closures of schools, universities and colleges. School closures in particular impact not only students, teachers, and families, but have far-reaching economic and societal consequences. As part of our unified response to Covid, we developed a mixed methods protocol and eSurvey to capture perspectives from parents & legal guardians of school children who are receiving distance learning. Specifically, we wanted

to know how the lockdown is affecting the mental health of parents & their school children- with a focus on feelings of social isolation & loneliness. We successfully recruited over 1100 participants into the SOLO study but would still be keen to capture your views using this short (10 min) electronic survey which can be accessed via PC or mobile. Image © freepik.com

Image © freepik.com AI Chatbot to identify shielded residents with unmet needs

An AI robot (Yokeru) has helped the London Borough of Hammersmith & Fulham Local Authority identify hundreds of households needing extra support during the coronavirus lockdown. The technology costs around a fifth of a traditional call centre. Responses are presented to the council and the appropriate officers make contact with those who need specific help. By reaching out to 9,000 shielded residents across the borough, the chatbot identified 927 households with “unmet needs” including those who are struggling to get food or medication, or suffering from loneliness, experiencing poor mental health and safeguarding concerns have so far been identified. Councillor Ben Coleman, Hammersmith & Fulham Council cabinet member for health and social care, said: “This pandemic has demanded ingenious solutions to unforeseen problems, and by working with Yokeru on this we’ve been able to keep thousands of our residents safe”. PCPH is evaluating this initiative and exploring how Yokeru’s AI chatbot modality could be used to support data collection from a large number of residents and different segments of society from across the borough, including measuring loneliness and social isolation in the borough which is home to more than 230,000 residents. This would build on existing work where we used LBH&F as a case study to estimate the prevalence of SI&L across the borough. This data was considered in context to determine how existing community assets could be leveraged to tackle SI&L. Austen El-Osta, Thomas Beany, David Salman & Mansour Sharabiani

Photo © wavebreakmedia_micro - freepik.com

WATCCH WIDENING ACCESS TO COMMUNITY CAREERS IN HEALTHCARE Since 2017, the Widening Access to Community Careers in Healthcare (WATCCH) programme has hosted over 100 individuals from diverse and disadvantaged backgrounds who are interested in a career in healthcare. The programme aims to support young people in making informed career choices, raise their aspirations and facilitate access to healthcare careers. Previous participants having gone on to take up offers on a wide range of healthcare- related degrees; amongst others, these include Dentistry, Nursing, Audiology, Biomedical Sciences, Pharmacy, Psychology, Radiography, Neuroscience and Medicine. The 2019/20 WATCH programme As the 2019/20 WATCCH has supported 40 students with programme comes to an end, our primary care work experience and online closing event will focus on educational workshops, including preparing students for the transition multi-professional healthcare panel to life in higher education via a question and answer sessions and practical introduction to coaching, admissions workshops including led by Dr Arti Maini, and talks personal statements and mock spanning mentors’ ‘top tips’ on Multiple Mini Interview (MMI) finances, accommodation, study circuits. This year’s programme has skills and student welfare. also included a mentoring scheme, whereby WATCCH participants are Looking ahead to 2020/21, we are linked to current Imperial College committed to delivering a valuable School of Medicine (ICSM) student WP programme despite the volunteers that have received challenges posed by the COVID-19 training in coaching and mentoring. pandemic. Applications to eligible

students just closed last month, as Undergraduate Primary Care we begin to plan an innovative Education Team in the School of series of interactive online Public Health. As well as evaluating workshops accompanied by remote the programme from the student mentoring. Using perspective of student participants, technology to our advantage we we are also interested in the impact hope to expand the online of near-peer WATCCH mentoring on programme to accommodate a the personal and professional higher number of students across development of mentors the UK and also collaborate with a themselves. wider range of healthcare professionals. Evaluation of the Once again, we would like to thank programme also continues via the all of the student participants, Higher Education Access Tracker schools, teachers, and our Imperial (HEAT) and the Medical Education WATCCH mentors for the and Research Innovation Centre enthusiasm and dedication that (MEdIC) based within the they bring to the programme. Quote from student in the current WATCCH 2019/20 cohort: \"The WATCCH programme was fantastic in helping me secure medical school offers by firstly providing a week of general practice work experience. This was a valuable opportunity to shadow healthcare staff that could be included in my personal statement and discussed in the interview. There was a focus on reflective learning following the GP placement and then there was helpful support in the personal statement as well as practice MMI mock interviews. These sessions overall strengthened my medical school application by improving my confidence at every stage of the UCAS application process\". Contact WATCCH for further information