Author: Azeem Majeed

I am Professor of Primary Care and Public Health, and Head of the Department of Primary Care & Public Health at Imperial College London. I am also involved in postgraduate education and training in both general practice and public health, and I am the Course Director of the Imperial College Master of Public Health (MPH) programme.

A carer proposes covertly medicating a patient – what should I do?

You are called by a worker at a care home. She is concerned about a dementia patient who, despite all non-drug measures being tried, is causing distress to other residents. She asks you to prescribe a sedative to ‘slip into her food’. How should you proceed?

Giving medication covertly to sedate an agitated patient raises serious legal and ethical issues. Treatment without consent is only permissible where there is a legal basis for this. In the scenario described here, giving a sedative to the patient without her knowledge and consent would be a breach of her human rights. There is also a risk that the patient could suffer side effects from the medication she was given. For example, administration of a benzodiazepine or an antipsychotic drug could lead to a fall or a fracture that resulted in serious harm to the patient. Covert administration of medication is also a breach of trust on the part of the doctor who prescribed the medication. Hence, it may lead to a formal complaint against the doctor, which would be difficult to defend. Hence, covert administration of sedative medication is a practice that doctors should not collude in, and you should refuse to prescribe. You should also discuss the staff member’s request with the nursing home manager. The care home needs to ensure that it is adequately staffed and that its staff are trained in the appropriate management of people with dementia. If the patient is new to the care home, then her unfamiliar surroundings may be the cause of her agitation. In this case, her behaviour is likely to improve over time as she becomes more familiar with her new home and the staff who care for her. If the increased agitation and confusion are of recent onset, then an organic cause such as an infection or drug side-effect needs to be excluded. If the problem is ongoing and does not settle, advice and support should be obtained from the local nursing home support service and community mental health team; for example, on holding a  ‘best interests meeting’.

A version of this article was published in the medical magazine Pulse.

What makes a good clinical training placement?

Dr Kevin Patel from the Imperial GP Specialist Training Scheme takes a reflective look at the factors that go into making a good clinical attachment for trainees.

As GP trainees we are ‘encouraged’ to reflect; challenging encounters with patients, conversations with colleagues that could have gone better, moments when you felt like you were born to do this job. All of this is good fodder for your ePortfolio.

Not one to miss out on a reflective opportunity, I took a step back from a discussion that was taking place about difficult rotations, a conversation I imagine that is oft-repeated amongst GPs and hospital doctors up and down the country, and thought about how we could use our experience as GP trainees to feed into this.

As trainees we rotate into diverse placements, from paediatrics to public health to care of the elderly. I counted at least 15 distinct departments I have worked in since finishing medical school just over 5 years ago. This is more than any other specialty trainee and if only through sheer volume, it provides us with a unique perspective on what makes a ‘good’ or successful placement and allows us to see how things are managed differently between the numerous specialties both clinically and non-clinically.

Back to the conversation, I heard talk of punishing on-calls, a lack of support; unsympathetic supervisors and acting above one’s role though interestingly not necessarily competence. I then thought about my own experience of certain jobs and what it was that made me love one rotation and what it was about another that filled me with dread going to bed each night.

Below I’ve listed a number of factors that I think are key to influencing one’s experience of a ward or practice. And whilst not exhaustive, I feel they are fundamental determinants of that ‘holy grail’ of rotations which are enjoyable, challenging and ultimately fulfilling.  There are however, some factors that are somewhat beyond our immediate control:

Time – This is something that no matter how hard we try we simply cannot create more of. But all departments have this problem, what is it about those places that don’t seem to be creaking at the seams, and what is it about those places that do?

Patient load – If there are sick patients, we see them. Be that in A&E or in GP where we (wo)man the gateway to the rest of the NHS. Yes, hospitals can be closed to admissions and there might not be enough scheduled GP appointments but those who are in need get seen. How busy you are on a rotation invariably colours your opinion of that time and the upstream consequences of such scenarios is a whole other blog-piece.

Staffing Levels – Feeling like you have sufficient time to give to your patients is essential not only for your peace of mind but also patient safety:

Did I do everything I needed to for that man, or was it the minimum until I see him in 2 weeks?

This child needs a cannula for his antibiotics but I need to review the girl with asthma first.

I don’t want to leave this woman who is having a miscarriage but my registrar needs me in theatre to assist for an emergency caesarean section.

My own experience and that of my peers seems to be that those rotations where we did not routinely come across these dilemmas were better regarded and often because they had that one extra doctor or where the rota was designed with a minimum number of SHO’s per day or, like in one utopian department, where they have a stand-by doctor who can come in when the team are up against it. With the real-life examples above, you are left upset, demoralised and at risk of burn out.

Of course there are funding issues and these are not easy to resolve, but we have seen recommendations for safe nurse: patient ratios since the Francis Report into Mid-Staffordshire Foundation Trust [1]. Does something similar need to happen for the doctor to patient ratio to allow us to provide the level care the public want and deserve thus ensuring we are not forced to give a substandard service?

However, there are many aspects which, for me make for an enjoyable experience and a happy workplace which are less bound by absolutes.

Pace – Some of us thrive off pressure, battling through to the end of the day. Others will be the polar opposite, but most I suspect will want a happy medium; keeping our brains engaged, working together with patients to find solutions to their problems and not faced with scenarios akin to those above. The sense that I get from talking to some of my colleagues is that a happy workplace is also one which allows you to take 10 minutes to make a personal call, work on a research paper when it’s quiet or pop to the bank. There is something about having the space to do these things that makes you feel valued as an individual and not being able to do so leads to a sense of resentment.

Personal Development: A workplace that sees your value as a person as well as a doctor. This is often influenced by your immediate supervisor but jobs that I have found the most rewarding were those where you are not so much permitted but rather encouraged to attend courses that are related to, and also sometimes tangential to your training. This could be where personal interests are incorporated into projects or just the source of 5 minutes of conversation. For example, a consultant once heard me talking to the art therapist on the ward about how I was taking an evening class in ceramics. She then ensured I finished on time every Tuesday afternoon so I would not be late.

Respect – This is something that is hard won as a junior. Being recognised for your experience in a previous ENT or psychiatry rotation, for example, is something that is quite powerful but when none of your efforts are acknowledged and your previously acquired skill-set is side-lined your morale can take a knock. Equally, we all know we are here to learn and do not know everything and so acknowledging strengths is just as important as how weaknesses are nurtured.

Empathy – The job can be difficult. We know this and those above us definitely know this because they have been there before us. A simple acknowledgement or willingness to muck in makes you feel stronger as a team and less isolated. More often than not, you’re spurred on to work a little harder. However, when there is a shrug to your succinct history or sigh at your plea for help the seeds for an unhappy workplace are sown.

Fun! –  I think this is a product of all the positive aspects above. If you have these then you probably have some, if not most, of the key ingredients to a happy workplace. Friendships develop between staff regardless of role, dinners just seem to get organised and an after-work drink every so often becomes the norm as compared to a mandated evening of fun once every 6 months.

Going back to the conversation at the start, I concluded that there is actually very little between what makes a ‘good’ or ‘bad’ placement for a trainee or rather how there is a fine line between the two. I also thought about how much of the good or indeed bad seems to trickle from those in senior roles and how it is true leadership that creates a culture that is fulfilling for those that are passing through or for those who are there for the long run.

Sex differences in cardiovascular events and procedures in people with and without diabetes

An article published in the journal Cardiovascular Diabetology examines gender differences in hospital admissions for major cardiovascular events and procedures in people with and without diabetes.

Secondary prevention of cardiovascular disease (CVD) has improved immensely during the past few decades but controversies persist about the cardiovascular benefits among women with diabetes. We investigated 11-year trends in hospital admission rates for acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in people with and without diabetes by gender in England.

We found that diabetes-related admission rates remained unchanged for AMI, increased for stroke by 2% and for PCI by 3%; and declined for CABG by 3% annually. Trends did not differ significantly by diabetes status. Women with diabetes had significantly lower rates of AMI and stroke compared with men with diabetes. However, gender differences in admission rates for AMI attenuated in diabetes compared with the non-diabetic group.

While diabetes tripled admission rates for AMI in men, it increased it by over four-fold among women. Furthermore, while the presence of diabetes was associated with a three-fold increase in rates for PCI and a five-fold increase in rates for CABG in men; among women, diabetes was associated with a 4.4-fold increased admission rates for PCI and 6.2-fold increased rates for CABG. Proportional changes in rates were similar in men and women for all study outcomes, leaving the relative risk of admissions largely unchanged.

We concluded that diabetes still confers a greater increase in risk of hospital admission for AMI in women relative to men. However, the absolute risk remains higher in men. These results call for intensified CVD risk factor management among people with diabetes, consideration of gender-specific treatment targets, and treatment intensity to be aligned with levels of CVD risk.

https://doi.org/10.1186/s12933-017-0580-0

Use of interrupted time series analysis in health services research

Although randomized control trials (RCTs) are the ‘gold standard’ to evaluate treatment effects in health care, they are frequently not practical, ethical or politically acceptable in the evaluation of many health system or public health interventions. In the absence of an RCT, evaluations often use quasi-experimental designs such as a pre-post study design with measurements before and after the intervention period, such as interupted time series (ITS). An ITS compares the intercept and slope of the regression line before the intervention with the intercept and slope after intervention. A one-time baseline effect of the intervention without influencing the secular trend can be detected as an intercept change. If the intervention changed the secular trend, there will also be a significant difference in the slope between the two periods. Use of ITS in biomedical research is described in more detail in an article published by Utz Pape and colleagues in the Journal of the Royal Society of Medicine.

The Self-Care Academic Research Unit (SCARU) at Imperial College London

In a recent horizon scanning exercise, the School of Public Health recognised the rising importance of self-care as a means to empower patients and support an NHS fit for 21st Century Britain, identifying ‘self-care’ as an important area of academic interest. Further to participation in the annual Self-Care Conference, the Department of Primary & Public Health recently met with Dr Pete Smith OBE (Co-Chair of the Self Care Forum) and Dr David Webber (Head of the international Self Care Foundation) with a view to help establish Imperial College as an academic base of self-care in England.

The Self Care Forum is a national charity that seeks to develop and promote self-care throughout life and work, and encourages the recognition and embedding of self-care in all our lives. It defines self-care as the actions that individuals take for themselves and on behalf of or with others in order to develop, protect, maintain and improve their health, wellbeing or wellness. This includes Health Literacy. The International Self Care Foundation continues to develop evidence-based self-care concepts and practices, whilst promoting the role of self-care in health worldwide.

This tripartite collaboration will ensure that Self-Care is researched as a cross-cutting theme in the contemporary setting for patient benefit, and will strive to make the absolute case for self-care to inform policy makers via an extensive portfolio of research activity. SCARU will help identify how empowering patients via increased health literacy would result in improved outcomes, lower dependency on NHS resources, whilst also identifying key evidence-based recommendations for the consideration of policy makers.

Activity at the newly established Self Care Academic and Research Unit (SCARU) will focus primarily on producing evidence to advance our understanding of self-care in the context of 21st century healthcare by research in the following domains:

  • Evidence synthesis via development of high quality protocols to investigate various aspects related to Self-Care and how this links to empowerment, health literacy, and resilience in the community
  • Understanding how Self-Care can benefit the wider health economy (starting with England, but also looking at European and international examples)
  • Health economic modelling and cost benefit analysis of Self-Care initiatives from the perspective of funding of outcomes as opposed to activities
  • Social science/Qualitative research to better understand patient/GP/Commissioner knowledge, attitude & perspectives (KAP) in relation to Self-Care
  • Explore the use of E&M Health Technologies, digital health & wearable tech in supporting Self-Care in the new setting
  • Service evaluations and audits of local/national importance- including HQIP
  • Self-Care in mental health theme
  • Policy reviews and position papers
  • Establishing a database of evidence on Self-Care

SCARU will work closely with Hammersmith & Fulham GP Practice Federation and Imperial College Health Care Trust (ICHT) Directorate of Public Health & Primary Care to pilot small interventions and to better understand knowledge attitude & perceptions of Self-Care from NHS staff and patient perspectives. The H&F GP Practice Federation and ICHT will also consider participating in the Self Care Week 2017, including participation in the Self-Care Forum Annual Conference.

For further information, contact Dr Austen El Osta.

A woman with a suspected viral rash in pregnancy

My article in the BMJ considers how doctors should approach the management of a woman with a suspected viral rash during pregnancy. Key points in the article include:

  • Consider country of origin in a woman presenting with a rash in pregnancy and ask for immunisation history.
  • Test for measles and rubella IgM and IgG antibodies, particularly if immunisation history is not clear.
  • Refer women with an active infection to the fetal medicine unit for fetal monitoring.

The full article can be read in the BMJ.

The diagnosis and management of Scarlet Fever in primary care

An article from the Department of Primary Care and Public Health published in the London Journal of Primary Care discusses the diagnosis and management of Scarlet Fever. There has been a recent increase in the incidence of scarlet fever with most cases presenting in General Practice and Emergency Departments. Cases present with a distinctive macro-papular rash, usually in children. In patients who have the typical symptoms, a prescription of a suitable antibiotic such as phenoxymethylpenicillin (Penicillin V) should be made immediately to reduce the risk of complications and the spread of infection.

A typical presentation of scarlet fever
An 8-year-old girl is brought to see you at your practice. She has a sore throat, abdominal pain and has been vomiting. Her health was fine until two days ago. Initially, she noticed pain on swallowing and had a temperature of 38 °C. Her parents decided to seem medical advice once they noticed the ‘sandpaper-like’ rash on her trunk and the inside of her elbows. When you examine her tongue, the enlarged papillae become immediately obvious giving it a ‘strawberry’ like appearance. Petechiae are also visible on her soft palate. Her anterior-cervical nodes are swollen and tender.

Read more in the London Journal of Primary Care.

DOI: http://dx.doi.org/10.1080/17571472.2017.1365677

Warning signs might have been missed in one in six heart attack deaths in England

Heart attack symptoms might have been missed in many patients, according to a study on all heart attack hospital admissions and deaths in England from Imperial College London. More research is urgently needed to establish whether it is possible to predict the risk of fatal heart attacks in patients for whom this condition was not recorded as the main reason for hospital admission. The study was published in The Lancet Public Health.

Heart disease is one of the leading killers in the UK. According to the British Heart Foundation, heart attacks lead to one hospital visit every three minutes. They are caused by a decrease in blood flow to the heart, usually as a result of coronary heart disease. Symptoms may include sudden chest pain or a ‘crushing’ sensation that might spread down either arm. Patients might also experience nausea or shortness of breath. However, some heart attacks have more subtle symptoms and may therefore be missed or overlooked.

In this study, we examined records of all 446,744 NHS hospital stays in England between 2006 and 2010 that recorded heart attacks, as well as the hospitalisation history of all 135,950 heart attack deaths. The records included whether or not patients who died of a heart attack had been admitted to hospital in the past four weeks and if so, whether signs of heart attack were recorded as the main cause of admission (primary diagnosis), additional to the main reason (secondary diagnosis), or not recorded at all.

Of the 135,950 patients who died from heart attack, around half died without a hospital admission in the prior four weeks, and around half died within four weeks of having been in hospital. 21,677 (16 per cent, or one in six) of the patients who died from heart attack had been hospitalised during the four weeks prior, but heart attack symptoms were not mentioned on their hospital records.

There were certain symptoms, such as fainting, shortness of breath and chest pain, that were apparent up to a month before death in some of these patients, but doctors may not have been alert to the possibility that these signalled an upcoming fatal heart attack, possibly because there was no obvious damage to the heart at the time.

These results suggest that possible signs of upcoming fatal heart attack may have been missed. The authors’ next step is to look into why this pattern emerged, and to try to prevent more heart attack deaths. We also found that of all patients admitted with a heart attack, those whose heart attack was recorded as secondary to the main condition were two to three times more likely to die than patients whose records stated heart attack as the main condition.

The study received extensive media coverage including by the BBC, The Independent and the Daily Telegraph.

DOI: http://dx.doi.org/10.1016/S2468-2667(17)30032-4

Releasing student potential: Widening access to opportunities in community healthcare

The WATCCH Team at the Department of Primary Care and Public Health

This summer, the Department of Primary Care and Public Health kicked off an exciting new programme: Widening Access to Careers in Community Healthcare (WATCCH). We hosted twenty 16-17 year olds who are aspiring to be the first in their families to go to university – at the Charing Cross campus for the inaugural WATCCH project. Our aim was to change perceptions of wider healthcare careers and provide vital work experience for their University applications. Competition was high and the team was very impressed by the number of high calibre students that applied for a place.

Year 12 Pupils from 19 London secondary schools attended an induction day in late July. During the workshop, an experienced multi-professional panel consisting of five professionals including an Imperial final year medical student, shared their career journeys with the pupils from their A level to postgraduate degrees. This was followed by pupils creating individual mind maps, which they thoroughly enjoyed, of where they are now and where they would like to be in the future. This was followed by a fun exercise in the clinical skills lab at Charing Cross where they could experience clinical skills such as phlebotomy, measuring blood pressure, and inserting nasogastric tubes into mannequins.

The pupils, in pairs, will now attend a 3-day work experience attachment at a General Practice over the summer, where they shadow various health care professionals ranging from pharmacists, to phlebotomists, nurses, physiotherapists and GPs.

Our budding health professionals reported that they had their eyes opened to new and different careers in healthcare they were not previously aware of. One pupil commented that they had learnt “how the different healthcare professionals work together to provide the best quality care”. Another said they had “learnt more about the opportunities available and how to find them”. Pupils also felt they got an insight into how to provide the best quality care, with admiration for the way in which different healthcare professionals worked as a team. It was even said that you “will never get bored” in healthcare!

In early September, we will run a final workshop day to review their reflections of what they have learnt and gained from their work experience. They have been advised to do a placement project to showcase something they have learnt from their attachment which they will share at the final workshop. The mind maps will be revisited to review if their thoughts have changed following the placement. We also hope to discuss how to incorporate their work experience into their personal statements for UCAS applications.

The WATCCH project is needed now more than ever. Figures from the Office for Fair Access (OFFA) show that in 2016 entry rates to “higher tariff” universities for 18-year-olds from the most disadvantaged neighbourhoods stood at just 3.6%. This is exaggerated within the health sector, where there is also a shortage of work experience, despite it being essential for applications. The shortage is particularly acute for those who have no family or social connections to healthcare professionals, despite good GCSE grades.

The NHS workforce is certainly facing a recruitment crisis and our aim is to help channel and support able and enthusiastic applicants towards a brighter future in healthcare. A well-functioning multi-professional team in the community will aid primary care in delivering better patient care

Students at the Clinical Skills Lab at Charing Cross Hospital

The GP teaching team at the Department of Primary Care and Public Health were instrumental in facilitating the induction day. If you would like further information about the WATCCH programme contact Dr Farah Jamil, lead GP for the WATCCH programme, at f.jamil@imperial.ac.uk.

Is there still a role for smaller hospitals in the NHS?

A paper published in the British Journal of Hospital Medicine asks the questions “Is there a role for smaller hospitals in the future NHS?”

The NHS is challenged by rising demand as a consequence of a population with more complex conditions and the rising costs of paying for that care. Inefficiencies resulting from fragmented primary, secondary and social care services highlight the need for greater coordination and continuity to improve patient outcomes at lower cost. Financial constraints can drive health system review, providing impetus to modify health service delivery within the NHS to maximize value and better align with the needs of our population.

The Naylor (2017) review calls for urgent rationalization of the NHS estate to meet the mandate of the Five Year Forward View. Smaller acute hospitals could be seen as a potential starting point for reconfiguring health services in England. However, local change is not always welcome and the perceived loss of services is often met with staunch political and public opposition.

The NHS Chief Executive Officer, Simon Stevens, has expressed his support for smaller hospitals. In the Five Year Forward View, smaller hospitals have an opportunity to once again be at the centre of defining patient pathways. This will require some change in provision of services. Gaining local public and clinician support will be crucial and small hospital leaders must be visionary. Support programmes such as the New Cavendish Group and New Care Models programme will be increasingly important in helping to ensure that smaller hospitals remain part of the fabric of the English NHS.

DOI: https://doi.org/10.12968/hmed.2017.78.8.424