Category: NHS

Hot air, rubbish and going green: Reflections on chairing a SW Clinical Senate Meeting

Chloe - APEx Administrator
by Prof David MG Halpin
Consultant Physician & Honorary Professor of Respiratory Medicine

The Climate Change Act of 2008 introduced an ambitious target of reducing greenhouse gas emissions by 80% by 2050 compared to the 1990 levels. In 2008 the NHS generated around 3% of England’s total carbon dioxide emissions making it the largest public sector contributor to greenhouse gas emissions. It is responsible for a staggering 21.4 million tonnes of CO2 emissions each year, 9.5 billion road miles a year – 5% of all road journeys – and 11,300 tonnes of waste a day, of which 22.7% is plastic. Sir Simon Stevens, the NHS Chief Executive, has said “The climate emergency is a health emergency,” and that “the NHS, as the single biggest organisation across this country is both part of the solution and part of the problem. We are 40% of public sector emissions, and although we have reduced our carbon footprint by around a fifth over the past decade, we’ve got to make major changes if we’re going to help this country become carbon net neutral.”

Late last year I chaired a meeting of the South West Clinical Senate held to develop recommendations on high impact changes that healthcare systems can make as meaningful contributions towards mitigating climate change.

Clinical Senates were established as part of the NHS reorganisation in 2012 to provide a source of strategic, independent advice and leadership on how services should be designed to provide the best overall care and outcomes for patients. I have been a member of the Clinical Senate and on its Council since it was established, and have been vice-chair since 2015.

Sitting on the Council is an interesting and rewarding experience – members come from a wide variety of clinical backgrounds and we have considered topics as disparate as student mental health and suicide, biosimilar monoclonal antibodies, weight loss and smoking cessation criteria to improve surgical outcomes, and NHS workforce challenges. The meetings are run in a similar format to the BBC programme “The Moral Maze”. In the morning we hear evidence from a variety of experts, for example John Campbell contributed to the workforce meeting, discussing his research on the challenges facing primary care. In the afternoon, the evidence is discussed in small groups including the external experts and then the Council Members consider all the points that have been made. Following the meeting, the Senate Management Team magically transform all the flip charts and copious notes into draft recommendations.

Topics as disparate as student mental health and suicide have been considered at Senate Meetings

Being vice-chair brings challenges and rewards. The climate change meeting was a great opportunity to promote awareness of work that is being undertaken across the region and elsewhere to reduce greenhouse gas emissions. As I’ve already mentioned, travel is a large factor in the NHS’s carbon footprint and for this meeting we decided we would link to our speakers from outside the region with teleconferencing. Unfortunately, technology in the NHS is not always up to the task, and making it work caused great angst and required the simultaneous use of multiple mobile phones by our Senate Manager and Project Officer. Not surprisingly, one of our recommendations was that IT systems should upgraded to facilitate virtual meetings !

Addressing climate change made members the Senate think about topics, such as waste management, that perhaps they did not give much consideration to as part of their normal working lives. We heard from the Bristol Trusts who have jointly declared a climate emergency following the examples set by Newcastle and Manchester, from the Royal College of Anaesthetists about reducing anaesthetic gas emissions, which are very potent greenhouse gasses, and I presented on the effect of pressurised metered dose inhalers. Inhaler use accounts for 3.1% of the NHS’s carbon footprint. They cause problems both as a result of the release of their propellants during use, but also because of poor disposal and lack of recycling. Even when “empty”, cannisters still contain significant amounts of propellant and unless they are returned to pharmacies for destruction by incineration, the residual propellant will eventually escape, particularly if the inhalers are simply put in domestic waste and sent to landfill sites. Using propellant free devices, when clinically appropriate, should be considered and prescribing guidance from NICE now encourages this.

Other presenters discussed the health impacts of climate change, how virtual consultations can reduce travel and importantly we considered patients’ views which are collated through the Citizens Assembly – which brings together the chairs of the Healthwatches in the South West. We also heard from the Royal College of General Practitioners representative for Sustainability Climate Change and Green issues who talked about the Green Impact for Health toolkit, which is endorsed by the College and designed to help GP surgeries improve their sustainability and environmental impact. More details are available at https://www.greenimpact.org.uk/giforhealth. As well as topics such as green prescribing, practices are encouraged to take steps such as reducing the use of paper, using energy monitors to establish the energy use of the whole practice, providing feedback to staff on energy use and carbon footprint, having an aspiration to reduce energy consumption year-on-year and having a “green impact” standing agenda item at every practice meeting.

As always, with Council meetings, I learned a lot more about a topic I thought I knew something about. You can read the recommendations we came up with, and see the presentations, on the Senate website (https://www.swsenate.org.uk/senate-council-meeting-reducing-nhs-contribution-to-englands-total-carbon-emmisions/2871/).

 

The NHS have reduced their carbon footprint by around 1/5 over the past 10 years.

Don’t throw the baby out with the bathwater – asking the right questions when evaluating computerised CBT for depression in primary care

jchoules

Over a third of all patient visits with a general practitioner are estimated to involve a mental health component, and 90% of these patients are primarily managed in primary

Picture By Jim Wileman – Medical School portraits.

care [1]. Due to this high demand, National Institute of Health and Care Excellence (NICE) guidelines recommend the provision of computerised CBT as an initial lower intensity treatment for depression in primary care [2]. Computerised CBT is more accessible, scalable and cheaper than face-to-face CBT and has the potential to reduce the burden of depression in primary care significantly.

Systematic reviews have confirmed the effectiveness of computerised CBT [3]. However, a randomised controlled trial published in the British Medical Journal in 2015 reported that supported computerised CBT did not improve depression outcomes compared with usual GP care alone [4]. On the back of this, the authors suggested that the routine promotion and commissioning of computerised CBT be reconsidered. I would caution against this for the following reasons:

  • First, it is unlikely that computerised CBT will reduce depression if patients do not adequately use the platform or actively engage with the cognitive and behavioural techniques offline in their day-to-day lives. The median number of online sessions completed by patients in the study by Gilbody et al. ranged from 1–2, and no data were reported concerning offline engagement. Were the negative findings due to an ineffective intervention or the lack of engagement?
  • Second, a large proportion of participants across all arms of the trial were using antidepressants (81%). It is therefore unsurprising that the trial failed to find a positive effect. The argument for computerised CBT is not that is will be more effective than usual care, but that it offers a viable alternative that takes the pressure off general practice and offers patients another treatment option that is less resource intensive.

The issues in the study by Gilbody et al. are by no means unique and are indeed prevalent across the field of computerised interventions for mental health. However, resolving these issues are fundamental to ensure we don’t prematurely reject interventions with the capacity to transform healthcare. As highlighted by the NHS -term plan, harnessing the power of technology and empowering people to take responsibility for managing their own health is vital to meet the increasing demand on healthcare services. This is well within our grasp, but we need to be asking the right questions!

Dr Jeff Lambert, Postdoctoral Research Associate in Primary Care, UEMS

References

  1. Ferenchick EK, Ramanuj P, Pincus HA. Depression in primary care : part 1 — screening and diagnosis. Br Med J. 2019;
  2. National Institute for Health and Clinical Excellence. Depression in adults: recognition and management. 2018.
  3. Karyotaki E, Riper H, Twisk J, Hoogendoorn A, Kleiboer A, Mira A, et al. Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data. JAMA Psychiatry. 2017;74(4):351–9.
  4. Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, et al. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015; 1–13.

Happy Birthday #NHS70

jchoules

Happy Birthday #NHS70 – an amazing Institution harnessing clinical, organisational, academic and management skills for the benefit of patients and the public. Right at the heart of the NHS is General Practice – the clinical specialty provided by 40,000 GPs and their teams, and delivering care at the front-end of the NHS. GPs are by their nature, disposition, training, and clinical practice, generalists in clinical medicine. GPs provide care that is coordinated, continuous and comprehensive, with many GPs having a long and valued relationship with individual patients and their families. They have central roles in the prevention, diagnosis, management, and follow-up of virtually all conditions for which a patient might seek medical help or advice. They and their teams care for over a million patients every working day – what a great job!

Here in APEx, the University of Exeter’s Collaboration for Academic Primary Care, our primary care research reflects this broad diversity of clinical interest and approach amongst primary care academics. I am proud to be part of such a great team, delivering research that matters, and high quality education that counts for the future.

Our research centres on the organisation and delivery of primary medical care in the UK, with a particular focus on access to care, alternatives to face-to-face consultations, the quality of care and the quality of patients’ experience of care, and the safety of primary care provision. Have a look here for a comprehensive summary of our work on patient experience – or you can find it in the 40 papers we’ve published on the subject in the past few years! Within APEx we have five great research groups, all delivering brilliant, patient-focused research. Here’s some examples!:

Case Study  – Monitoring and Managing Patients’ Experience of Primary Care

We’ve worked with colleagues in the University of Cambridge over the past ten years to develop, and to undertake research in respect of patients’ experience of primary care. These researchers were involved in working with the NHS and with IPSOS Mori in designing the national GP Patient Survey. This survey instrument is now routinely used across all of primary care in England (7800 practices) and the resulting data provides an important overview of patients’ experience of primary care by English general practices. For example, have a look at myNHS where you can see patient experience data for all practices in England. The resulting data also forms the basis of much of the date used by the Care Quality Commission in their inspection of general practices. In previous years, GPs and their practice teams have been rewarded for both taking part in monitoring patients’ experience of care, and, at some points, for providing high quality patient experience. Such arrangements have now changed, but the GP Patient Survey remains central to the monitoring and delivery of primary care in England.

Professor John Campbell, Professor of General Practice and Primary Care, University of Exeter Medical School

So, Primary Care research matters! It would be a long blog if I tried to cover all our interests, and we’re part of a much wider community of Primary Care Academics who are delivering great primary care research and education across all of the UK.

Thanks for having a look at this – keep in contact! We’ve got a great team here in Exeter and we’re always happy to let you know what we’re up to. We’re supporting the NHS for the next 70 years!

John Campbell 
Professor of General Practice and Primary Care and Director, APEx

@profjcampbell
@uoeapex
john.campbell@exeter.ac.uk

‘We are likely to “throw the baby out with the bathwater”. If we don’t value continuity’ … Reflections from Professor Phil Evans, a GP in the NHS for half its lifetime

jchoules

Hi, my name is Dr Phil Evans and I have been working in the NHS for exactly half of its lifetime, and well over half of mine! Of the 70 years since the NHS was formed, I have been working for 35 of them as a doctor and I have recently retired as a GP partner after 30 years in the same practice in Exeter. The NHS has given me a wonderfully stimulating and exciting career. In my opinion, general practice really is the jewel in the crown of the NHS but nevertheless is often under-valued, as are the skills and attributes of its hard-working GPs.

The NHS has given me an amazing opportunity to practise what I preach in terms of promoting continuity of care with the same doctor and the ability to get to know patients and their families, sometimes up to four generations of a single family, over a long period of time. The phrase “from cradle to grave” sums up the whole of general practice. The privilege of meeting patients week after week, year after year and trying to address their changing medical, psychological and social concerns is at the heart of what we do. Each consultation is still however a trip from the known into the unknown.

The partnership model in NHS general practice has allowed me, as a GP partner, not just to see patients but to run our own practice as an organisation that provides high quality medical care in a way that we wished. We could invest in our practice to value patients, promote patient-centred care, but also promote the other attributes that are close to my heart, teaching and research.

The NHS has given me the opportunity to undertake my own research and gain a higher degree in the process, working in our practice to answer important research questions. More recently I have been fortunate to work with other researchers in universities and across the NHS in my national role in the Clinical Research Network (CRN) to promote research and embed research in everyday practice. The CRN is an integral part of the NHS and runs research studies across all parts of the NHS, including general practices. Other countries are very envious of the NHS and its research!

The traditional model of GP working which I have so much appreciated is threatened in the NHS changes when “bigger is better” as far as practices are concerned and there is an emphasis on speed of access rather than developing deeper relationships with patients. We are, in my opinion likely to “throw the baby out with the bathwater” if we don’t value continuity and all its proven advantages – many of which I have experienced as a doctor. We must find ways in the NHS to value continuity, firstly by measuring it, then promoting and incentivising it.

So having worked in the NHS for half of its life it has been a privilege, but I worry that the things I value as GP are now threatened as the NHS moves into its next decade.


Associate Professor in General Practice & Primary Care

‘The “front door” is not always as open as we would like….’ Reflections on the NHS at 70 from Dr Jo Butterworth, GP and doctoral research fellow

jchoules

What the NHS means to me
As a GP in the NHS, I feel proud to be part of one of the largest and most impressive work forces in the world, particularly when its aim is to provide good quality healthcare for all patients in the UK, regardless of their wealth. I am also a user of this service that covers everything; from routine health screening, to antenatal checks, emergency healthcare, management of long-term conditions and end-of-life care. As one of over a million patients accessing NHS care in a 36 hour period, I felt safe and provided for; as a new mother on a hospital ward, and later at home with my community midwife.

In addition, I contribute to primary care research and to education within the NHS. Along with over 200 academic GPs in the UK, I aim to provide guidance, through research and evidence, for the future development and organisation of the UK health service. I teach, and I promote lifelong learning, to ensure a competent and confident workforce; from the medical student, to the junior doctor, to the fully-fledged GP.

What is the role of primary care within the NHS?
Primary care is known as the “front door” of the NHS as it is the first point of contact for most NHS patients. It is delivered by GPs, dentists, pharmacists, optometrists, NHS walk-in centres and the NHS 111 phone service. A whopping three hundred million consultations take place in General Practice each year. Whilst patients are generally satisfied with the care that they receive, it is often difficult to access a GP. The “front door” is not always as open as we would like.

What has changed in primary care in my career?
I qualified as a doctor in 2007 and completed my GP training in 2013. Over the last ten years I have witnessed significant restructuring of the NHS and ongoing reform of primary care services. Of note to me as a newly qualified GP, clinical commissioning groups replaced primary care trusts, with the aim of enabling clinicians to lead on the planning and commissioning of healthcare services for their local area. Many GP practices are merging with the aim of sharing knowledge and resources. However, funding for hospital services has been increasing at twice the rate of funding for general practice services and we are seeing more and more privatisation of health services. NHS staff have become demoralised; junior doctors are leaving to work abroad, senior doctors are taking early retirement and we are currently in the midst of a GP workforce crisis.

What needs to change in the future?
As the population grows, so too will the number of older patients with multiple health problems and these patients are known to consult frequently. This will put incredible strain on the NHS and we will need to be financially ready to cope with it. Patients and their carers should be involved in making decisions about their healthcare and the services that are commissioned. Healthcare needs to be patient-centred and individualised. We need to seek ways to enable continuity of care with the same healthcare practitioner and longer consultations for our most vulnerable patients.

In order to increase positivity amongst the GP workforce the workload needs to be made more manageable. However, consideration should be given to the wellbeing of GPs, and that of other healthcare practitioners, when restructuring and delivering new health services for patients.

We need to encourage more medical students, along with nursing, pharmacy, physiotherapy and occupational therapy students, into careers in primary care. We need to use their skill-sets flexibly, and in a close-knit multidisciplinary unit, to provide high quality but cost-effective healthcare. We should give undergraduates the skills to manage the uncertainties that they will inevitably face once qualified, and encourage them to become health service pioneers and leaders. We should invite them to problem-solve, look beyond guidelines and question evidence, to work cohesively with their colleagues in secondary care, and to embrace the challenge that is the future of the NHS.

The NHS at 80?
Let’s make sure it’s still here!