Spring 2020 NHS must fix its poor record on staff health, for the sake of patients as well as workers Vector By Macrovector Official @ FreePik
Spring 2020 In recent weeks, our personal and professional lives have been dominated by the global Covid-19 pandemic. This has led to radical changes in our working practices; with a very rapid shift to online learning and student supervision. Many members of the department, including myself, are supporting the NHS through our clinical and public health work. The pandemic has also resulted in our medical students graduating early so that they can support the NHS response to Covid-19. We are also rapidly developing a programme of research on Covid 19. We are investigating areas such as the impact of Covid-19 on health outcomes in NW London; how we maintain the health of older people who are now self-isolating; and the wider impact of Covid-19 on areas such as child health and cancer care. I appreciate this is a worrying time for our team because of the personal Professor Azeem Majeed risks that they and their family Head of Department of Primary Care and Public Health members face. Thank you for your hard work during this difficult period. 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
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Dr Thomas Woodcock - Improvement Science Fellow As the COVID-19 pandemic sweeps across the globe, PCPH staff are contributing to the response – whether providing expert advice and guidance, working clinically in the NHS, ensuring teaching can continue remotely, rapidly mobilising new research projects, or supporting and enabling others to work effectively whilst adapting to social distancing and self-isolation measures. The department’s research running for all of us, projects contribution focusses on are underway to support the understanding and mitigating health and care system through the impact of the pandemic on rapid and robust data analysis communities, public health and and research to help the health and care system. As organisations, teams and well as the huge effort of communities cope with the clinical colleagues going above pandemic. and beyond in keeping the NHS
To give just some examples of the work that is going on in the department: The Global Digital Health Unit, led by Dr. Céire Costelloe, is working on predicting outcomes associated with deterioration in patients with COVID-19, screening for COVID-19-negative patients on admission to hospital, and modelling to inform hospital management strategies. The Applied Research Collaboration (ARC) Northwest London has several COVID-19 workstreams. Professor Helen Ward and Meerat Kaur lead on mapping the community response (see next story), and on studying the impact of the pandemic on inequalities. Professor Paul Aylin and Dr. Tom Woodcock are leading on an analysis of the Whole Systems Integrated Care (WSIC) dataset to understand changes in patterns of service use, patient pathways, and outcomes for patients as a result of the pandemic. Prof Paul Aylin, Dr Violeta Balinskaite and Prof Alex Bottle at the Dr Foster Unit are harnessing their access to national hospital administrative data (HES) to provide input into scenario modelling for hospital capacity to understand how much space could be freed up in inpatient and critical care wards by stricter admission thresholds. They are also supporting the Royal Marsden and their partner hospitals in planning their post-outbreak activity when they tackle the backlog of cases and in assessing the impact that this backlog has on patient outcomes. Other work focusses on supporting the public and NHS staff through guidance during the pandemic, with Dr. Felix Greaves leading on public guidance with Public Health England, and Professor Azeem Majeed, Dr. Eszter Vamos and Dr. Austen El-Osta designing a tool to support staff with queries or concerns. Dr David Salman and Dr Thomas Beaney are developing a resource on physical activity for older adults in isolation. All of this is part of a wider effort at School, Faculty and College level, each group, team and individual contributing in their respective areas of expertise. Colleagues in other departments are working on modelling the progression of the pandemic, understanding how the virus spreads and how the body and immune system react, and developing a vaccine. Despite the challenges we face over the coming weeks, this collective endeavour of science, technology, medicine and community offers hope for the global fight to reduce the terrible human cost of this virus.
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How do we harness the potential of communities during a pandemic? Meerat Kaur, Deputy Theme Lead (interim), Engagement and Involvement theme, NIHR ARC NWL As you may have observed and experienced, individuals and community groups have responded to meet the needs of people in the current COVID-19 situation across the country. Local authorities have been tasked by the government to create hubs where people can sign up as volunteers or state what help they need. But our colleagues in the Clinical Commissioning Groups predict there are informal initiatives being set up by community organisations, of which we are not fully aware. The NIHR ARC Northwest London And crucially, we will feed data back to Engagement and Involvement theme, led the community organisations to help by Professor Helen Ward, aims to further them shift mobilisation to address areas understand how we meaningfully work of need. Our longer-term aim is to capture with patients, the public and learning from such initiatives, and assess communities. The current activities by the value of such ways of working for these groups in response to COVID-19 healthcare systems and statutory provides us with an opportune case study organisations. to help realise our aim. This work complements COVID-19 We are therefore mapping responses to research being carried out by Prof. Ward’s COVID-19 by community organisations in wider team. This includes the newly our patch to better understand where published report by Imperial PERC: ‘Rapid there may be significant activity, and Community Engagement and Involvement where there may be gaps that are not in COVID-19 Research & Outbreak being addressed. We have sent out a Response: Early Insights from a UK survey to key people and community Perspective’, which explores people’s organisations across North West London experiences of the outbreak and their to capture relevant information, including opinions on related research. This rapid, what organisations are doing, and who early insight from 420 respondents they are serving. described priority areas for research, unmet needs of communities, and We aim to use this data to provide a visual recommendations for involving a diverse map of newly created community-level range of communities in an outbreak. infrastructure or responsive mechanisms that have been set up. We hope to assess When describing participatory the equality of access for people to such development initiatives between farmers help, whatever their age, race, gender etc. and scientists in India, Mosse (2016)
stated farmers needed to be involved “not Photo: COVID19 © Silvision Creative Commons just to be democratic, but because this would be better science”(1). My own learning from my humanitarian relief and international human rights experience in America, India and sub-Saharan Africa echoes this. An initiative I helped set up to understand the scale of farmer suicides, and support those left behind when these breadwinners die, is continuing some 15 years later. Working with community researchers provided a crucial census for this work. And families of people who have been disappeared extrajudicially across the world, including those I worked with in Punjab, have been instrumental in building momentum and applying the pressure needed to win legal cases. Communities provide not only much needed insight for our public health research, but also have the potential of being part of our ‘workforce’. They can, and do, help us tackle health inequalities through existing infrastructure that is responsive to people’s needs. The question for our theme in ARC NWL is how we harness and optimise that potential in partnership with communities. References 1. Mosse D. Citizen participation: knowledge production & policy in development aid. In: Citizen Participation in Health: Critical Perspectives. London, UK; 2016.
DEPARTMENT NEWS DEVELOPING EXCELLENCE IN STOPPING SMOKING IS UNLIKELY MEDICAL EDUCATION CONFERENCE TO WORSEN SYMPTOMS OF ULCERATIVE COLITIS In December four members of the undergraduate Primary Care Education Non-smokers and people who stop Team attended the Developing smoking after being diagnosed with Excellence in Medial Education ulcerative colitis are unlikely to have Conference (DEMEC) in Manchester. more flare-ups or other signs of They presented their work on four worsening disease, compared with separate topics which included: those who continue to smoke. • Students’ Perceptions of Smoking is linked to reduced rates of Social Accountability (Jenna developing ulcerative colitis in some Mollaney) studies. Some patients also believe that smoking can also lessen the • A guide to quality assuring symptoms of the disease, although GP Practices for Education previous research about this has had (Nadine Engineer) conflicting results. This study indicates that smoking does not have a • Educational Communities of significant effect on the illness after Practice (Sonia Kumar) and diagnosis. Designing F-Zero Researchers followed 6,754 UK adults • A new Longitudinal diagnosed with ulcerative colitis for 12 Integrated Clerkship Course years. They compared outcomes for (Ravi Parekh) former smokers, non-smokers and smokers, and for people who stopped This was a great opportunity to share smoking after diagnosis. After the Department’s work and to network adjusting for other factors, they found with the undergraduate and similar rates of corticosteroid use, postgraduate teams from across the flare-ups, hospital admissions and UK. colectomy (surgical removal of all or part of the large bowel), regardless of SHAME BLUFFS AND DRUG MULES smoking status. Dr Richard Ma spent £20 of his NIHR People with ulcerative colitis can be fellowship budget to promote his encouraged to stop smoking, for the poster on social media and met his usual health-related reasons. recruitment target and demographic needed focus groups discussing Further Reading contraception strategies. We heard about his results in his talk ‘Shame Bluffs and Drug Mules’.
CHILD HEALTH UNIT WHO CC FOR PUBLIC HEALTH TRAINING & EDUCATION CHU kicked off the first meeting of the decade in January by going right In the current fight with the pandemic, back to the birth. Professor Salman Rawaf, Director of the WHO Collaborating Centre has Dr Sunita Sharma flagged that been invited to become member of the postnatal care is the Cinderella Regional Technical Advisory specialty of women’s care which is Committee (TAC) for the WHO. TAC neglected and underfunded. will serve as a think-tank for our However, she and other local actions during this emergency. The providers in the North West London Committee will hold virtual meetings ARC are trying to co-produce periodically to discuss the situation information and materials that will and seek members’ expert opinion, help women who have just given guidance, and support. birth through their first weeks as new mothers, with her ‘living STATISTICIAN FOR SOCIETY library’ project. As a fellow at Royal Statistical Society, NEW ROLE AS EDITOR Violeta Balinskaite took part in the project ‘Statistician for Society’ and Congratulations to Matthew Harris helped the Sydenham Gardens charity (Clinical Senior Lecturer in Public in London to evaluate the impact of Health) who has been appointed as their projects. The charity helps people an Editor of the Pan-American rehabilitate and recover with a primary Journal of Public Health Special focus on those experiencing mental ill- Issue on Human Resources for health problems. It aims at using Universal Health. various sessions like cooking, making handmade candles or cards etc. to Additionally, Matt has also been improve mental wellbeing, ability to appointed as an Editor of the series undergo physical activity, social ‘Reverse Innovation in global health inclusion and interaction, systems: learning from low-income developments in life outside project, countries’ in the BioMed Central quality of life and confidence. journal Globalization and Health. Results showed a statistically COVID – 19 GROUP significant improvement in wellbeing observed, though it wasn’t considered PCPH has formed a Covid-19 group meaningful. to rapidly respond to questions. Where possible, it aims to publish responses either as journal articles or as blogs. We have had one article published from this work and one accepted, with others in preparation. Contact Prof Majeed to join
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NEW HEART DISEASE DRUG TO BE MADE AVAILABLE FOR NHS PATIENTS THROUGH GROUND-BREAKING COLLABORATION Up to 30,000 lives could be saved over the next decade thanks to a proposed pioneering government collaboration with pharmaceutical company Novartis to tackle heart disease – a leading cause of death in the UK. The yet to be approved drug inclisiran, a annually, it could help prevent 55,000 heart treatment to lower cholesterol, will be attacks and strokes, and has the potential of studied in UK patients as part of a large-scale saving 30,000 lives in the next 10 years. NHS clinical trial expected to start later this year. Additionally, in a world-first, the drug is Heart disease is the world’s biggest killer and expected to be available through a the second biggest cause of death in the UK, population-level agreement – pioneering a with over three million people suffering from game-changing approach to reducing the risk atherosclerotic cardiovascular disease and of heart disease. two and a half million currently relying on statins to lower their cholesterol. Recent trials Early results from clinical trials suggest that if have shown inclisiran can halve bad inclisiran is given to 300,000 patients cholesterol in just two weeks.
Health Secretary Matt Hancock said: “As Health Secretary, I'm determined find ways to save as many lives as possible, and to do my best to stop terrible conditions like heart disease from taking people from their family and friends far too soon…This partnership is fantastic news and is a huge stride forwards in helping to achieve this. This collaboration has the potential to save 30,000 lives over the next ten years and is proof that the UK continues to be the world-leading destination for revolutionary healthcare…I will always help the NHS reach its full potential, and novel and innovative collaborations such as this put patients at the forefront of the most promising medical breakthroughs” Inclisiran, a bi-annual injection, is expected to term plan commitment to preventing 150,000 be filed for approval as a preventative add-on cardiovascular deaths over 10 years. The treatment to statins for patients who have collaboration between Novartis, NHS England, already been diagnosed with cardiovascular the National Institute for Health Research disease later this year. (NIHR), and Oxford University represents an innovative approach to tackling major public It will also be put through the National health issues and positions the UK as a world- Institute for Health and Care Excellence’s leading destination to develop revolutionary (NICE) approval programme at the earliest medicines. opportunity possible and NHS England will agree a population-level commercial The UK plans to remain at the forefront of the arrangement with the company to make it global life sciences industry, giving our NHS widely available to patients as soon as 2021. and patients faster access to innovative medicines while supporting the growth of the The agreement will make a significant sector. contribution towards meeting the NHS long Professor Sir John Bell said: “The discovery and development of Inclisiran marks an important change in the approach to pharmaceutical interventions for public health. This program has introduced the use of health care system data from the NHS to dramatically reduce costs by rapidly identifying patient populations through health records…I am excited by this collaboration which is likely to have far- reaching impact on the way population level disease therapies are developed in the life sciences sector” About ASCVD Atherosclerotic cardiovascular disease cholesterol build up on the walls of blood (ASCVD) is a leading cause of death vessels. This build-up is called ‘plaque’. As worldwide. ASCVD results from a thickening blood vessels build up plaque over time, the and loss of elasticity in the arterial wall. It is a insides of the vessels narrow. This narrowing severe disorder and the leading cause of blocks blood flow to and from the heart and morbidity (sickness) and mortality (death) in other organs and eventually causes heart most developed countries. High levels of LDL disease or stroke.
About inclisiran interference to specifically prevent production of the PCSK9 protein in the liver, which Inclisiran, potentially the first and only enhances the liver’s ability to remove LDL-C cholesterol-lowering therapy in the siRNA from the bloodstream, thereby lowering LDL- (small-interfering RNA) class, is an C levels. Inclisiran is not yet approved by the investigational twice-yearly therapy in Phase FDA or any other regulatory authority. III clinical development. As a siRNA, inclisiran harnesses the body’s natural process of RNA “The press release by the NHS and Lord Pryor and Sir John Bell about making the first gene silencing drug for cholesterol available to UK NHS patients after The National Institute for Health and Care Excellence (NICE) approval is a culmination of 5 years of work we have led. In 2017 our New England Journal Medicine (NEJM) publication and in 2019 our Journal of the American Medical Association (JAMA) Cardiology publication identified the potential for inclisiran a drug which through Ribonucleic acid (RNA) silencing technology can be injected once or twice a year. These publications from the phase 2 ORION 1 trial identified a dose of 300mg as the dose to take to phase 3 for registration with NICE, EMA and FDA. In August 2019 we presented the first phase 3 trial ORION 11 and then in November the ORION 9 and 10 trials providing safety and efficacy data in over 3400 patients. The potential of this approach led to Novartis buying the Medicines Company for $9.7 billion in 2019. Our work on burden of CVD in the UK due to non-adherence to statins published in JAMA Network Open in 2019 developed the concept of population exposure to elevated cholesterol and the potential for gene silencing approaches to provide population health improvements. These are summarised in our 2020 Circulation publication (see figure Brandts J, Ray KK). Currently we are in discussions to use the unique opportunities offered by the DISCOVER NOW HDR Hub through a programme of implementation research i.e. if inclisiran is available how does primary care find and treat these patients, and does it make a difference? The next 2-3 years will give us those answers” Professor Kausik Ray, from Imperial’s School of Public Health and principle investigator of the Orion- 11 trial
SUPPORTING THE COVID-19 RESPONSE By Richard Pinder | Director of Undergraduate Public Health Education This month – March 2020 - the world changed. In mid-January 2020, we began hearing about a new infectious disease originating in Wuhan City, China – an atypical pneumonia. Reports were sketchy. Comparisons were immediately drawn with SARS: a disease which emerged while I was at medical school and which is etched clearly onto the minds of people in East Asia. Yet for those of us in the West, it was a transient news item: not much more. Travelling in East Asia today, one still notices the legacy of SARS - infrared cameras and health checks with masked immigration officers. In public health, we’ve always known that We start every morning with a handover. a global pandemic was coming. But over Colleagues report what has happened recent weeks we’ve scarcely wanted to over night and we hear back from local believe our own science, hoping beyond Gold and Silver command meetings – all hope that the pandemic would melt away of these are being held through ‘Microsoft or remain sufficiently alien – like SARS, Teams’ which seems to be coping very MERS, Zika and Ebola. Instead, this well. While much of the public health morning I filled in a questionnaire about team’s work is in providing specialist my airway skills and my last experience of health protection advice and liaison working in intensive care. As a public between council and NHS partners, the health doctor, I’ve not seen a patient core work of the council goes on. Whether since 2011. Coronavirus is real and it’s it’s safeguarding, schools, bin collections here. or social housing: amid the chaos children still need to be protected from Normally I spend Thursdays working in a exploitation and faulty gas boilers still local government public health need to be fixed. In fact, amid COVID-19, department in south London. Since the all the things that you don’t necessarily pandemic began, I’ve been spending a lot think of are potentially the things that will more time supporting the COVID-19 go wrong. And each of these groups has response. We have over 300,000 residents workers who are anxious or querying their living in our borough. And we’ve a exposure to COVID-19 infected persons. comparatively well-resourced public health team despite on-going central We’re expecting the epidemic to peak government cuts made to local public around Easter in London – but until we health capacity. We’ve four Imperial MPH have widespread antigen and antibody graduates working there at the moment – testing there remains huge uncertainty three of whom are seconded into the about the data. We have numerous COVID-19 Hub that comprises about six discussions about statistical modelling. Yet specialist staff. we hardly comment on the daily release of infection and mortality statistics. Our area has been reporting some of the
highest infection counts since this all “…only thing began, and the only thing we’re sure we’re sure about about is that all these statistics massively is that all these under-estimate the scale of the epidemic. statistics But there are reasons to feel proud right massively under- now. We have a thriving voluntary sector, estimate the scale and our investment in enabling of the epidemic” communities to thrive in the good years returns its dividend in times like these. We have incredibly committed staff across the public and private sectors. Our hospitals are receiving donations of hot food like there’s no tomorrow. The idea that the NHS could switch almost all our outpatient appointments to remote consultations just four months ago was risible – and yet we have. And in the most obvious demonstration of national intent, a 4000-bed hospital has been inaugurated nearby. Talking to a variety of interested parties over these last several weeks, it’s too easy to dichotomise failure from success. Our politicians and scientific experts are having to take the ‘least-bad option’ balancing unknowable risks. There is no rulebook and no simple solution to any of the challenges we face. While we must ramp up testing capacity and sort out our PPE supply chain, the nation is torn between scrutiny and support. These are not mutually exclusive positions. I’m moving back on to the public health on-call rota later this week, and I’m open to being redeployed into the NHS if the situation becomes so severe that my almost non-existent clinical skills can still be of some use. No one knows when this will end, but it will. We will be facing a world that has changed beyond all recognition. I bought a new barbecue last week. And I’m determined to use it this summer.
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By Beth Golding During these challenging times, I’ve joined a virtual mindfulness class with my dad. He has bipolar disorder and requires a careful programme to manage his stress levels. At the time of the first class, I remember thinking: “This is going on for way too long” (as well as “…has dad actually fallen asleep and started snoring?” – and yes, indeed he had). But the following week, working with colleagues to redesign a course module around COVID-19, I realised that the techniques the mindfulness instructor had used to break us up into groups were going to be perfect for bringing a digitally interactive, flipped classroom approach to the course design.
Many of my friends report finding the their projects and meet with community blurring of boundaries between home and leaders. This is enabling them to ensure work life challenging since most of us that their voluntary COVID-19 community moved to remote working. Someone said action projects are truly responding to to me yesterday: \"It's like suddenly we are and meeting the needs that really matter all living in your world\". My to local people – particularly those who permeable/barely existent work-life are most vulnerable or isolated. Whilst it boundaries are a running joke amongst is the power of digital that has allowed us my friends, but it's partly the nature of my to achieve this within current guidelines, job. When you're working so closely with it’s important that we don’t forget the communities, there's a degree to which risks associated with digital exclusion. Like the boundaries between friendships and many others, my colleagues and my dad working relationships blur, and it's almost are fortunate in having people who can impossible to keep to the standard 9-5 help them to navigate the digital world schedule. where needed – but not everyone has this privilege, and some of our students’ Self-care is absolutely vital, particularly at projects are examining the implications of a time like this, and it will look different exactly this. for different people. I have long argued, though, that there is a subtle but The voluntary project work provides a important difference between a healthy space for those of our medical students work-life balance and putting ‘work’ and who want to help support efforts around ‘life’ into completely separate silos. We COVID-19 but cannot volunteer in person talk a lot about ‘cross-fertilisation’ of to make a valuable contribution. research and knowledge transfer, but what about the benefits which can spring up from natural synergies between our work and personal lives? In her seminal text on coaching skills, Jenny Rogers points out the dangers of focusing solely on work-related issues – even in executive coaching – as ‘banning the discussion of personal issues results in thin, lopsided coaching, and no problem worth looking at in coaching is without an emotional dimension’. Without that mindfulness session with my dad, it would never have occurred to me that there was this digital method for empowering our students to work together in varied ways whilst apart, all hearing from inspirational speakers then dispersing into virtual groups to work on
Drawing on needs analyses around health inequalities and experiences of different marginalised groups (which, in turn, a former cohort of medical students helped to research and shape), our students are working on a wide range of projects spanning from: - - a joint effort with Queens Park Rangers in the Community Trust and Community Champions around creating well-being packs and digital exercise and cookery classes for local families and older people - to researching international community responses to COVID and their transferability to North West London - and forming strategies around volunteer mobilisation and recruitment for medicine and grocery delivery at a hyper-local level. Due to the partnership we have formed often largely be determined by whether with North West London Clinical we choose to focus on the good or the Commissioning Groups, the outputs from bad. I am grateful for the fact that when I students’ projects will have an added look at the wonderful people I work with layer of quality assurance – and with this in the Undergraduate Primary Care comes the opportunity for wider Education team (and more widely across dissemination and impact. Imperial College), the incredible attitudes and efforts of our medical students and At times like this, we see daily examples of statutory and voluntary sector colleagues both the best and the worst in human at this difficult time, and my friends and nature; in the words of Hamlet ‘there is family, I see good people trying to change nothing either good or bad, but thinking the world through great acts; that is how I makes it so’, and our state of mind will am coping with COVID. Follow Beth on Twitter: @BethanyrGolding
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By Professor Azeem Majeed NHS must fix its poor record on staff health, for the sake of patients as well as workers As one of the largest organisations in the world, employing around 1.5 million people, and the provider of publicly funded healthcare in the UK, the National Health Service should be a role model in workplace health. It should be providing employers with guidance and good practice that can be replicated elsewhere. However, currently the NHS performs poorly on many measures of staff health. For example, sickness absence rates among NHS staff are higher than the average for both the UK public sector and private sector. The health of NHS staff is a key factor Council report. The report noted that in determining how well the NHS workplace pressures are associated provides healthcare to patients. with risks to patient care and the Improving workplace health and the wellbeing of doctors, leading to support available to staff with health ‘burnout’ and poor staff retention and problems—such as enabling them to exacerbating shortages of medical return to work after absence due to professionals in the NHS. sickness—should be priorities for the NHS. A key message from the report was that the support that doctors received The importance of good working in the workplace from other clinical environments in the NHS was colleagues and managers was an emphasised in a 2019 General Medical important factor in determining how
well they coped with the pressures of people return to work after long term working in the NHS. Doctors at low risk sickness absence, reduce the risk of of burnout were more likely to report recurring sickness absence, and help that they were well supported by their stop people moving from short term to colleagues and were also less likely to long term sickness absence. be absent because of work related stress. Key recommendations include making health and wellbeing a core priority for Sickness absence senior managers so that organisations foster a caring and supportive culture Common causes of staff absenteeism and a proactive approach to in the NHS include musculoskeletal employees’ health and wellbeing; problems such as back pain and mental adapting the workplace to allow staff health disorders such as anxiety, with health problems to continue stress, and depression. Additional working; and offering people on health problems arise from potentially sickness absence early intervention modifiable causes such as smoking, and referral to an occupational health excessive alcohol intake, poor diets, or other health service for support. and lack of exercise. Health promotion programmes to reduce these problems Employers are advised to monitor include simple one-off interventions rates of sickness absence to identify (influenza vaccination for example), vulnerable groups, explore the factors signposting and referrals to other leading to ill health, and implement services (smoking cessation targeted prevention strategies. The programmes), and more complex guidance also highlights areas of health interventions such as cognitive uncertainty about best practice, behavioural therapy for anxiety and where further research is exercise programmes to encourage needed—for example, research weight loss. to identify the best way to promote an early return to A healthy working environment can be work for staff on sick leave. achieved only by integrating workplace health promotion into an NHS Trusts are large organisation’s management culture employers and should have and by taking every opportunity to the capacity to implement improve staff health and wellbeing, to evidence-based guidance on help minimise both short term and good practice published by long-term sickness absence. the GMC, NICE, and others. Smaller NHS employers Guidance published in November 2019 such as general practices by the National Institute for Health and may struggle, however, as they Care Excellence (NICE) provides advice generally have more limited to employers on how they can help management resources and
poorer access to occupational health and providing case studies, guidance, services. General practices would and support to other public sector and benefit from additional support, and private sector organisations. clinical commissioning groups and primary care networks could provide The Covid-19 pandemic that the world this for practices in England. Equivalent is currently facing makes good organisations could be a source of workplace health even more support for practices in the devolved important. The pandemic has created health systems of Wales, Scotland, and enormous stress and anxiety amongst Northern Ireland. health professionals and support staff. This is in addition to the risks posed A healthier NHS workforce would bring from infection. We should therefore substantial benefits for NHS patients work urgently to improve the health and better patient outcomes. NHS and well-being of our NHS staff. We workplaces should aim to be centres of will need them now and we will need excellence for workplace health them in the future. They are a resource promotion, setting a positive example we should treasure. Read full BMJ editorial Vector by Rawpixel Ltd Vecteezy.com
SPOTLIGHT ON UG PRIMARY CARE UNIT A few weeks ago the Medical School took the difficult decision along with the rest of the country, to suspend all clinical placements and on campus teaching for the rest of this academic year. Over the past few weeks the UG Primary Care team have worked at pace to convert all primary care tutorial teaching and clinical experience in local practices to a digital online format. Dr Nina Dutta and Dr Neepa Thacker have the impact on the students, patients tirelessly worked on this mammoth task and and GP practices. led two teams to create literally in days, full timetables of online learning for the students This is an uncertain and to work from. The teams have held student stressful time for us all, and webinars from their living rooms and even as a department we have managed to hold small group Zoom tutorials, been keen that we try to checking in with the students and their on- continue to maintain going learning, and also, importantly, to check some normality with how the students are doing themselves. working from home, holding The Medical School has also had to suspend meetings remotely all clinical examinations. Of note, they held and team wellbeing the first of its kind remote open book exit sessions where exam for the final year students. This similar possible. The UG format will be rolled out in the next few Primary care team months for the year 3 and 5 clinical exams. As have been a many of you may have also read, many of our great final year students have taken up the source of opportunity to graduate early, to help serve support on the NHS frontline in the next few weeks. to each other and The Undergraduate Primary Care team has also to been working hard to also set up ICSM-C led myself, as by Dr Ravi Parek and Ms Nadine Engineer, the we have community arm of the medical school- very volunteering programme. We plan to induct abruptly and link together a small army of medical moved to a students with local GP practices, where the very new way students will be able to support vulnerable of working and patients at home by remotely calling them, teaching our delivering medications and following up on students in the their chronic disease management as many of midst of a the primary care staff are being diverted to national crisis. COVID-19 duties. We plan to evaluate the impact of this unique scheme, by looking at Thank you to everyone in Undergraduate Primary Care, we are lucky to have each and every one of you.
By Dr Sonia Kumar
Transforming the health system for the UK’s multiethnic population Cultural Diversity by pikisuperstar – freepik.com
The UK health system must take urgent action to better understand and meet the health needs of migrants and ethnic minority people, say Sarah Salway and colleagues, Daniel Holman (Research Fellow), Caroline Lee (Research Associate), Victoria McGowan (Research Associate), Yoav Ben-Shlomo (Professor of Clinical Epidemiology), Sonia Saxena (Professor of Primary Care), James Nazroo (Professor of sociology). Ethnic diversity is a global phenomenon resulting from historical and contemporary movements of people. However, healthcare policy makers, practitioners, and researchers have been slow to wake up to this reality. We urgently need to improve our understanding of, and responses to, the health needs of mobile and ethnically diverse populations.
As a country with a colonial past, a long history of migration, well established minority ethnic groups, and high investment in health- related research, the UK should be leading the way in evidence informed, equitable healthcare. However, the UK has significant shortcomings. We believe the health system’s failure to respond to ethnic diversification reflects a deeper, politically led, ambivalence towards the notion of multiethnic UK. Policy makers, practitioners, and researchers can and should challenge the persistent marginalisation of this agenda. Failure of policy and practice genital mutilation, which has led to negative stereotyping of the Somali There is widespread evidence that UK community in Bristol. policy responses to ethnic diversity are ambivalent, fragmented, confused, and Research reveals large ethnic inequalities often harmful. This is despite the in healthcare. Lower uptake and poorer apparently strong legal framework of the satisfaction with care have been 2010 Equalities Act. documented among ethnic minority Some important health problems that groups across diverse NHS contexts. disproportionately affect ethnic minority Maternity and mental health services groups are ignored by national policy (for show particularly worrying and persistent example, the higher risk of hepatitis B ethnic inequalities in experiences and among people who have migrated from outcomes. We also know that healthcare east Asia). Other health policies can practitioners often feel ill equipped and stigmatise ethnic minority populations poorly supported to meet the needs of rather than promote culturally competent ethnically diverse patient groups. action on inequity. One example is safeguarding legislation against female enhance equity, routinely identify those who are not receiving services, and hold Stronger national leadership leaders to account. Local innovations are appearing around the country, such as There are signs that some national and drop-in GP clinics for newly arrived local leaders in the health system are migrants, yet more can be done to learn beginning to take ethnic inequality from and scale up such solutions. seriously. This collection of articles in The BMJ (bmj.com/racism-in-medicine) is Audit are welcome signs that the need to clearly one such indicator. Integrated care investigate ethnic inequality is systems present an opportunity to Closing the gaps Recent publication of relevant Public Health England resources and the Race Disparity
increasingly recognised. In addition, Effective channels for routinely applying concerted effort is needed to plug data evidence to policy and practice are also gaps and reinstate routine equity audits in needed. The recently launched NIHR order to identify who is not benefiting applied research collaboration (ARC) for from services. We can learn from local East Midlands identifies “ethnicity and authorities that are undertaking strong health inequalities” as a priority; we hope assessment work to increase this may influence the other 14 regional understanding of local health needs. For ARCs. example, in Nottingham and Leicester there has been good engagement with Rather than countering discriminatory ethnic minority groups to identify health processes of wider society, the UK health concerns. These authorities also system often mirrors the forces that developed clear recommendations to act undermine the health of migrants and on gaps in data and to implement longer ethnic minority people. We overlook, term strategies around quality standards, misconstrue, and respond poorly to the monitoring and evaluation, financial health needs of these groups. An planning, and specific provision and inadequate knowledge base contributes coordination between services. to this unacceptable situation. We need radical action to increase the creation of Improvements to data collection must go high-quality research evidence and data at hand in hand with assurance of data local, regional, and national levels. Such protection. Recent data sharing between knowledge must be routinely expected NHS Digital, the Department of Health and and used to inform action. Stronger Social Care, and the Home Office for national leadership is required. This must immigration enforcement presented be coupled with greater involvement of substantial risks to the health and ethnic minority people and sustained wellbeing of migrant and settled ethnic support for local innovators who can lead minority communities and must not the way. resume. FULL ARTICLE IN BMJ Diversity by freepik.com
By Camille Gajria, Clinical Teaching Fellow in Primary Care
I often ran the leadership session for our year 5 students on GP placement; it includes a simulation on managing a national emergency. Since the COVD19 outbreak hit our shores, my words to the students echo, that they could one day be in this situation. I just didn’t expect it so soon. We’re two months on since the first UK managing more complex issues in GP. No case, and the infection rates rise part of the health system has adequate exponentially following the trajectory of personal protective equipment which is the worst-hit countries. By the time you putting staff at risk. Meanwhile we read this, everything would’ve changed. continue to lose staff to illness and In UK general practice, the rate of change isolation, as testing is still not available. It similarly been phenomenal. Ways of reminds me of approaches taken in working that normally take months if not disaster medicine and I have asked my GP years to implement, have been developed colleagues who normally work in within the last week. GPs are working humanitarian relief to provide their across boundaries and organisations, insights in this respect. cutting red tape and find solutions. I have also been co-ordinating and General practice is on the frontline of this delivering peer support in my patch. The crisis. We are dealing with the usual range deluge of information can be of general practice plus public’s disconcerting, and we quickly need to immediate concerns, interpreting the upskill on both clinical and non-clinical public health advice for their situations, aspects while managing our personal / and helping them make plans for the family issues just as everyone else does. untoward. It is very typical general There is variation in how national practice in some ways, one minute I am initiatives are adopted, and how flexible discussing end-of-life plans (without local organisations have been in relaxing knowing if palliative medicines will be regulations, and this affects various staff available) and the next minute reassuring groups differently. In successful areas I someone about a minor ailment, which is think there has been distributed probably a reflection of general anxiety. leadership centred on trust, collaboration, The main hospital my practice refers to and compassion. has been at the epicentre of the response, so a lot of my consultations have related Hopefully this will continue when we to this. emerge. It is a known phenomenon that disasters drive innovation, I hope the We are managing more uncertainty and digital transformation is matched by a risk in our clinical decisions and personal revolution of compassion within and safety than ever before. Normal routes for towards primary healthcare. This would investigation and escalation are closed as be a wonderful silver lining to share with our hospitals are overwhelmed, so we are future students.
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This year, the advent of the COVID-19 pandemic has placed a singular importance on the value of individual self- reliance, putting self-care centre stage once again. From social distancing to distant socialising, we highlight the importance of self-care as a defining theme of COVID-19 and the new decade.
SELF-CARE PRAXIS FOR COVID-19: AN INTERNATIONAL CASE STUDY From London and Paris to New York, governments worldwide have introduced special measures to tackle the rising challenge of the COVID-19 pandemic. These include social distancing, self-isolation, quarantine and lockdown. Remarkably, all these measures are concerned with promoting an individual’s capability to self-care, positing self-care as the only possible course of action given that no treatment or vaccine currently exists for the novel coronavirus. All these recommendations depend solely on the individual’s capacity to self- care, and mirror exactly the Seven Pillars of Self-Care. # Self-Care Pillar Guideline for COVID-19 1 Good health literacy Coherent health messaging from PHE to raise awareness and health literacy about coronavirus & COVID-19. and awareness Strategies to combat social isolation & loneliness- 2 Mental health & particularly at a time when social distancing and self- isolation are recommended. wellbeing Using self-care for mental health apps, connecting with friends, family & colleagues (telephone or videocall etc.) 3 Healthy eating None of the PHE/PHE official recommendations could be 4 Physical activity mapped against this pillar specifically. Exercise at home regime. 5 Risk avoidance Despite the recommendation to ‘Stay Home, Save Lives’, we are still permitted to leave the house to allow one 6 Good hygiene form of exercise a day such as running, walking or cycling. 7 The rational use of Social distancing, self-isolation & quarantine measures. Use of Personal Protection Equipment (PPE). products and Shielding of vulnerable groups. services Frequent hand washing, not touching face, using alcohol gel/sanitizer. Testing, face masks, correct use of PPE and OTC medicines (including paracetamol when feverish). Calling NHS 111 instead of visiting GP.
The advent of Covid-19 has put self-care and the importance of individual self- reliance centre stage. There was already much evidence for the value of self- care to combat non-communicable diseases (NCDs) and lifestyle diseases, including type 2 diabetes, cardiovascular disease and obesity. The case is now quickly growing for the important role that self-care could play in combating communicable diseases including COVID-19. COVID-19 relevant item Person centred self-care perspective Regular hand washing Self-care (Good hygiene) Social distancing Self-care (Risk avoidance) Shielding of vulnerable groups Assisted self-care (Risk avoidance) Self-isolation Self-care (Risk avoidance Personal protective equipment Self-care (Risk avoidance) (PPE) Monitor COVID-19 symptoms Self-care (Self-awareness) Using paracetamol (OTC) for fever Self-care (rational use of products & services)
Undergraduate Primary Care Education The Undergraduate Primary Care Education team has set up a novel outreach programme for medical students who are engaging with local primary schools, teaching pupils core science in fun and innovative ways. A rigorous academic evaluation of the programme was undertaken which thematically analysed Imperial student written reflections on the programme.
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This showed students increased project on the school community. learning of teaching skills, as well The key themes identified in the as understanding how to analysis of the teacher interviews communicate with children in a were the benefits of having an new setting. The programme was inspirational external figure in also designed as a tool to provide raising aspirations of the school inspirational and relatable role children and the longer-term models for the primary school impact of the university’s pupils, to raise ambitions and connection with the school to breakdown perceived social drive up ambitions for the school barriers to healthcare careers. children. The work was presented at the Regional SE SAPC Members of the school were conference in January 2020 and is interviewed to gather being prepared for submission to information on the impact of the an academic journal.
In the midst of Covid 19 concern, a bit of good news. The parents of babies born preterm will be entitled to extra paid leave of around GBP160 per week for up to 12 weeks while their baby is in a neonatal unit. This is in addition to standard maternity and paternity allowances.
National Neonatal Research Database at Imperial’s Chelsea and Westminster campus supports important policy change to benefit parents of preterm babies The Department for Business, Energy & Industry Strategy (BEIS) was tasked with doing the analysis to determine whether the policy was affordable. The National Neonatal Research Database, which was developed and is maintained and managed by Professor Modi’s team (pictured), was identified as the only source of suitable data. The National Neonatal Research Database contains detailed clinical information on all admissions to NHS neonatal units in England, Wales and Scotland. The team were able to provide the data needed as well as advice on the analysis and are delighted that the policy is to be adopted. It is a wonderful example of how the collaborative effort of neonatal teams across the country in creating the National Neonatal Research Database has supported important policy change that will benefit parents around the country.
By Neepa Thacker The last 3 weeks have been filled with so much uncertainty and have significantly transformed our professional and private lives. On a personal level, as a Portfolio GP, this has impacted both my academic and clinical roles. Following the suspension of all medical school clinical placements and campus- based sessions from Monday 16 March, the Undergraduate Primary Care Education team had to swiftly convert all clinical placements to full online courses. As the Course Lead for Year 5 undergraduate medical students on their GP placement, I have been excellently supported by departmental and senior colleagues, and together we have created a comprehensive remote learning timetable consisting of interactive
e-learning modules, case-based digital seeing patients that either have minor resources and videos, group tutorials and injuries or ailments or those that are webinars. These have been received really unable to get an appointment with their well by our students with positive own GP. In the light of recent events and feedback, particularly for the online small advice for patients to stay home, numbers group tutorials as students valued this attending this service have dramatically opportunity to still interact with peers and reduced which means that people are feel supported and connected. It has been thankfully listening to the Government’s so rewarding to receive appreciative advice and self-managing their symptoms feedback from students as it makes all of as much as possible. The current plan is to the long hours of preparation feel provide clinical cover for ‘hot clinics’ worthwhile. I feel that remote working (seeing patients with definite or possible definitely has its benefits and can be Covid-19 who do not require hospital incredibly productive, but I do miss my admission for face-to-face consultations) brisk walk to work, the daily interaction or to backfill practices who are losing (and banter) with my Imperial work family doctors either through redeployment, and our Friday lunch club! illness or isolation. The situation is changing rapidly, and I do find it One of my specialist interests is unnerving and difficult to keep up at menopause/women’s health, and I work times. The general fear amongst primary as a GP with a special interest in care physicians is the clarity and lack of secondary care within a local specialist adequate personal protective equipment, menopause service. Our outpatient clinic which now includes eye protection/visors, was converted to a telephone clinic a few but I am hoping that this situation will weeks ago and then all appointments improve in the coming days. were completely cancelled last week, with the exception of a handful of urgent What has really struck me is the sense of patients. This was very frustrating as some compassion and gratitude around me. of our patients wait for months for their 8pm on Thursday evenings has brought a follow-up appointments and we do not few tears to my eyes, and seeing the faces even know when we will be able to see of colleagues, friends and family (even them again, but all of our patients have digitally) is extremely heart-warming. been incredibly understanding which has There is a definite feeling of togetherness been quite a relief. Our multidisciplinary despite our shared underlying anxiety. gynaecology team includes nurse Within the Undergraduate Primary Care consultants, gynaecology trainees and Education team, we have been able to nurses, all of whom have undergone move educational mountains in a short additional training and been reallocated space of time. I feel very lucky to work to other roles within the hospital including with such inspiring colleagues and labour ward and intensive care. I have excellent leaders, and also feel privileged been anxious about the clinical risk in that I may be able to make a small their new roles, but we all remain in difference personally during this constant contact providing support and unprecedented challenging time. sending uplifting messages, and everyone seems to be coping well at the moment. Opposite Page: Frederik Meijer Gardens & I also work in a GP Urgent Care Centre Sculpture Park – Photo by H. Michael Miley within a local hospital A&E department © Creative Commons
An exciting new curriculum development for Year 5 Medical students at Imperial Photo copyright Freepik.com
The Longitudinal Community Clerkship (LCC) is a community-based, year-long module. This is an exciting re-design of Year 5 following on from the success of our previous Longitudinal Integrated Clerkships (LICs), including the Integrated Clinical Apprenticeship (ICA). LICs are focussed on the principle of continuity (primarily continuity with patients and supervisors) and an integration of specialties. These modules emphasise the need for authentic clinical practice and learning, with students taking responsibility and being involved in the care of their own cohort of patients. The LCC is due to pilot for 48 students Students will also participate in a commencing in July 2020, with full roll out community collaboration project with to the whole year group of 350 students local schools, in which they will co-design expected by 2023. The model involves and deliver a lesson based around a students spending one day per week national health need. (Thursday) throughout the year at the same GP practice, with the mornings It is envisaged that this module will allow being spent consulting with and following students to explore the complexity of up patients and the afternoons spent in a medicine, prepare for real-world practice variety of different learning environments. and encourage them to become trusted and integral members of the healthcare team. Fig 1 (above): Overview of LCC Fig 2 (right): The structure of Thursday afternoons on the LCC
On collaborative design of the Global Health curriculum: co-creating an authentic assessment on health in the Syrian conflict with a team of partners. This year, the Global Health BSc team introduced a range of authentic assessments on the course. One of these is a data analysis and communication assessment focused on syndromic surveillance data from the Aleppo Governorate in Syria, and military attacks on healthcare in this area. The assessment was designed collaboratively with a range of partners across sectors (e.g. civil society/NGO and academic), expertise (e.g. research methods, international humanitarian policymaking and healthcare and data visualisation) and roles (e.g. student and educator). The project was supported by a StudentShaper award for an alumnus to be fully involved in the educational design process. Our StudentShaper Vicki Pilkington describes her experience below. We will be presenting this project at the forthcoming Transform Med Ed conference so please come and visit our poster! As a StudentShaper, I had the opportunity to From the start of the assessment design be involved in the design of a new assessment process, being on a large, highly qualified for the Global Health BSc. I was part of a team could have been daunting, but I always collaborative education design team and I felt able to comment openly on ideas and was represented the student perspective in a welcomed to give my honest opinions. I group which included epidemiologists, data- genuinely felt that my thoughts were given a analysts, clinical consultants and health-policy lot of weight by senior members of the team. advisors. I was able to influence the design of My student perspective on aspects from the assessment from early stages and logistics of working hours and attendance, to advocate for a project that was interesting, ability levels, assessment content and relevant and reflective of real-world practice. structure seemed genuinely valuable. I applied to be a Student Shaper because I My Student Shaper project helped to steer wanted to stay involved in the Global Health the design of a new assessment towards what teaching team and get experience in medical I would have wanted to have done during my education. I am really enjoying my Global BSc. It also developed my skills in clear Health BSc, and I particularly loved doing my communication, planning and combining project, which was in HIV prevention. In the individual contributions towards a team goal. year after I completed my BSc, I continued The experience has been helpful for job research with my project research group. I ran applications, future clinical practice and in tutorials and sessions to support the new working within research groups. It also gave cohort of BSc students with their assessments me a chance to see the other side of medical as Education Officer for Students for Global education and taught me a lot about the aims, Health Imperial. This meant I’d been able to logistics and specific considerations for keep up to date with a lot of the changes to education design. the curriculum that had already been made.
By Leah Ellis The warm lighting of chandeliers sparkled though the opulent ballroom of the Palais Brongniart as the sounds of Paris traffic hummed from the street below. The room held its breath as teams waited anxiously to hear if they had become a Top 5 finalist at the EIT Innovation Day Winner’s Event. A whisper came from the seat to my left, “No matter what happens, I’m so proud of us!” My colleagues, who had gone from complete strangers to trusted teammates in a matter of hours, all smiled in agreeance. The applause of hundreds of people suddenly broke the silence as the announcer rang out “Rhea, the Detector Pad!”
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