Summer 2021 Department of Primary Care & Public Health Co-creating LGBTQ+ inclusive medical education: A new approach for third-year medical students Photo by Tasha Jolley on Unsplash
Summer 2021 In this edition of our newsletter, we highlight the work that our staff and students have being doing to support the Covid-19 vaccination programme. This includes work to address vaccine hesitancy, improve confidence in vaccines and increase vaccine uptake among the residents of NW London. We discussed this work with one of our local MPs, the Rt Hon Greg Hands, Minister of State for Trade Policy in the Department for International Trade. With Covid-19 cases in the UK now falling, we hope that we can return to more normal working from September onwards. We will remain cautious, however, and will continue to implement appropriate infection control measures to Professor Azeem Majeed minimise the risks of Covid-19 outbreaks among our staff and students during the Head of Department of Primary Care and Autumn and Winter. 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 Candida Vasconcelos Copyright © 2021 Department of Primary Care & Public Health, Imperial College London
LANCET COMMISSION ON THE FUTURE OF THE UK’S NHS “I would like to thank The Lancet for giving me the opportunity to contribute to their Commission on the Future of the NHS. I fully support the recommendation for a strong and sustained increase in NHS funding to address the current weaknesses in the NHS. For me, the most striking data in The Lancet Commission on the Future of the NHS was this figure, taken from Securing a sustainable and fit-for-purpose UK health and care workforce, showing the changes in the number of NHS GPs and consultants per 1,000 people between 2008-18. Note the decline in GP numbers compared to the increase in consultant numbers. Although we hear a lot from NHS managers and politicians about the need to shift the focus of the NHS to the community, staffing statistics do not support this. The reality is that NHS primary care funding and workload need to reflect staff levels, not meaningless rhetoric”. Numbers of GPs and hospital consultants across the UK per 1000 people, 2008–18 Azeem Majeed
NEWLY FUNDED INEQUALITIES FELLOWSHIP The West London Cancer Alliance, RM Partners, has generously funded a one-year Health Inequalities Research Fellowship that will be jointly hosted by Chelsea and Westminster Hospital's Public Health and the Applied Research Collaboration’s (ARC) Implementation Teams. The fellowship will focus on developing a Health Inequalities Framework for equitable recovery of acute services post COVID-19. The fellowship has been awarded to Kate Lambe (pictured), who joins us from the Population Health Sciences division at King's College London where latterly she was part of a team developing a stratified model of care for acute rehabilitation after hip fracture. MEETING OUR LOCAL MP TO DISCUSS HOW STUDENTS ARE CONTRIBUTING TO THE COVID-19 RESPONSE On 23rd April, Professor Azeem Majeed, Dr Sonia Kumar and Dr Arti Maini met with Mr Greg Hands, the MP for Chelsea and Fulham and Minister of State for Trade Policy in the Department for International Trade (DIT) to discuss the work of our Undergraduate Primary Care Education team and Medical Education Innovation and Research Centre (MEdIC), including the excellent work our Imperial College medical students are doing to support the Covid-19 vaccination programme and the response to Covid-19 while learning on their clinical placements. Projects discussed included students helping in local vaccination hubs, working with patients and communities to address vaccine hesitancy in areas of deprivation and working with local secondary schools to lead STEM-based afterschool sessions about the COVID-19 vaccine. We discussed our assets-based approach to working with local communities and the ways in which we prepare our students to work in inclusive, person-centred ways with patients and communities as an integral part of their healthcare teams. We also shared our evaluation findings of this work including the positive impact on students and local communities. We look forward to continuing the conversation with Mr Hands and raising the profile of this important work on a national
MEDIC AND UNDERGRADUATE approach as lead tutor on the newly PRIMARY CARE EDUCATION launched i-Explore Social Accountability in FACULTY NOMINATED FOR Action module. 2021 STUDENT CHOICE AWARDS Dr Arti Maini, Deputy Director of Congratulations to several members of Undergraduate Primary the Medical Education Innovation and Care Education, was Research Centre (MEdIC) and nominated for an Undergraduate Primary Care Education Outstanding Teaching who were nominated by students for the Award, recognising her 2021 Imperial College Union Student engaging approach to Choice Awards. teaching students and her support for their learning beyond their course. Ms Bethany Golding, Community Dr Neepa Thacker, Collaborations Lead, Course Lead for the was shortlisted for Phase 1c Medicine in an Outstanding the Community Professional Support Apprenticeship (MICA) Staff Award. Her was nominated for an work has brought Outstanding Personal together students and local communities Tutoring Award for her in innovative ways, generating powerful ongoing high level of support and her learning experiences and supporting accessibility to her students. development of skills in collaborative working to help address community Dr Viral Thakerar, priorities. Course Lead for the Phase 1a and b Dr Camille Gajria, Patients, Communities Academic Tutor, was and Healthcare (PCH) nominated for an module, was Outstanding nominated for an Personal Tutoring Outstanding Personal Award for her Tutoring Award, being recognised for ongoing high level of working in highly engaging and inclusive support both ways with his students to support them academically and pastorally for her tutees. academically and pastorally. Dr Josh Gaon, Senior Thank you to all our colleagues Teaching Fellow, was above for their hard work and to all nominated for an our students for their nominations. Outstanding We very much look forward to Teaching Award for continuing these hugely valuable his inspiring, collaborative relationships. interactive teaching
WHY FOREIGN TRAVEL RULES ARE IMPORTANT DURING THE COVID-19 PANDEMIC The rapid spread of the delta variant of the coronavirus in the UK in recent weeks shows the importance of foreign travel rules, such as on testing, immunisation and quarantine, to limit the import of Covid-19. Countries need to look at their own situation and put in place the most appropriate rules for them. This will include rules on Covid-19 testing for inbound and outbound travellers, and when and for how long travellers should quarantine; as well as guidance on whether travellers who are fully immunised can be exempted from some of these rules. Holidays in foreign destinations carry proven to be much more infectious than risks. Settings such as restaurants, bars, previous variants, and it is very likely that night clubs and indoor concert venues it will spread rapidly across Europe in the have all been linked to large outbreaks of summer months, putting travellers at risk Covid-19. We all need to do our part to of infection. reduce these risks when we travel by following the local rules on social By following the Covid-19 rules in the UK distancing and on the use of other and in the countries we visit, we can help preventive measure such as wearing face protect ourselves and others from the risk masks; and ensuring we get tested if we of infection, and limit the international have symptoms of Covid-19 or have been spread of the delta variant and any other caught up in a Covid-19 outbreak. The new variants of the coronavirus that may delta variant of the coronavirus has emerge in the future.
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COVID-19 VACCINE PASSPORTS: ACCESS, EQUITY, AND ETHICS In an editorial published in the British Medical Journal, Tasnime Osama, Mohammad Razai and Azeem Majeed discuss the practical and ethical issues in the implementation and use of vaccine passports, and the need to ensure they do not exacerbate current societal or health inequalities. With millions of people receiving covid-19 immune and pose minimal risk of vaccines globally, some countries have spreading infection may be unethical, as already started planning the lack of freedom of movement is one of implementation of “vaccine passports”— the most common adverse impacts of the accessible certificates confirming covid-19 pandemic on people’s lives. vaccination linked to the identity of the Additionally, vaccine passports could holder. The purpose of vaccine passports, help prevent other health and governments argue, is to allow people to socioeconomic harms caused by travel, attend large gatherings, access lockdowns, thereby accruing public venues, and return to work without individual and collective health, compromising personal safety and public economic, and social health. There remain, however, benefits. considerable practical and ethical challenges to their implementation. Vaccine passports are not only permissible Vaccine passports need under international health regulations, they already exist. The World Health to be internationally Organization endorses certificates confirming vaccination against yellow standardised and must fever for entry into certain countries. Contrary to immunity passports, which have verifiable may, perversely, incentivise infection, vaccine passports incentivise vaccination, credentials that an international public good with many positive benefits4 including individual and safeguard against population immunity. problems such as The public health principle of least infringement states that to achieve a forgery and loss of public health goal, policy makers should implement the option that least impairs privacy. WHO does individual liberties. While lockdowns may be required, the continued restriction of not currently endorse covid- the civil liberties of those who are 19 vaccine or immunity passports because of these concerns. It has, however, initiated a Smart Vaccination Certificate Working Group to establish key specifications and standards for effective and interoperable digital solutions for covid-19 vaccination. Photo by Brett Jordan on Unsplash
Ethical concerns remain about the societal and create a situation where people from divide that these passports could cause. high income countries are able to travel, The Nuffield Council on Bioethics states but not those from low income countries. that such passports could enable coercive and stigmatising workplaces, thereby As vaccine passports would probably be compounding current structural digital and require access to private disadvantages. Vaccine passports must be medical records, there are important available and accessible to all to prevent questions around internet access, costs of exacerbating existing societal inequalities acquiring and maintaining the passports, and worsening the health divide. Vaccines privacy, and data protection that must be are scarce and access remains unequal, tackled. Many consider adequate internet both globally and within countries. Covid- access a fundamental human right; as 19 vaccines are also contraindicated in large numbers of people do not have some people with serious health smartphones or stable internet conditions and allergies. People facing connections, their exclusion breaches vaccination access problems will be their rights to equality, particularly for unable to obtain vaccine passports. those in low- and middle-income Pregnant women are at an increased risk countries. Whether it is legal for of severe covid-19 illness; however, as workplaces, airlines, and entertainment clinical trials did not include pregnant and leisure venues to access vaccination women, the uncertain risk of vaccination data remains controversial, as this can perpetuate a form of elitism. during pregnancy may also lead to Furthermore, ensuring that patient understandable hesitancy in this sensitive data are not used for other purposes is essential. group. Ethnic minorities are also more likely to be While the merits of vaccine passports may vaccine hesitant. be undeniable, implementation will require ethical justifications and practical With most vaccine doses solutions that do not discriminate against delivered in high income countries, WHO the poor, the less technically literate, and warned that the world is on the brink of a people from low- and middle-income catastrophic moral failure. Because of countries. Without mitigation strategies vaccine nationalism and insufficient and alternative solutions, the hardships efforts to support globally coordinated experienced by marginalised and access to covid-19 vaccines, nearly 25% of vulnerable groups will be intensified the world’s population may not have through the perpetuation of access to a vaccine until at least 2022. This discrimination. If they are to be rolled out, will widen the global north-south divide the benefits of vaccine passports should not be dispersed unequally, and societies globally must strive to ensure that they are available to all. FULL ARTICLE Further Reading - STAYING SAFE AT THE BEACH AND THE PARK
USING THE NHS APP AS A COVID-19 VACCINE PASSPORT The UK transport minister, Grant Shapps, announced on 28 April 2021 that the UK government plans to use the existing NHS App to provide proof of covid-19 vaccination status for international travel. For many years, proof of smallpox, polio, and yellow fever vaccinations have been an entry requirement for many countries. The World Health Organization ‘yellow card’ scheme has been in place since 1969, and proof of ACWJ meningococcal vaccine is required for Hajj to Saudi Arabia. So while discussions on “vaccine as evidence passports” are old, the scale of the covid- about the 19 pandemic will require a large number efficacy of of global travellers to use a vaccine existing and new passport, which is an unprecedented covid-19 vaccines development; and the technological increases. This options are far more advanced than for however has not the previous paper-based certificates used deterred some for other vaccines. There are arguments countries—notably for and against vaccine passports. We are Israel—pushing ahead facing a global pandemic, with huge with their digital “Green variations in disease prevalence and Pass” scheme, with the USA vaccine mobilisation between countries. also exploring options for And while we watch the tragic scenes vaccine certification. from India, many people in the UK are preparing for their first opportunity this Should the UK government year to visit oversees relatives or take an decide to proceed with a vaccine international holiday. passport policy, what method would we use? General In a statement on 5 February 2021, the practitioners, who are already World Health Organization (WHO) laid struggling to meet unprecedented down their reasons (at that time) for not demands, while delivering around 75% supporting the idea of vaccine certificates; of covid-19 vaccines thus far, cannot be based on ethical, legal, scientific, and expected to provide proof of vaccinations. technological reasons. WHO recommends There are digital solutions available such that people who are vaccinated should as the NHS App, or possibly the NHS continue to comply with other risk- Covid-App. Many UK patients nationwide reduction measures when travelling. WHO already use their NHS App for a range of also stated that their recommendations services including to seek medical advice, will evolve as vaccine supply expands and view their GP records, make
appointments, submit secure electronic data recording can then occur, in addition enquiries to their GP, and to order repeat to creating extra work for hard-pressed prescriptions. It is also possible for people primary care teams. If the NHS App is to to use the App to view their covid-19 be used to confirm vaccination status, it is vaccination record. This area of the essential that all IT issues are resolved existing NHS App, already used by millions promptly to ensure the NHS App contains of patients, is clearly a safe and obvious an accurate record of people’s vaccination place to use as a digital “vaccine status and extra work is not created for passport.” Increased downloads and use primary care teams. of the NHS App by those using it as their “vaccine passport” could have additional An editorial in The BMJ discusses some of long-term benefits for patients and the the wider practical and ethical issues in NHS through encouraging use of other the implementation and use of vaccine digital NHS services. passports; such as the need to ensure they do not further exacerbate current Covid-19 vaccination is recorded health inequalities. For example, many using the national PharmaOutcomes (also people in the UK do not own a modern known as Pinnacle) IT system. NHS smartphone capable of running the NHS App, a feature of the ‘digital divide’. The England decided to use this rather than UK government’s proposal of using the recording directly into GP patient NHS App may work for the majority of the record systems because data can be population, but we must consider entered using a web browser, and alternative options for those without thus the system can be used access to suitable technology, so they are across all vaccine sites, not prevented from overseas travel. including those that have no access to GP medical record There is debate for and against vaccine systems such as EMIS or passports, which are being implemented SystmOne. However, by several countries already, but are not some people have currently recommended by the WHO. The reported that the UK government’s proposal to use the NHS information on App to provide proof of covid-19 their vaccination vaccination status is a practical and is not always pragmatic solution for most UK citizens. transferred to However, we suggest that IT issues need their GP to be addressed before we can rely on the medical NHS App as a “covid-19 vaccination record, and passport,” to prevent extra bottlenecks indeed GP and delays in airports. GP teams, who are Teams have also already struggling for time, need to be noted other protected from a tsunami of requests for discrepancies. certification to travel; and solutions also need to be found in case of technology When inaccuracies are noted, covid-19 failure, and for those unable or unwilling vaccination data must then be entered to use the NHS App. manually by the GP practice. This is not an ideal solution as errors and omissions in FULL ARTICLE Photo by John Cameron on Unsplash
By Dr Vinitha Soundararajan & Dr Lucy Ryan Lifestyle Medicine and Prevention (LMAP, pronounced EL-map) is a pair of brand-new core modules aimed at first- and second-year medical students at Imperial.
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WHAT IS LIFESTYLE MEDICINE AND PREVENTION? LMAP accounts for 15-20% of the both individual- and population-levels. By curriculum delivered in the first two years exploring these influences on patients, of training. The modules provide a unique our future doctors are encouraged to insight into the impact that behaviour and reflect on their own health and wellbeing the environment can have on health at The key aspects of lifestyle medicine that new series of learning on global health we cover are physical activity, nutrition, governance. sleep, financial well-being and mental health. We look in-depth at the wider The modules are a collaboration led by determinants of health and examine the the new Undergraduate Public Health COM-B model of behaviour change. In the Education team (within PCPH) with second year, students learn about Imperial College School of Medicine and epidemiology, research skills and a brand- the Digital Learning Hub.
Colleagues who’ve worked on the GMPH will be familiar with the DLH methodology of planning every single activity using Post-its! INNOVATIVE PEDAGOGIES Building on the experience of SPH’s Global clinicians – identified as trusted MPH programme, the LMAP modules messengers for students with an intense have been built from the ground up as focus on physician health and the realities blended learning: using a flipped of NHS practice. classroom model. The online content is built on the Insendi learning platform, Since the pandemic emerged, we’ve which incorporates video, audio, switched much of the learning online and interactive and reading activities – have very fortunately been less affected preparing students before they enter the compared to other modules that had a classroom. Teaching events are led by more lecture-driven teaching approach. WHY IS LIFESTYLE MEDICINE AN IMPORTANT TOPIC IN UNDERGRADUATE MEDICINE? We draw upon a blend of biomedical apply the lifestyle medicine evidence evidence and social sciences that base. underpin behavioural influences on health. Lifestyle medicine and social The term lifestyle medicine is not free prescribing have a crucial role in clinical from controversy with critics suggesting practice and preventative medicine. It is that it might create an environment of therefore the duty of medical educators blame or evidence-free. In the spirit of the to equip students with the knowledge and College, our LMAP modules are heavily skills to address their own well-being and
In the first LMAP module students are taken through a narrative arc that follows Priya and a constellation of pressures and challenges she faces in her personal and professional life. We recorded scenes on location in Bermondsey, reflecting on a bottomless prosecco brunch and the impact of binge drinking. Teaching takes place predominantly in clinician-led small groups of between 12 and 24 students. We repeat every session about 12 times creating over 400 sessions delivered each year on top of the online learning activities available on Insendi.
evidence-driven and there’s not a vitamin as a future doctor. Students also reflected infusion in reach! on how this has challenged or altered their understanding of health, especially Student feedback collected in the third in relation to preventive medicine, the term of the modules’ first run, showed doctor as a role model and the that 93% of respondents (n=260) importance of empathy in addressing recognised LMAP’s relevance for their role wider health determinants. TEACHING BY EXAMPLE studying. Leading by example, the LMAP teaching staff have completed a shared It is important to show our students that challenge of running or cycling 621 km in behaviours such as physical activity can be order to improve our physical activity incorporated into busy schedules. We levels. integrate “active podcasts” into guided online learning sessions, which allow trainees from emergency medicine, acute physical activity to be undertaken while medicine, general practice and public health. We have received really positive OUR TEACHING NETWORK feedback from volunteers, who’ve found the teaching experiences beneficial to In order to provide an authentic learning their own professional development and experience, we utilise a network of wellbeing. predominantly junior doctors who volunteer time to lead live sessions. They are encouraged to incorporate their own experiences within sessions so that students can better understand the healthcare perspective. So far, we’ve had Insendi has taken over from Coursera in early years MB BS and provides a clearly structured and signposted learning journey through a range of different components.
OUR FUTURE PLANS The LMAP modules will complete their first two-year cycle this summer. As one of the first medical schools to incorporate core lifestyle medicine education globally, we will critically evaluate its impact and share our experience with the wider educational network. Focusing on internal curriculum development, we will set a population health agenda beyond years one and two. Our LMAP strategy ultimately will inspire our students and enable them to thrive now and throughout their professional careers. THE TEAM MODULE LEADERSHIP TEAM Dr Richard Pinder: Module lead & Director of Undergraduate Public Health Education Dr Christopher Harvey: Senior Strategic Teaching Fellow & Topic Lead for Sleep Dr Amy Bannerman: Strategic Clinical Teaching Fellow: Dr Lucy Ryan: Clinical Teaching Fellow (pictured below right) Dr Vinitha Soundararajan: Clinical Teaching Fellow (pictured below left) Dr Ed Maile: Honorary Research Fellow, and module development co-lead TOPIC LEADS Dr David Salman: Physical Activity Dr Celeste Loots: Nutrition Dr Viral Thakerar: Financial Wellbeing Dr Lindsay Dewa: Mental Health Dr Arti Maini: Health Coaching We also thank members of the School of Public Health for their inputs to the curriculum design, delivery and support.
The module launched in October 2019 with a chaired panel discussion that brought in Doctors’ Kitchen and ICSM alumnus Dr Rupy Aujla, well known GP Dr Zoe Williams, Dr Rosie Gilbert (Ophthalmologist) and Dr Ailsa Lumsden (Oncologist). Here the panel with MB BS Phase 1 Director Prof Mary Morrell. Later, fascinating discussions and endorsements emerged online about the need for this type of learning as a central component of medical education.
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The latest data from the Office for National Statistics confirms that ethnic minorities in England are considerably less likely to receive a covid-19 vaccine than their White counterparts. While 90.2% of those aged 70 years and over living in England had received at least one dose of vaccine by 11 March 2021, uptake rates were 58.8% and 68.7% in Black African and Black Caribbean groups, respectively. [2] This was followed by Bangladeshi (72.7%) and Pakistani (74.0%) populations, with the most pronounced differences seen in those living in the most deprived areas of England.
Vaccine take-up also varied by the possible risks. Some anti-vaccination religious affiliation with Muslims advocacy groups may try to take (72.3%) and Buddhists (78.1%) advantage of this association to further having the lowest rates, despite their own agenda, but clinicians and Pfizer-BioNTech, AstraZeneca and public health specialists need to reaffirm Moderna confirming that their the safety of covid-19 vaccination, and vaccines do not contain animal also the high risk of serious illness, long- products, and despite endorsement term complications, and death in people of the vaccines by the British who are not vaccinated. Islamic Medical Association, the Dalai Lama, the Hindu Council UK Vaccine safety and effectiveness and the Board of Deputies of concerns are, however, not our only British Jews. Vaccination rates challenges; effective vaccine allocation were also lower among disabled strategies can alleviate other barriers, people (86.6%), who are more including vaccine-related access and likely to live in poverty and account convenience of appointments. Reaching for a large proportion of covid-19 communities, through culturally- deaths. After accounting for sensitive communication, remains even geography, underlying health more crucial in light of the Joint conditions and some Committee on Vaccination and socioeconomic inequalities, these Immunisation resisting calls to prioritise stark differences in vaccine uptake ethnic minorities across the different persisted. phases of the vaccination programme or through larger allocations of vaccines to Despite the considerable obstacles, areas with the highest rates of covid-19. there is an opportunity to improve the historically low vaccine uptake rates in The origins of vaccine hesitancy and ethnic minorities. With new data vulnerability are rooted in everyday life, continuing to emerge on the requiring intersectoral approaches and relationship between the mitigation efforts from outside the AstraZeneca/Oxford vaccine and a very health sector to transform the social rare risk of specific types of blood clots, determinants of health. The legacies and such as cerebral venous sinus current practices of racial exclusion, thrombosis (sometimes associated with disinvestment, discrimination, and low platelet counts), the Medicines and violence that continue to enable health Healthcare products Regulatory Agency inequalities provide conditions for covid- (MHRA) and the European Medicines 19 to persist in ethnic minorities even Agency (EMA) have stated, once again, when life-saving vaccines are available. on 7 April 2021 that the benefits of A refusal to address the root causes of covid-19 vaccines considerably outweigh these ingrained societal inequalities may lead covid-19 to become, like many other infectious diseases, a “disease of poverty.” The recent government
report, denying the reality and risk must be targeted, protected, and consequences of structural racism— supported, thereby ensuring that health despite overwhelming evidence—will outcomes are improved. make it extremely difficult to establish trust and overcome justifiable anger and Social justice is the moral foundation of mistrust in some ethnic minorities. public health. However, the pandemic response demonstrates that it is not One of the core aims of health policy is always central to government policy. maximising overall population health Unless we mitigate the consequences of while achieving equitable health past and ongoing wrongs, and unless distributions. Tensions between vulnerable populations feel seen, heard efficiency and equity often lead to and advocated for, the low uptake rates positive and negative impacts of health seen across older people from ethnic policies and interventions being minorities will become even more distributed unequally within pronounced when the vaccination populations, as observed during the programme starts to target younger covid-19 response. For public health people, among whom vaccine hesitancy interventions to be considered effective, and distrust is highest. and not only efficient, those at highest This article was first published by BMJ Opinion Covid-19 vaccination hesitancy In another article published in the British Medical Journal, we give an overview of vaccine hesitancy and some approaches that clinicians and policymakers can adopt at the individual and community levels to help people make informed decisions about Covid-19 vaccination. The World Health Organization defines vaccine hesitancy as a “delay in acceptance or refusal of safe vaccines despite availability of vaccine services.” It is caused by complex, context specific factors that vary across time, place, and different vaccines, and is influenced by issues such as complacency, convenience, confidence, and sociodemographic contexts. Vaccine hesitancy may also be related to misinformation and conspiracy theories which are often spread online, including through social media. In addition, structural factors such as health inequalities, socioeconomic disadvantages, systemic racism, and barriers to access are key drivers of low confidence in vaccines and poor uptake. The term vaccine hesitancy, although widely used, may not adequately convey these wider determinants that influence decisions to delay or refuse vaccination.
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Prince Charles has suggested that people struggling to return to full health after having the coronavirus should practise yoga and practice self-care. In a video statement to the virtual Wellness After Covid symposium, Prince Charles said doctors should work together with “complementary healthcare specialists” to “build a roadmap to hope & healing” after Covid. In 2019, the Prince of Wales said yoga had “proven beneficial effects on both body and mind” and delivered “tremendous social benefits” that help build “discipline, self-reliance and self-care”. Drs Velgia Kuganathan collaborated with Dr David Mummery & SCARU to explore the benefits of self-care in promote mental and physical health & wellbeing, with a particular emphasis on using yoga & self-care to support recovery after Covid.
SPOTLIGHT ON Photo by bill wegener on Unsplash
Countries around the world are advancing self- care policy and practice to strengthen accountable and responsive health systems and to support universal health coverage (UHC). The World Health Organization’s (WHO) first normative guidance on self-care approaches was published in 2019 and provided motivation for these advancements, as did the COVID-19 pandemic which tested already strained health systems. These advances offer an opportunity to better capture changes in policy development and implementation and to highlight opportunities for further policy reform.
In 2020, the Self-Care Academic Research Unit (SCARU) at Imperial College London was supported by the Self-Care Trailblazer Group (SCTG) to develop a first of its kind pragmatic self-care policy and practice mapping tool. The purpose of this tool was to understand the extent to which countries are implementing the 24 recommendations outlined in the 2019 WHO Consolidated Guideline on Self-Care: Sexual and Reproductive Health and Rights (SRHR) in policy and practice. The tool was developed with support from the wider SCARU team (Iman Webber, Aos Alaa, Manisha Karki & Eva Riboli-Sasco) working under instruction from Professor Azeem Majeed. With support from the SCTG, the tool was first advanced for perinatal health and family applied in Kenya, Nigeria and Uganda planning; while some were more nascent, between October 2020 and March 2021- at a including those for self-sampling for sexually time when Nigeria and Uganda were in the transmitted diseases. The policy environment process of developing national self-care for eliminating unsafe abortions was the least guidelines by adopting the global normative advanced. The preliminary results are guidance. available in this Self-Care Policy Mapping Deck, while full manuscripts are under The study found that self-care policies and development. practices in all three countries were relatively WHAT’S NEXT? The policy mapping exercise is being used to advance self-care policy and practice in exciting ways: SCTG National Self-Care Networks–led by White Ribbon Alliance affiliate in Nigeria and the Centre for Health, Human Rights and Development in Uganda– used the results to inform their national self-care advocacy objectives: • In Nigeria, SCARU presented the self-care policy mapping findings to the Federal Ministry of Health-led Self-Care Think Tank, which informed the country’s self-care policy mechanism and advocacy objectives for 2021, including building health literacy for effective self-care implementation and advocacy for improved self-care products and the removal of existing barriers. • In Uganda, the SCARU policy mapping analysis highlighted the gaps in the legal and policy frameworks for self-care while being used to identify advocacy opportunities for self-care policy reform. With support from Population Services assess what consumers require to adopt them International’s Maverick Collective initiative, effectively, safely & sustainably. The SCTG is the policy mapping tool will be applied in also developing an accompanying policy Mozambique, Malawi & Nepal to inform dashboard to articulate the self-care policy recommendations for a basic minimum status across a broad range of interventions in package of self-care interventions tailored to a growing selection of countries. We hope this each country’s context. This initiative will tool can be used by self-care advocates, gather evidence to inform future policy manufacturers, implementers and policy guidelines and programs by creating an makers to track the progress of self-care understanding of the feasibility and policies and to use the information to inform acceptability of self-care interventions and to strategy development.
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Though primary care services are integral to the health & wellbeing of the population at large, they are facing increasing shortages of healthcare providers and are requiring healthcare staff to take on a more diverse range of tasks. The UK is estimated to need 6000 more general practitioners (GPs) than the NHS currently employs to meet rising demand.
Photo by Zach Vessels on Unsplash “The Cuckoo Lane Practice in Ealing is unique because it’s the only primary care centre in England that is supported entirely by advanced care practitioners. Our patients often don’t know they are not being seen by a doctor & they seem to be very happy with the support they get” Julie Belton, Nursing Director Cuckoo Lane Practice
One of the proposed solutions to the GP shortage is the increased adoption of alternative providers of primary care in which non-doctor health care professional (including advanced nurse practitioners, pharmacists and physiotherapists) take on a more active role in the provision of primary care. Advanced Care Practitioners (ACPs) who work in conjunction with a healthcare physician or autonomously in both the primary and secondary care setting can help meet patient needs whist delivering a high-quality primary care services. Julie Belton has teamed up with the NWL Research Trailblazer Group to develop the DRWHO study which seeks to gain insight into the knowledge, attitude and perceptions of individuals who receive care from a general practitioner as well as those who receive care from advanced nurse practitioners at the Cuckoo Lane Practice, which is run by Julie Belton. Is this topic of interest to you? Please consider participating in this online survey to give us your views.
Countries globally are considering the implementation of Covid-19 vaccination programmes for children. In this article for the Daily Mirror, Matt Roper and Azeem Majeed answer some of the common questions from parents about Covid-19 vaccination for children. I’m worried about vaccinating my child – how safe is it? Clinical trials of Covid-19 vaccines in children aged 12-15 years in the UK and USA confirm that the vaccines are very safe. The rate of side effects in children in these studies was similar to that seen in young adults. As in young adults, most side effects were mild to moderate, such as a sore arm or tiredness. Will children need two jabs like adults? Children will need two doses of vaccine because this provides much better protection against serious illness than one dose of vaccine. How likely is it they will suffer from side effects? The most common side effects in children aged 12 to 15 years of age are pain at the injection site (> 90%), tiredness and headache (> 70%), muscle pains and chills (> 40%), joint pains and a high temperature (> 20%). Is there anything I can do to offset any side effects? Following the vaccination, paracetamol can help provide some relief from side effects such as muscle pain and headache. The side effects are generally transient and will resolve within a few days.
We’ve been told Covid doesn’t affect children as severely as adults, so why do we need to vaccinate them? Although hospitalisation and death are rare in children following a Covid-19 infection, children can still sometimes have a prolonged illness and can also develop complications such as Multisystem Inflammatory Syndrome or other types of ‘Long-Covid’. Vaccination of children also helps to protect older members of the family, such as parents and grandparents, and teachers. Is long Covid a concern in relation to children, and will the vaccine help there? Long Covid can occur in children. At present, we don’t yet know if vaccination will protect against Long Covid, but we hope that if vaccines reduce the risk of symptomatic infection and serious illness, they will also reduce the risk of the long-term complications of Covid- 19. Will they need regular boosters later on? Because the virus that causes Covid-19 is continually mutating, it is likely that booster doses of vaccine will be needed for both adults and children. For protection against current strains, it is possible that immunity may gradually weaken over time and this would be another reason for providing booster doses. If they don’t get their jab, do we think they might be exposed to more risky variants in the future? The vaccines do protect against serious illness even for the newer, more risker variants such as the delta variant. Children who are not vaccinated will be at higher risk of a serious illness if they are exposed to a new variant of the coronavirus in the future.
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Attainment of primary care quality of care indicators and emergency hospital admissions in people with type 2 diabetes England has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. In a study published in the Journal of the Royal Society of Medicine, we aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions.
Diabetes, cardiovascular and all-cause admissions after adjustment for unplanned hospital admission rates were confounders. 7%–12% lower among those who met the Quality and Outcomes Framework HbA1c Longer latency to diabetes, cardiovascular indicator, and 8%–14% lower among and all-cause unplanned admissions was those who met the cholesterol indicator. also observed among those who met the By contrast, univariate analyses HbA1c or cholesterol indicators, and again demonstrated that blood pressure an association was not observed for the indicator attainment was associated with blood pressure indicator. Completing 7–9 higher rates of all types of unplanned National Diabetes Audit processes was admission. However, this association only associated with lower rates of all types of persisted for diabetes-related admissions unplanned admissions, and meeting all in multivariate analyses, and blood nine National Diabetes Audit care pressure attainment was associated with processes was linked to 22%–26% lower a significantly lower rate of rates for all types of unplanned cardiovascular-related unplanned admissions. High quality primary care and achievement of key quality targets lowers the risk of amputations in people with type 2 diabetes Amputations are an important and largely preventable complication of type 2 diabetes mellitus that impact considerably on the life expectancy and quality of life of those affected. In England, more than 9000 diabetes-related amputations are performed each year, with decreasing rates but higher absolute numbers of major amputations, and the annual direct healthcare costs of diabetic foot ulceration and amputation are approximately £1 billion. In an article published in BMJ Open 47% lower among those who met the Diabetes Research & Care, we cholesterol indicator for our primary investigated the associations between outcome. attainment of primary care quality clinical indicators, completion of National Comprehensive primary care-based Diabetes Audit care processes, and non- secondary prevention may offer traumatic lower limb amputations among considerable protection against diabetes- people with type 2 diabetes. We observed related amputation. This has important that minor or major, as well as major-only, implications for diabetes management amputation rates were 26%–51% and 3%– and medical decision-making for patients, 51%, respectively, lower among those as well as type 2 diabetes quality who met the HbA1c indicator and 14%– improvement programs.
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Safe management of full-capacity live events in the era of Covid-19 In an article published in the Journal of the Royal Society of Medicine, we discuss the safe management of full-capacity live events in the era of Covid-19. The importance of the live events industry to the UK economy is significant, with the creative industries1 alone contributing £117bn to the UK economy in 2018. However, the public health response to COVID-19 led to an unprecedented fall in theatrical sales of 93%, with the entertainment industry estimated to lose £110 m per month of full closure. Several high-profile live music previous infection) will help the UK events have been cancelled. There to reach low transmission levels; has been limited experience of the however, the success of the vaccine reopening of live events in other programme will largely depend on countries; however, this has only convergent evolution of the virus, been possible due to effective but this remains unknown. public health interventions to reduce community transmission to Additional measures to stringent near zero levels. The sustainability social distancing, isolating at home of stringent border control and high uptake of the vaccination measures to virus transmission is programme to achieve herd much debated; however, it is clear immunity to existing and emergent that the ability for the UK to achieve mutant strains of coronavirus will all and then sustain low community be required to maintain low transmission levels will require transmission levels in the UK. rigorously monitored borders and However, because of vaccine quarantine measures for inbound hesitancy among some groups, travellers. there may be areas of the UK where COVID-19 outbreaks continue. Widespread population immunity through vaccination (and from
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Co-creating LGBTQ+ inclusive medical education: A new approach for third-year medical students We know that members of the LGBTQ+ community experience barriers to accessing healthcare. We also know that social pressures and ‘othering’ of LGBTQ+ people has led to high rates of hate crimes, that healthcare staff report not having had in-depth training on equalities and LGBTQ+ related topics and that some LGBTQ+ patients report discrimination in healthcare based settings. This is of particular concern when we consider that the rates of depression and suicide in the community are increasing. Some patients also experience long waiting times, for example with the Gender Identity Clinic.
It is vital that awareness of these key to see an accurate portrayal of the issues and barriers facing LGBTQ people consequences that result from doctors are highlighted and brought to the and healthcare professionals not receiving attention of our next generation of important information about the LGBTQ+ doctors. It was therefore very important community. The SCC is a starting point to us to be involved in setting up a Q&A providing a window into the health and story sharing session between third- experiences of this marginalised group. year medical students and LGBTQ+ panellists from local voluntary sector The autobiographical stories did not make organisation Mosaic LGBT Young Persons’ for easy listening, as LGBTQ+ individuals Trust. The panellists shared powerful painted a picture of a system which was autobiographical stories with the not engineered with their needs and students, relaying amongst other things experiences in mind. Feedback from the barriers and issues they have faced in students revealed that they had “never accessing healthcare. been more engaged at medical school”. “Why do we not learn more about this?” The work was trialled during a “Student students asked and tweeted later. We Selected Component” (SCC) for third-year hope that this course is just a first step in medical students at Imperial. In addition, a movement of positive change. ‘Promoting Health Equity’ SCC provided students with an opportunity to reflect on Medical school must be about training key aspects of medicine relating to social doctors who are equipped to support all determinants of health with which the their patients. Fundamental to this is curriculum does not necessarily usually awareness raising, constructive engage. The course is only taken by a challenging of people’s views and small number of students, it leads hope to ensuring that clinicians are empowered to share some of the learning from this work serve marginalised communities with more widely through other courses and confidence. approaches. This event was a step in the right We are passionate about seeing a shift in direction. We need to have more open medicine and society away from conversations within medicine about how microaggressions and marginalisation of prejudices seep into care and that starts LGBTQ+ identities. Embedding an with creating a curriculum that itself does understanding of LGBTQ+ needs, barriers not ignore, diminish or perpetuate to healthcare and experiences in the stereotypes about the LGBTQ+ medical curriculum is absolutely key to community. Having worked on such a achieve this and could have an impact on successful SCC, we are hoping to see how our next generation of future doctors changes in how these conversations are interact with our next generation of addressed in the wider curriculum, and LGBTQ+ individuals. how attitudes - and most importantly patient experiences - can improve. Instead of the occasional reference to “HIV in MSM communities”, we are keen
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BUILDING A SUSTAINABLE INFRASTRUCTURE FOR COVID-19 VACCINATION By mid-June 2021, the UK had administered over 70 million doses of covid-19 vaccines; with the majority (estimated around 75%) delivered by primary care-led vaccination sites. Since the start of the vaccine programme in December 2020, the UK has offered a variety of locations for covid-19 vaccination; GP led sites, mass vaccine sites, community pharmacies, and hospitals. The rollout of covid-19 vaccination is a major and much needed success for the NHS, and there are many positive lessons to be learned and taken forwards. However, we must not be complacent. We are still in the midst of a global pandemic, with covid-19 rife in many countries; and with new, more infectious variants of SARS-CoV-2 continually emerging. It is essential for the UK to maintain its vaccination momentum, as well as to consider extending the vaccination programme to older children; and being prepared to offer booster doses to adults if these are required to maintain immunity. We must also focus on vaccine hesitancy, which is a major global health risk in its own right.
General practices in the UK are very around the storage and handling of the experienced at mass vaccination mRNA Pfizer BioNTech vaccine precluded programmes; being largely responsible for the use of community pharmacy sites, but administering seasonal flu vaccines with the Oxford AstraZeneca (like seasonal flu support from community pharmacy sites. In vaccine) has been widely administered in 2020, the cohorts offered flu vaccines were community sites. The more recent changes extended to include household members of by the MHRA allowing up to 31 days storage high risk patients, and all people aged 50- in a vaccine fridge for the Pfizer vaccine has 64. The same extended groups will be the potential to further expand the range of targeted for a flu vaccine next winter. suitable sites for its use. General practices are embedded in their communities, are local and trusted, have In England, GPs have been working in health compliant regulated premises, primary care networks (PCNs) since July rigorous cold storage systems, resuscitation 2019, representing groups of practices equipment on site, hold full electronic typically covering 30,000-50,000 patients. patient records, and have long standing Primary care networks are ideally placed to knowledge of their patients. For all these offer population-based health services reasons, when the covid-19 vaccines including covid-19 vaccination. Some became available, it was primary care primary care networks have offered covid- teams nationwide who were able to quickly 19 vaccinations in house by reorganising step forward and deliver the majority of their services, while others have worked vaccinations. with other primary care networks to use large sites such as sports centres, The initial cohort for the Covid vaccination entertainment venues, and village halls. programme—people aged 80 and over— Many primary care networks have also were not easily reached by email or text offered ‘pop up clinics’—for example in messages, are sometimes not technically homeless shelters, community centres, literate, and many needed phone calls to places of worship and hostels—with great book their vaccination appointments. The success, to increase uptake in marginalised amount of time and effort this took was groups who are typically at higher risk of considerable and it is a credit to infection, serious illness, and complications overstretched primary care teams from covid-19; and thereby help to reduce nationwide (with special praise for practice health inequalities. managers, receptionists, care co-ordinators, link workers, nurses, volunteers and other There has been great commitment from support staff) that our most vulnerable both the existing primary care workforce patients, including nursing home, and volunteers to deliver the covid-19 housebound and clinically extremely vaccination programme, with many retired vulnerable patients received their initial staff coming back to help, primary care staff injections so quickly and efficiently. being redeployed, and volunteers acting in roles such as marshals, data entry clerks and As we moved to the ‘lower risk’ cohorts, the car park wardens. In addition to all the range of vaccine sites quickly expanded, and administrative workload in booking without any consultation central recalls appointments, there are huge numbers of were sent out, resulting in many queries from patients about their vaccines unnecessary queries, much confusion, and both before and after the event. This hidden unnecessary travel for patients. The logistics work is also being carried out, unfunded,
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