A study from my research group published in JRSM Open examined why some children do not attend their hospital outpatient appointments. The study found that the commonest reason for non-attendance is unawareness of the appointment due to incorrect contact details being held by the hospital. Potential strategies for reducing non-attendance at paediatric clinics include developing a confirmation or reminder system and improved communication with parents.
This popular study tour for Imperial MPH students is organised annually in collaboration with WHO Geneva. As part of the tour participants were introduced to the work of Médecins Sans Frontières, The UN High Commission for Refugees, the Red Cross, The UN, and WHO and its regional offices. MPH students have had the opportunity to meet with large numbers of senior colleagues in these key international organisations and learn about the nature of their work. The 3 day study tour was very busy, full of learning experience and fun.
The Annual Teachers’ Conference took place on Friday 9 June 2017 Celebrating the Student and Teacher Partnership. About 100 delegates joined together to network, offer peer support and learn through conversation, lectures and a series of workshops. A brief overview of the key themes and reflections from the day follows.
A story
Dr Sonia Kumar, Director of Undergraduate Primary Care Education, opened by sharing a story of coming across an old man with a bike puncture while out with her husband. While her husband repaired the puncture they got to know a little of his life; how his wife had died and he now lived in sheltered accommodation with cycling being an important way for him to get out and about. Later that day Sonia was reflecting on how hearing his story had made her feel sad and sorry for his changed circumstances, whereas Dev, Sonia’s husband, had taken away a different impression – a wonderful life where he continued to be cared for, maintaining his independence and a lifelong hobby in the form of his bike. And so with teaching, sometimes the student – teacher agenda and perspective to a situation can be different and recognising this is key to a successful teaching partnership.
A Vision for the Future
Professor Val Wass spoke to the subject “Doctors Without Borders”, drawing on her life experience as a GP, medical school dean, RCGP International lead and recent publication on By choice – not by chance: supporting medical students to careers in general practice for NHS Health Education England. She highlighted four important barriers (Generation Gap, Societal Borders, Specialty Borders and Self-Knowledge) we need to recognise in how we deliver education to support students to flourish in their future.
Reflecting with students
The student prizes showcased a huge amount of creativity with videos, paintings, interviews allowing us all to reflect on how healthcare delivery and our own attitudes shape the patient experience. One sensed a huge injection of energy and inspiration into the room, affirming to the audience members their inner calling of ‘this is why I want to teach’, and lots of reflections for teachers of their own practice – a true teacher-student partnership. This creative animation by a pair of students who got to know a patient over a number of months as she navigated the NHS and her own identity is highly recommended.
Professor Salman Rawaf was appointed by WHO Europe as a member of the newly formed Advisory Group on Primary Health Care. The first meeting of all Members was attended by the Regional Director Dr Zsuzanna Jakab and Kazakhstan’s Minister of Health, Dr Alexey Tsoy. Professor Rawaf gave a presentation on integration of public health and primary care services and highlighted the role of Healthy Living Centres in the UK. He also described some possible models for the integration using the experience of countries around the globe. The WHO European Centre for Primary Health is leading the work across the 53 member states of WHO Europe.
This course was developed and run jointly between the Zagreb Institute of Culture of Health and the WHO Collaborating Centre, at the Centre for Advanced Academic Studies in Dubrovnik. More than 40 health professionals from across Croatia took part in this intensive course over 5 days. The modular format of the course allowed participants to choose the sessions which are relevant to their needs. The course was organised and led by Professor Rawaf from Imperial College London, and Professor Marijana Bras and Professor Velijko Dordevic of University of Zagreb. We plan to run the course annually at the Centre for Advanced Academic Studies.
This summer, the WHO Collaborating Centre delivered the well-established Advanced Leadership and Health Management course in London for delegations from China and the Gulf Region. The participants came from various health professional background with responsibilities to lead in their health systems.
Colleagues from China are mainly from hospital management, some from hospitals with over 4000 beds. The WHO Collaborating Centre Advanced Leadership and Management for healthcare course is a one-week intensive training addressed to health professionals. The content of the course is built around the WHO framework and aims to help participants become more successful leaders in complex knowledge-based health systems around the world.
Dr Andy McKeown, Co-Course Director (Year5 MB BS Course Lead) and Dr Shivani Tanna (Year 3 GP Course Lead) have both received President’s Awards for Excellence in Teaching for 2017. These awards follow three similar awards received by our academic GPs in 2016 and showcase the fantastic teaching being delivered by the Department of Primary Care and Public Health.
On Thursday 21 September 2017, our Master of Public Health (MPH) students presented their research projects. This was the last assessment for the 2016-17 course. We had a wide-range of presentations on very topical issues in global health and health policy.
In a letter published in the British Medical Journal, I respond to comments from Dr David Shepherd and Dr Hendrik Beerstecher about an editorial I wrote on shortages of general practitioners in the NHS. Dr Shepherd argues that capitation-based funding for general practice can work if the total amount of funding was increase and better methods were used to allocate funds to general practices. Dr Beerstecher argues that there is a mismatch between the supply of general practitioners and demand for their services.
In my response, I state that that increasing the amount of funding for primary care would be a step forward. Moving from the current Carr-Hill formula for allocating budgets to general practices to a formula with more patient level clinical data would also be helpful. But case mix adjusted formulas such as the Johns Hopkins adjusted clinical groups (ACG) system have limitations—particularly when used for smaller populations such as those covered by the typical NHS general practice.
Furthermore, an entirely capitation based formula would not prevent the shift of unfunded work from specialist care to primary care, which is one of the major problems currently facing general practices and one that clinical commissioning groups in England seem unwilling or unable to tackle.
I agree with Dr Beerstecher about the mismatch between the supply of GPs in the NHS and demands for their services. I allude to this when I state that GP services might need to be scaled back to fit the public funding available. Demands on GPs could be reduced if practices had a more tightly defined contract with the NHS.
The current GP contract is vague and open ended, setting few limits on the quantity or range of services that GPs are expected to offer the NHS and their patients. Furthermore, government policy in recent years has been to encourage GPs to offer even more services and make themselves more available to patients—for example, by requiring GPs to open their practice for longer hours without a substantial increase in the GP workforce. These policies have led to higher demands on primary care.
GPs are also faced with patients expecting them to fill gaps in local health services. For example, patients with dental problems often present (inappropriately) to their GPs because of problems accessing dental services. These are all problems that need to be tackled by NHS commissioners.
Delayed diagnosis in primary care is a common, harmful and costly to patients and health systems. Its measurement and monitoring are underdeveloped and underutilised. A study from Imperial College London published in BMC Family Practice created and implemented a novel approach to identify problems leading to and solutions for delayed diagnosis in primary care. We developed a novel priority-setting method for patient safety problems and solutions called PRIORITIZE. We invited more than 500 NW London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to delayed diagnosis in primary care. 113 clinicians submitted their suggestions which were grouped into a composite list of 33 distinct problems and 27 solutions. A random group of 75 clinicians from the initial cohort scored these and an overall ranking was derived.
The top ranked problems were poor communication between secondary and primary care and the inverse care law, i.e. a mismatch between patients’ medical needs and healthcare supply. The highest ranked solutions included: a more rigorous system of communicating abnormal results of investigations to patients, direct hotlines to specialists for GPs to discuss patient problems and better training of primary care clinicians in relevant areas. A priority highlighted throughout the findings is a need to improve communication between clinicians as well as with patients. The highest ranked suggestions had the highest consensus between experts.
The novel method we have developed is highly feasible, informative and scalable, and merits wider exploration with a view of becoming part of a routine pro-active and preventative system for patient safety assessment. Clinicians proposed a range of concrete suggestions with an emphasis on improving communication among clinicians and with patients and better GP training. In their view, delayed diagnosis can often be prevented with interventions requiring relatively minor investment. Rankings of identified problems and solutions can serve as an aid to policy makers and commissioners of care in allocating healthcare resources.