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

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.

National trainee research collaboratives – Time for general practice to join the party.

Dr Sam Merriel

A career in general practice provides a myriad of opportunities for young and aspiring GPs. The core work as a generalist of providing holistic, patient-centred care to our patients ‘from the cradle to the grave’ and establishing continuity of care with our patients over a long period of time is truly rewarding. GPs can also lend their unique skill sets to other elements of primary care to improve the health of our patients and our community. Developing and building a GP practice or practices through partnership, commissioning NHS services as part of a CCG, and teaching the next generation of GPs are all possibilities open to early career GPs. Academic general practice, contributing to the improvement of primary care through research, is another vital area that GPs can turn their hand to.

But where to start? And how?

First5 GPs and GP trainees are busy people. As GPs we are trained to be lifelong learners, and there is a steep learning curve to begin with in transferring from hospital to community care. Newly qualified GPs need time to find their feet. Some opportunities exist for formal academic training through academic foundation posts in primary care departments, academic clinical fellowships for trainees, and in-practice fellowships for GPs, but these posts are very competitive and require commitment to an academic career. Opportunities to ‘dip one’s toe in the water’ in primary care research are harder to find.

Trainee research collaboratives

A successful model for trainee-led research, audit and quality improvement that has been used by other medical specialties in recent years is that of trainee research collaboratives. These local, regional and national groups exploit the networks of hospital specialty trainees across multiple sites to conduct research and audit projects. The advantages of this approach are that patients can be recruited and data can be quickly and cheaply collected across a number of centres(1). For doctors involved, they can engage in the process on many levels, from identifying patients or collecting data at their local site right through to developing and proposing new ideas for research, audit or quality improvement projects. They can also develop their teamwork, leadership and communication skills(2). Medics without any research experience have the opportunity to gain an insight into how studies are conducted, and their eyes may just be opened to the world of academia.

Trainee research collaboratives in the UK have rapidly expanded in some disciplines in the last 10-15 years. Surgery and anaesthetics in particular have a number of established regional research collaboratives and networks, including the Severn and Peninsula Audit and Research Collaborative for Surgeons (SPARCS) and the South West Anaesthesia Research Matrix (SWARM) in the south west of England. Between 2012 and 2016, the proportion of general surgery units across the UK which participated in at least one study run by trainee research collaboratives grew from 44% to 99%(3). Numerous randomised controlled trials and national audits have been delivered by these collaboratives, resulting in truly impactful research that is improving patient care(4).

PACT – Primary care Academic Collaborative for Trainees

General practice is ideally placed to take full advantage of the trainee research collaborative model. GP trainees are embedded in GP surgeries in all parts of the UK and cover all sections of the population. Electronic medical records can easily be searched for patients who meet inclusion criteria for research and audit, and the general practice model means changes arising from quality improvement projects can more easily be implemented at a local level. General practice in the UK is moving towards networks and federations of practices, making engagement in a collaborative a great opportunity for GP trainees and First5 GPs to experience working with colleagues across multiple GP surgeries towards a common goal.

The Primary care Academic Collaborative for Trainees (PACT) was launched by its chair, Dr Polly Duncan from the Centre for Academic Primary Care in Bristol, at the recent National GP ACF and early career researcher conference in Manchester. We have established a core committee of GP trainees and First5 GPs from right across the UK, and we will be coming to the 48th SAPC Annual Scientific Meeting in Exeter in July to deliver a workshop to develop the very first collaborative project PACT will undertake. PACT will generate numerous opportunities for GP trainees and First5 GPs to bring forward their ideas, and will seek to support them in delivering these projects to improve care for our patients across the UK.

Dr Sam Merriel GP and Clinical Senior Research Fellow, University of Exeter
Vice chair, PACT – Primary care Academic Collaborative for Trainees
@sammerriel

References

  1. Kasivisvanathan V, Kutikov A, Manning TG, McGrath J, Resnick MJ, Sedelaar JPM, et al. Safeguarding the Future of Urological Research and Delivery of Clinical Excellence by Harnessing the Power of Youth to Spearhead Urological Research. Eur Urol [Internet]. 2018;73(5):645–7. Available from: https://doi.org/10.1016/j.eururo.2017.10.026
  2. Kasivisvanathan V, Ahmed H, Cashman S, Challacombe B, Emberton M, Gao C, et al. The British Urology Researchers in Surgical Training (BURST) Research Collaborative: an alternative research model for carrying out large scale multi-centre urological studies. BJU Int. 2018;121(1):6–11.
  3. Nepogodiev D, Chapman SJ, Kolias AG, Fitzgerald JE, Lee M, Blencowe NS. The effect of trainee research collaboratives in the UK. Lancet Gastroenterol Hepatol. 2017;2(4):247–8.
  4. Jamjoom AAB, Phan PNH, Hutchinson PJ, Kolias AG. Surgical trainee research collaboratives in the UK: An observational study of research activity and publication productivity. BMJ Open. 2016;6:e010374.

 

Placement reflection

The Health Services & Policy Research Group hosted two summer interns from the BMedSci programme again this year. They actively contributed to ongoing work and were valued highly within the team. They have both since reported that:

“My 4-week placement with the Health Services & Policy Research Group has been invaluable, exposing me to research and providing a plethora of opportunities to gain crucial techniques and skills that will carry forward not only throughout my undergraduate studies but also to take into the world beyond BSc Medical Sciences. Through working on a scoping review into healthcare system performance for patients with multimorbidity I learned the key differences between scoping reviews systematic reviews, learnt how to perform complex searches in databases, which had previously intimidated me during my undergraduate studies, and helped to screen at text-level, learning the useful ability to read things quickly but thoroughly! I felt incredibly welcomed amongst the team; rather than feeling like a work experience student making tea, I felt fully part of the group, attending meetings and lectures, and learnt a lot by being thrown in at the deep end. I am delighted I have had this wonderful opportunity, gained a wide range of experience, and met brilliant people, and I’d like to thank everyone who made it so great.”

“Being part of a research team focusing on Patient Reported Outcome Measures (PROMs) is a great opportunity for me as a first year medical sciences student. Learning about the diseases in lectures is one thing, but hearing it from a patient’s perspective as to how it affects them is another. The purpose of the study I was part of was to see how chronobiology played a role in the symptoms of the people suffering from multimorbidity. This was specifically narrowed down to people suffering from a combination of asthma, osteoarthritis or depression. Through this, GPs may have a better understanding on how different people express symptoms over the day or year and possibly advise them on when would be a better time for them to take the medication. Based on the results of the questionnaires and the interviews, there are slight variations of symptoms being experienced over the day and seasons. For example, people with osteoarthritis tend to have more pain towards the evenings and people with asthma tend to have a flare up of symptoms when the pollen count is high during the summer. This has also provided a good insight for patients as some may have not noticed a variation in their symptoms before and from this they might be able to better manage their conditions.

It has been pleasurable working with a research team who have been very welcoming to me since my first day which made my experience here even more beneficial. During my placement, I have learned how to input quantitative data into a statistics program called Stata. I have some understanding as to how bids are placed and the process behind it. My time in this placement has definitely sparked my interest in pursuing a career in this field of research.”

UEMS BMedSci students

 

Happy Birthday #NHS70

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

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

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!

“I see no reason why I shouldn’t change careers as I progress through life”… The NHS through the eyes of a University of Exeter medical student

My decision to aim for medicine
The NHS is undoubtedly a source of great pride in this country. The fact that anyone can book into any of the 7,000 GP practices (or 168 acute trusts) in this country and receive top quality care for free is surely one of our greatest achievements. There is a strong argument to spend more on the NHS, as the UK spend less as a proportion of GDP than comparable countries, but that we have been able to achieve this level of access is quite incredible.

That being said, we are a nation of complainers, and the NHS receives more than its fair share of groans, eye rolls, and tut-tut-tuts. I often find myself defending the NHS against these (often totally justified) complaints, because I feel like a real part of the system, and truly believe the NHS to be a national treasure. Perhaps this is part of what first attracted me to a career in medicine.

From my (admittedly limited) experience of working around doctors of all specialties and grades, it is evident that medicine is an arduous job, with long unsociable hours, high pressure, low levels of flexibility and literal life-and-death situations on an almost daily basis for some. This is something that everyone entering this noble career needs to understand; it isn’t all running around with defibrillator paddles shouting “Clear!” and shocking people back to life. It isn’t all chest compressions, medical mysteries, and slow-motion moments either. Medicine is a stressful, difficult, and often frustrating career, and it certainly isn’t for everyone.

For me, this was always vastly overshadowed by the positives of this career. I felt that working with people in what can be the most difficult time of their lives, opportunities for leadership, the requirement for lifelong learning, and the clear career progression (not forgetting the more-than-comfortable salary of course) were all strong enough reasons to look past the angry drunks in A&E, the nights on Geriatrics, and the screaming in Paediatrics. Thankfully I am still of this opinion now and, if anything, am even more confident that I made the right choice when I embarked on this professional journey.

What does the NHS mean to me?
The NHS is much more to me than a network of trusts, deaneries, CCGs and administration teams. It is more than an interconnected web of doctors, nurses, porters, cleaners, ODPs, HCAs, and secretaries, too. It is a symbol of a national ideal that I feel is often lost in the name of ‘strengthening the economy’, ‘encouraging competition’, and ‘streamlining services’: the notion that everyone, no matter their background or income, is entitled to care for their entire life without having to worry about finding the money to pay for it. This basic right, so often taken for granted in the UK, is absolutely fundamental as we strive for equality and justice in this country. The success of the NHS flies in the face of the laissez-faire attitudes of some people in this country, and shows that what we can achieve together is vastly greater than what we can achieve on our own. The progression towards a fair society begins, I believe, with seeing just how powerful a force the united peoples of this country can be. Establishing the premise that everyone deserves to be treated fairly, regardless of their income or background is the first step in achieving true equality, and it is this idea that, for me, the NHS embodies perfectly.

My hopes for a career in the NHS
Like many people in my cohort, I can see my career in the NHS taking a tortuous route. I currently feel that some part of acute medicine is where I want to be – be that A&E, MAU, ICU, anaesthetics etc, but I am certain that I won’t be going straight through a training pathway into a consultancy post as people often felt they had to before. I have always had an interest in medical education, which has only been reinforced by the Masters in Clinical Education I have undertaken this year, and definitely feel this will form a part of my career. I also hope to conduct research alongside my clinical work, and aim to complete a PGCert in Clinical Trials alongside my fifth-year study to further this aim. I am also currently in the latter stages of an application to become a Magistrate, and feel that volunteering and working outside the NHS is important for maintaining morale and avoiding burnout. Finally, I see no reason why I shouldn’t change careers as I progress through life. While the fast pace and more antisocial hours of acute medicine appeal to me now, I have enjoyed my time in primary care so far and would like to consider this as an option as my career and life progress.. I essentially want to have my fingers in as many pies as possible. After all, variety is the spice of life!

My concerns about working in the NHS
My main concern about entering a career in the NHS is that it may not exist by the time I retire. Even within the few years during which I have been conscious of these things, I have seen a gradual effacement of the NHS at the hands of various government and private companies. This of course did not start recently, and goes back in my opinion to the hallowed Blair years of extremely high spending but also privatisations and PFIs. Today, despite the recent announcement of a £20bn funding boost, the NHS remains chronically deplete of money. My worry is that this is part of a concerted effort to devalue and destabilise the NHS so it can be increasingly moved into the private sector – being as it is totally antithetical to the belief that the state should hold as small a role in the lives of working people. Perhaps this is why I argue so vehemently against those who moan about the NHS, as every disillusioned voter is another step towards the end of the NHS.

The NHS I would like to be looking back on
I hope that, at the end of my career, I can look back on an NHS that has not only continued to lead the world in terms of efficiency but has improved outcomes to a world leading level and that has also grown to absorb more aspects of healthcare. Why do we complain about 2 month waits for non-emergency surgery, yet tolerate 2 year waits for dentist lists? Why do we accept a £15 charge to visit an optician, while begrudgingly paying an £8 prescription charge for drugs that would otherwise cost £30?

I believe the NHS will once again be an organisation that can claim to truly support people from cradle to grave, but first we have to ensure that we see its true value, not only as a collection of buildings and workers, but as a bastion of unity, togetherness, and equality unparalleled anywhere in the world.