“As we moved to the ‘lower risk’ cohorts, the range of vaccine sites quickly expanded, and without any consultation central recalls were sent out, resulting in many unnecessary queries, much confusion, and unnecessary travel for patients” Photo by Ricardo Gomez Angel on Unsplash
and largely unrecognised, by primary care transparency and also an appreciation for teams. Each time there is a change in policy the huge efforts made by GP teams by the government or a health scare in the nationwide. media, primary care teams are inundated with calls, and this workload and its By using primary care sites for the importance in ensuring the continued high vaccination programme, there is the uptake of covid-19 vaccines needs to be potential to invest in and strengthen our recognised by the government. infrastructure for local healthcare delivery, which will assist in the covid-19 NHS The UK government has recently announced recovery plans and leave a legacy for the that they may offer a covid-19 booster in the future. By contrast, there is a risk that mass Autumn 2021 and, with new variants vaccine sites—like the Nightingale emerging, this is likely to be a key health hospitals—will eventually be dismantled. policy to protect the NHS over the winter. Policy makers need to carefully evaluate the Hence, now is the right time to appraise the use of mass vaccine sites versus GP led sites, various options for vaccine delivery. Having along with the desire of patients to receive a mixed range of sites able to offer mass their care closer to home and in a familiar vaccination in theory should speed up the setting. However, there must be adequate process, but it has been clear throughout resources attached for this work, so that the vaccination programme that the limiting routine care and timely access to other factor is actually vaccine supply, not capacity primary care services is not compromised by to vaccinate. delivering the covid-19 vaccination programme. We recommend that NHS England publish data on the respective costs of delivering We know that many GP teams are at vaccines via primary care networks (general breaking point and must be fully supported practice sites) versus mass vaccine centres. if they are expected to provide mass covid- Any such calculations must include set up 19 vaccination in addition to their core costs, running costs, and also explain where work. Investment in primary care led the clinical staff are coming from—knowing vaccination sites, supported by local that staff shortages are already running at pharmacies, is likely to be the most cost- over 10% across the NHS. The work in effective option for ongoing mass dealing with queries from patients also vaccination, as well as being the option that needs to be factored into this evaluation— is preferred by most patients. It is essential this is currently largely being directed at therefore for the government and NHS primary care teams, who are often left to managers to work with primary care teams, deal with the most complex patients. We giving them the resources needed to put in would also request an official breakdown of place a sustainable, long-term infrastructure the percentage of vaccines given in each for vaccine delivery. setting thus far, so that there is full This article was first published by BMJ Opinion FURTHER READING - Assessing the long-term safety and efficacy of COVID-19 vaccines
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Medical students from around the world joined a MEdIC panel discussion to share experiences of their education during the pandemic. The Medical Education Innovation and Research Centre (MEdIC) event gave global medical students a platform to reflect on and share their personal and professional experiences during the pandemic. by Sarah Saxton
Dr Sonia Kumar, Director of Undergraduate Primary Care Education and MEdIC said: “After receiving over 600 entries from 52 countries to our Global Creative Competition last year, we knew that there was a need for global medical students to be heard and to share their experiences over this last year. It was a real privilege to share the stage with such a thoughtful and wise group of medical students from around the world. Their honest and open reflections provided such unique insights into how medical students have dealt with and learnt from the pandemic and developed as future doctors”. Chaired by Dr Kumar and fifth year Imperial medical student Nour Houbby, the event saw contributions from students from Cameroon - Akelekeh Ndah (one of the winners of the Global Creative Competition 2020), Saudi Arabia – Museera Irshad Khan, Australia – Reuben Tee, the Philippines – Lloyd Anicier Barba, and Italy - Gökdeniz Aksit. LACK OF PATIENT CONTACT All participants felt that one of the pandemic’s greatest effects on their studies was the inability to see patients. Some saw rotations cancelled, while for Akeleke Ndah: “Patient attendance was low after lockdown. All we could do was read, read, read, but it was hard to practice what we had learnt”. Gökdeniz Aksit agreed about the challenges of learning remotely without patient contact: “I’ve learnt more in the first week of my cardiology clerkship that in the last semester of book learning.”
EXPECT THE UNEXPECTED Each of the students found their personal resilience tested during online learning, but it wasn’t an entirely negative experience. Museera Irshad Khan said: “I’ve learnt that life is uncertain and that plans don’t always go smoothly. I need to expect the unexpected and be ready to adapt”. Nour Houbby found herself: “appreciating the little things that I took for granted before. I have really valued family and friends. I’m trying to take the lessons from this year and apply them going forwards.” Lloyd Anicier Barba has seen the pandemic lead to a change of career direction: “Originally I wanted to be a surgeon, but now I’m thinking about health systems management. We need medical leadership and I think doctors should steer the wheel.” SELF-CARE AND STUDENT-LED ACTION Mental health challenges were front and centre of the discussion, with Reuben Tee emphasising the need to: “Be kind
to yourself. We need to remember that we are human before we are doctors”. Akeleke Ndah agreed: “You need to be aware of what you can and can’t do. You need to take care of yourself first and know your limits. Having a hobby helps me, as I draw when I feel stressed.” For Lloyd Anicier Barba not being allowed to go to the hospital meant that he looked elsewhere to help others. “I’ve joined a network of medical students and we are conducting an anti-fake news and medical mis-information campaign”. Akeleke Ndah has: “taken part in debates on WhatsApp, on vaccine hesitancy, to help share information.” BUILDING EMPATHY All participants highlighted the importance of showing and developing empathy as a medical professional. Museera Irshad Khan found that: “I have more empathy for patients since the pandemic. Previously I was looking at the disease rather than the patient. I didn’t feel confident talking to them about medical
stuff, but I was advised to talk to them about other stuff instead. Now I try to look beyond medicine and see them as whole.” Reuben Tee felt that: “The pandemic has exposed a lot of things sitting under our noses such as domestic violence, mental health and racial discrimination. We need to try to be aware of this and be as sensitive and empathetic a clinician as we can be.” Several of the participants also highlighted the need for family, friends and universities to show empathy and support for medical students, particularly when they are working in hospitals whilst the pandemic continues. BEYOND ACADEMIC SUPPORT Dr Kumar encouraged participants to reflect on how their universities and tutors could best support them as this challenging period continues. For Gökdeniz Aksit (pictured left): “Having a good relationship with a good mentor who you can discuss issues and problems with” was really important. Reuben Tee wanted to see: “advice on managing workloads and also a recognition that it is ok to take time out – a medical career isn’t necessarily linear, it can take lots of twists and turns and it isn’t a race to graduate.” 2021 competition: Building on the conversation and network built by MEdIC, the 2021 global competition will be on the theme of ‘Global Unity’. Visit the MEdIC website for more information.
Photo by Sasha Freemind on Unsplash
The Covid-19 pandemic has affected educational systems worldwide, leading to the near-total closures of educational institutions in the UK. As of 6 May 2020, schools were suspended in 177 countries affecting over 1.3 billion learners worldwide, and in many cases, closures have resulted in the universal cancellation of examinations. UNICEF estimated that almost 4 months of education will be lost as a result of the first lockdown.
School closures have far-reaching having a dedicated space where economic and societal the child can study and the consequences, including the disruption of the child’s sleep disruption of everyday behaviours patterns during the lockdown are and routines. In the UK, over 2 the main factors associated with million workers have already lost significantly higher odds of parents their jobs, and although the long- reporting feelings of loneliness. term impact of the pandemic on education is not yet clear, the pre- We concluded that school closures existing attainment gap between and social distancing measures the poorest and richest children implemented during the first 100 may widen significantly as a result days of the COVID-19 lockdown of COVID-19. Children and young significantly impacted the daily people make up 21% of the routines of many people and population of England, and by the influenced various aspects of time they returned to school after government policy. Policy the summer break, some would prescriptions and public health have been out of education for messaging should encourage the nearly 6 months. sustained adoption of good health- seeking self-care behaviours In a paper published in the journal including increased levels of BMJ Open, we explored how the physical activity and the lockdown affected the mental maintenance of good sleep health of parents of school-age hygiene practices to help prevent children, and in particular to assess or reduce the risk of social the impact of an extended period isolation and loneliness, and this of school closures on feelings of applies in particular where there is social isolation and loneliness. a single parent. Policymakers need to balance the impact of school We collected data for 6 weeks closures on children and their during the first 100 days of families, and any future risk lockdown in the UK and found that mitigation strategies should ideally female gender, lower levels of not be a further disadvantage to physical activity, parenting a child the most vulnerable groups in with special needs, lower levels of society. education, unemployment, reduced access to technology, not
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STAFF SUCCESS After receiving many excellent applications, the winner of the 2021 Simon Newell award is Dr Cheryl Battersby. Cheryl is a Clinical Senior Lecturer at Imperial College London and an Honorary Consultant Neonatologist at Chelsea and Westminster hospital. In 2020 she received a NIHR Advanced Fellowship award of £1.3M to lead a five-year research programme neoWONDER, using whole population data to improve lifelong health and wellbeing of preterm babies.
Professor Nick Bishop, Vice President for Science and Research said: “Cheryl Battersby has used national data to substantially improve outcomes for preterm infants focusing on firstly understanding the antecedent factors for and then reducing severe necrotizing enterocolitis. Her work has clear impact for preterm infants globally. She is now developing as an independent researcher following the award of an NIHR Clinician Scientist. Her future work will be informatics-focused, using big data approaches to answer difficult questions, with a clear commitment to patient/parent involvement. She has a strong commitment to training the next generation of researchers in paediatrics through her founding of the Neonatal Trainee-led Research and Improvement Projects group. Cheryl is a worthy winner of the RCPCH Simon Newell Award 2021”. Cheryl’s plans for her research career: “Over the next five years, I will be leading a research programme supported by the NIHR to help understand and improve the longer-term outcomes of children born very prematurely. Health and education data for over 100,000 babies will be brought together. This combined information will inform us how these babies progress through their childhood. From this we could learn what neonatal unit interventions, social and environmental factors may have impacted on their development. To find out more or get involved, visit the study website”. FULL ARTICLE Photo by Isaac Quesada on Unsplash
Our recent paper in collaboration with the University of Cambridge was published in the Journal of Public Health. In this study we ask which upper- tier local authorities in England could benefit the most from school-based physical activity promotion? And then assess whether the popular initiative The Daily Mile reaches high-need areas. We identified three distinct clusters of need for physical activity interventions in 123 local authorities - high (red - cluster 1), medium (blue - cluster 2) and low (green - cluster 3). These clusters represent ~4.5 million primary school children in England. The three clusters of need were characterised by determinants of children’s health need for physical activity. The important drivers of need were deprivation in children, children’s mental health needs, physical activity and use of outdoor space. Local authorities with low physical activity, high sedentary behaviour, high excess weight and high deprivation were clustered together. Those with the poorest health outcomes were concentrated in the North and those with the best health outcomes were in the South.
Photo by Taylor Smith on Unsplash The Daily Mile is being taken up in areas that can benefit from it the most - schools located in areas of high need were 25% more likely to register to The Daily Mile. 1 in 5 schools in low-need areas registered and 1 in 4 high-need areas. We have learnt that grassroots movements can reach those who need them the most, but long-term sustainability, effectiveness and adherence needs to be studied. This analysis is a novel way of assessing need using routinely available data in England. What does this mean for the government’s new ‘levelling-up' agenda? The geographic inequalities observed here are likely to get more acute in a post- pandemic world, further disenfranchising those that are already disadvantaged. Targeting policies that match the needs of the population is far more equitable than blanket policies directed at the whole population with differing needs.
The Self-care Academic Research Unit (SCARU) has teamed up with GP Dr Vasu Siva to investigate the prevalence of domestic violence and abuse (DVA) in the community setting. DVA is a global public health problem and a violation of human rights. It is prevalent in society and is almost invisible in primary healthcare, affecting all genders, ages and ethnicities, and can have a very detrimental impact on the individual’s physical and emotional health and that of their family. Since the UK national lockdown, there has been a drastic increase in the calls and visits to helplines, as well as the reports of cases of DVA. The inability to escape abusers has left victims trapped by law, often exacerbating pre- existing poor mental health conditions (e.g. depression, anxiety) and psychosomatic distress reactions (e.g. insomnia, OCD). The lockdown meant that physicians are seeing a fraction of their usual patients, and often offer remote consultations, which is a clear barrier to identifying victims of DVA. Our eSurvey based study primarily aims to investigate the prevalence of DVA. Completing the brief (5-10 minute) survey can help raise awareness about DVA in the community including how to recognise signs of the various types of DVA in both children and adults. Raising awareness about DVA in the community not only helps survivors of DVA to openly discuss and encourage receiving support, but also helps victims to recognise and acknowledge the abuse they are experiencing. Please consider supporting this study by completing our anonymous survey.
Investigating domestic violence and abuse in the general population (RAPID) Photo by @rawpixel.com via freepik.com
Why mortality alone is not enough In an editorial published in the British Medical Journal, we discuss why we must look beyond mortality to the wider burden of pandemic related harms. Over the course of the covid-19 pandemic, daily releases of national statistics on cases and deaths have been widely reported and used to support interventions and judge the success or failure of control measures around the world. However, differences in rates of testing and in reporting of deaths have led to uncertainty about whether national headline figures on deaths are directly comparable. Excess mortality is an alternative metric, which gives a measure of the number of deaths above that expected during a given time period and thus accounts for additional deaths from any cause during the pandemic, irrespective of how covid-19 deaths are defined. Measuring excess mortality alone offers covid-19 remains endemic and where only partial insights into the impact of the health services are unable to function covid-19 pandemic on the health of normally. Establishing where health nations. If we are to truly understand and systems have fallen behind, and intervene to mitigate the impact of the characterising the true extent of unmet pandemic, we must also look to quantify need, is a critical step towards reducing excess morbidity within and between these ongoing harms. nations. A focus on deaths alone gives only a partial picture of the impact of There has been a huge toll of the covid-19 covid-19 on populations, particularly pandemic on mortality in high income among younger people in whom death countries in 2020. However, its full impact from covid-19 is rare. The importance of may not be apparent for many years, ‘long Covid’, for example, has recently particularly in lower income countries been highlighted, but the true burden of where factors such as poverty, lack of this condition has yet to be quantified, vaccines, weak health systems, and high and policies are urgently needed to population density place people at overcome its long-term challenges. increased risk from covid-19 and related harm. In the UK, life expectancy in lower The covid-19 pandemic has resulted in socioeconomic groups has fallen in recent widespread disruption to health systems years, an inequality likely to be across the world. Diagnostic and exacerbated by the covid-19 pandemic, treatment pathways for cancer and other without concerted action. time sensitive conditions have been disrupted, and the monitoring of long- Finally, although mortality is a useful term conditions has often taken place metric, policy informed by deaths alone through novel telemedicine platforms, if overlooks what may become a huge at all. By April 2021 more than 4.7 million burden of long-term morbidity resulting people in England were waiting for from covid-19. An urgent need exists to hospital treatment, the highest number measure this excess morbidity, support since records began. Such disruption is people with long term complications of likely to lead to poorer health and earlier covid-19, and fund health systems globally deaths in countries across the world for to tackle the backlog of work resulting many years to come, particularly where from the pandemic.
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Five minutes with… Hilary Watt Teaching Fellow
Describe your role here at PCPH? My role has evolved over 8 years to include teaching Statistics, where I have a passion for making Statistics easier to understand. I have developed novel transparent explanatory interpretations of p-values and confidence intervals (with relevant graphs), designed to reinforce the core concepts underlying Statistical inference. These are designed to make Statistics easier to understand. I have been lucky enough to work alongside other people who also care deeply about teaching Statistics, including Victoria Cornelius amongst many others. Together, we have developed the Statistics module on the MPH. Year on year, staff reported increasing levels of student understanding of statistics. The external examiner was very impressed at Statistical ability demonstrated in dissertations. I was Statistician co-applicant on an NIHR HTA-funded randomised controlled trial of a brief video intervention to support parents of very young children with behavioural issues (‘Happy Start, Healthy Start’ with chief investigator Paul Ramchandani). We are in the process of writing a series of publications on this trial. I am statistician co- applicant on an NIHR RfPB-funded trial of a drug treatment for patients with Alzheimer’s disease (with chief investigator Paresh Malhotra). This trial is currently recruiting patients. It aims to test whether a drug that aims to improve patient’s attention is a helpful addition to commonly prescribed drugs that are aimed to improve patients’ memory. I am currently teaching on the inhouse MPH Introduction to Statistical thinking and analysis module. Along with a team of tutors, we teach R statistical software via Zoom. This includes teaching statistical interpretation of output from this software package. I also continue my role as NIHR Research Design Service adviser, where I offer advice on grant applications. I continue working towards publications resulting from the “Happy Start, Healthy Start” trial. I have inputting into database and study design, I have undertaken statistical analysis of the Alzheimer’s trial to check for safety, to present to the data monitoring committee and have inputted into related studies. I have written a detailed Statistical analysis plan. Why PCPH? Within the department, I have been encouraged to develop my own interests and research, and for this I am very grateful. The atmosphere of the department allows creativity to flourish, including development of fresh research ideas. It is a very inclusive department, in allowing different people to undertake research and to put their opinions across. I’ve been allowed to develop my own passion for teaching
Statistics. The department is empowering to people, for instance I am being supported now in teaching publications, with expertise now available to me. What do you enjoy most about your job? I have a passion for making Statistics easier to understand and enjoy imparting this knowledge. This has evolved also into linking with potential Statistical misinterpretations that are common within applied research. I then realised that I could tie my ideas into issues around common misinterpretations of Statistical data. I modified my interpretations further to more fully take on board good practice, as defined by the American Statistical Association statement on p-values. This resulted in a teaching publication in the International Journal of Epidemiology. I also have a publication (in progress) with Statistics Teaching journal, which explains the rationale for the explanations more fully, and gives some evidence for their effectiveness. I am excited to share these ideas, and to work towards further teaching publications. I do not have children of my own, so I am happy to support and encourage young adults towards interesting and valuable careers. What are your outside interests? Who are you outside of work? I love hiking in the countryside and enjoy nature. I also like singing Indian raga music, which is meditative and expressive. I took part of Imperial Lol lab in 2018, and performed a short stand-up comedy act in a local pub. The course had a fantastic atmosphere, with most of us never having performed stand-up before. My act was about Florence Nightingale, and the related story of bacteria and incorporating genes too. I chose Science that fascinated me for the act. I took this and related acts into some comedy clubs, where I had some good feedback. I would like to explore comedy further as a medium for communicating Science. I feel that as a society we are becoming very polarised in our opinions. I would like to use small amounts of Science to open people up to the possibilities of perspectives different to their own. What 3 tunes and luxury item would you choose to be marooned on a desert island with? My luxury item would be a joke writing book, to encourage me to make light of the situation and to laugh. ‘Girls just want to have fun’ by Cyndi Lauper. ‘Dona novis pachem’ - musical chant. ‘What a wonderful world’ by Louis Armstrong.
“I would like to explore comedy further as a medium for communicating Science. I feel that as a society we are becoming very polarised in our opinions. I would like to use small amounts of Science to open people up to the possibilities of perspectives different to their own” Photo by Jon Tyson on Unsplash
Photo by Artem Maltsev on Unsplash Medical Education Masterclasses for UK Medical Students The Medical Education Innovation and Research Centre (MEdIC) will be running a series of free virtual Masterclasses in Medical Education between 26th July – 5th August. UK medical students can apply to attend the Masterclasses, and we will be encouraging students from diverse and under-represented backgrounds to apply. Students will have an opportunity to learn, discuss and explore topical areas in medical education, and be empowered to apply their knowledge and understanding in their own medical schools and consider a possible future career in the field of medical education. For further info: MEdIC Medical Education Masterclasses | Faculty of Medicine | Imperial College London
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