As my time with Nottingham City Public Health nears its end and with postgraduate studies on the horizon, I thought now would be a good time to reflect on my time spent in the department, my work and skills discovered. First and foremost I have a further appreciation for data; the raw quantifier needed to establish where you are at before you can even begin to determine where you are going, or where strategic diversions are needed. When scoping the prevalence of certain eye conditions, working with city population estimates deduced from estimated national prevalence figures has proved challenging. My MPH studies are sure to improve my understanding on the methods used when dealing with such data, recognising its limitations but also its value when needed. Secondly I’ve been able to see just how interconnected public health work is within nearly all sections of local government involved in improving aspects of public society. Collaborations were found within different sections of the same department, between other departments (e.g.commissioning teams) and with external bodies, including arms of the voluntary sector. Together they form an extensive network of interwoven working relationships. I encountered and liaised with individuals in all the above sectors and so the importance of working together was clearly evident in my work on vision loss within the city. I’ve thoroughly enjoyed my time with the Public Health team and I wish them all the best in their projects.
During the CLAHRC event “Making it Real – Patients and public improving healthcare research”,Leicester, one of the sessions I attended was delivered by a patient who had extensive involvement within various clinical trials over the past few years. He was a great example of how health research, once recognised as an invaluable part of the improvement of treatment pathways for illnesses, can attract a greater number of patient participants. For him the trials were not separate from his current clinical treatment, but instead were directly related to revealing ways of making that treatment better. Barriers he observed to research participation included poor advertising and the scientific terminology used to describe the research aims, objectives and patient requirements . These were two of many observations flagged up as impeding access to trial information for patients. Present in the audience were health researchers and healthcare professionals involved in research and so one would hope that hearing the comments on potential improvements from a participant’s point of view may influence their methods of recruitment in future.
Patient involvement in research is ever-increasing, further embedding itself into standard research practice here in the UK which is great to see. The UK Clinical Trials Gateway and the national advisory group INVOLVE are among those that provide resources and information that help to keep patient & public involvement high on the health research agenda. By involving the patients and the public, clinical research will hopefully continue to democratise, increasing the amount of accountability of the researchers by allowing transparency throughout the research process. Overall this will pave the way to better research practice on the one hand, and increase public awareness and confidence in research on the other. I think that striving to do so may be a good way of increasing patient involvement within clinical trials.
Yesterday Adam Tansey, co-founder of the children’s charity ‘KEEP THE BEAT’, described his emotional journey with his youngest son, 4-year-old Albert, who was born with half a heart. From day one Tansey’s family have relied on the expertise and the Intensive Care Unit in Glenfield Hospital which have been key to keeping Albert alive especially for his unexpected turns for the very worst . Therefore Adam’s passion to do all that he can to save Glenfield Hospital is understandable especially seen as there has been debate over the validity of the data and techniques used to come to the decision to close the four childrens’ heart surgery units, Glenfield being one of them (more details about the Safe and Sustainable Review can be found on the NHS specialist services website, including the report of the public consultation). It showed me that, through all the political wrangling and to-ing and fro-ing within the judical process, it is ultimately the lives of Albert, Adam and his family that will be affected. For them, losing this hospital will be devestating, a feeling many in boardrooms may have failed to realise.
To support Keep the Beat, supporting families affected by congenital heart defects, visit http://www.keepthebeat.co.uk/site/index.php
A huge thanks to Adam for a very poignant talk.
On the 5th March I attended the Society for Academics in Primary Care (SAPC) regional conference to present my work on “non-clinical patient needs: mapping diversity in primary care” a parallel session. Dr Alf Collins, Consultant in Pain Medicine at Taunton and Somerset NHS Foundation Trust, and Professor Nigel Mathers were the keynote speakers in attendance. Their talks focused on patient-centred care and, in particular, its influence in the management of long term clinical conditions. Dr Collins talked about the three principles deemed necessary for the personalisation of care: coordination of care, the engagement of patients in decision-making and thirdly, the supported self-management of care for individuals. He described how a fine balance of all three is something that the UK health system is already working towards but that it requires cultural changes within the system for it to work effectively. Following on from this, Prof. Mathers elaborated on the components needed for true patient ‘activation’; the combination of knowledge, skills and confidence which will allow patients to actively and safely manage their health.
Poster viewing sessions were scheduled throughout the day and I found one particular study’s poster quite relevant to the work that I have been doing over the past six months. It was on the feasibility and acceptability of Clinical Commissioning in general practice, drawing on evidence from interviews with GP’s, some of whom were saying that it was not their place to do so and that they had entered into the profession to help to care for people, not to ‘population-manage’ or budget for services. This was of particular interest to me as it provided a possible explanation as to why some of the practitioners I had interviewed responded apathetically to mapping out their population’s needs even though after recognising the benefits of such mapping for their patient population (i.e. informing commissioning decisions with cost implications)
Being the first presentation that I have delivered in front of an audience of health care professionals with academic interests, the planning was slightly more challenging than usual! But having the chance to run-through the presentation beforehand and to receive feedback from the SAPPHIRE group helped me to make the final adjustments. On the day it was well-received and I think it has given me the confidence to do something similar on an even bigger stage!
I presented on the topic of “non-clinical patient needs: mapping diversity in primary care”. Department of Health guidelines continue to emphasise the importance of seeing the patients as customers to a service, listening to them and catering to their requirements. For this to be done effectively within primary care organisations, they will need to have certain knowledge about their patients’ characteristics. There has been on-going interest to reduce health inequalities through using data intelligently, but less focus had been placed on non-clinical data (e.g. age, sex, spoken language, ethnicity, employment status, learning difficulties, visual impairments etc.) and the inequalities to health that arise through patient cohorts with these diversity characteristics. The annual GP surveys have reported a trend in certain patient cohorts who continually report back as being ‘underserved’. Therefore the idea of mapping out a practice’s population based on these needs may help a practice decide how best to allocate their resources (staff time and practice money) to reduce these inequalities. This could reduce inefficiencies in service provision by moving away from a ‘one size fits all’ even spread of services, or allocating services in an ad hoc fashion (as revealed through my interviews with practice staff), to making informed decisions based on real data. It is also key to think about these issues as we move to having Clinical Commissioning Groups or CCG’s nationally. Such data may lead to the smarter commissioning of services.
The Athena SWAN event took place last Wednesday at the University of Leicester. This year’s theme was ‘Breaking through the Barriers of Bias’ with an insightful keynote speech by Professor Jennifer Saul, professor of Philosophy from the University of Sheffield.
Women, across all academic fields, are underrepresented in the STEM subjects (science, technology, engineering and mathematics). The event aimed to discuss whether our hidden biases as individuals were unconsciously denying women opportunities with academia. The two main strands were concerning implicit biases and stereotypical threat. In summary, implicit biases are biases which individuals have towards certain ‘groups’ of people who they have unknowingly stigmatised within societies. I use the word groups quite loosely her, as it refers to different socially constructed groups dependent on the context; gender and race can be included within these groups but other groups do not have to be as fixed or apparent. Our instinctive reactions to different members of these groups were what Professor Saul wanted to draw attention to, and the “Project Implicit” psychological test illustrates this point in practice – https://implicit.harvard.edu/implicit/ .
Stereotypical threat was an interesting theory of how an individual may unconsciously undermine their performance do well due to an awareness of belonging to a particular group thought of as being ‘less good’ at certain tasks. The individual may begin to ‘live up’ to their group’s labelled characteristics, subsequently leading to underperformance. An example was given of a study involving children at a young age; infant school girls were told that boys were better at maths before embarking on a test and their results were compared to control groups of girls. The test was repeated with different sets of children and, consistently, those who had been told the additional information did end up doing significantly worse than the others. It did make me wonder just how early we form our biases and which elements within the environment around us influence our biases more.
Group discussions during the second half of the event brought through ideas of combating implicit bias as mentioned by Professor Saul (i.e. citing more women in papers, having a male/female balance on university students reading lists) aswell as opinions surrounding the effect of implicit bias on recruitment of academics, promotions, merit awards, pay and promotion. Comments surrounding maternity leave and the strain this causes on ‘keeping up to speed’ with developments in your academic department dominated the discussions on promotions and pay. We shall wait to see how the recent government amendments will have an effect on these views and what plays out in practice.
At the end of the session I did feel that there were a lot of problems highlighted but there were complex challenges of to making change happen. This is especially as many individuals (regardless of gender) may feel that they are immune to bias and will therefore not take the step to even recognise the effect of implicit bias in their decision-making, let alone positively work on ways to limit its hidden effect.
On Monday (25/2/13) I successfully completed a two week online pilot for a new Health Services Evaluation Course created by the CLAHRC LNR (Leicestershire, Northamptonshire and Rutland). After defining the purpose for the evaluation (establishing whether the project was indeed an ‘ evaluation’ and not a clinical audit or a piece of research), the course talked me through how best to define the evaluation question, aims and objectives;the identification of the relevant stakeholders and evaluation team members, defining their input into the project; and how to select the most suitable methods of carrying out the evaluation, agreeing on timescales, resources and strategies for dissemination. The most important stage, in my opinion, was the succesful identification of all the stakeholders and recognising their appropriate levels of involvement within the evaluation. Sometimes the views of certain stakeholders are maginalised in favour of stakeholders who are more influencial to the project. This can be problematic when those individuals are the direct recievers of the particular healthcare service being evaluated, yet their voices are not heard the loudest.
Using the online interface was a good way to interact and discuss ideas with others working on a wide range of health evaluations in primary and secondary care, despite the fact that they were based in various locations. Discussion boards and the Wiki format were actively utiltised and comments posted were always on topic and constructive. I can see the online course format working well in practice when it is rolled out to health professionals in the area.
Many thanks to Tammy Holmes and Rachel Lovesy for providing me with the opportunity to take part.