̽��ֱ�� of Cambridge - patient

Supertroopers: CAR-T cell cancer therapy

lw355 — Wed, 16 Oct 2024 08:00:15 +0000

A life-saving cancer therapy is being scaled up in Cambridge to deliver more treatments to more patients for more cancers.

Cancer isn’t fair – but care should be

lw355 — Sun, 04 Feb 2024 07:50:57 +0000

Listening to people's lived experiences is helping to improve the awareness and uptake of cancer care. On World Cancer Day, we take a look at some of the ways researchers are working with communities to ‘close the cancer care gap’.

No evidence to support claims that telephone consultations reduce GP workload or hospital referrals

sc604 — Wed, 27 Sep 2017 22:30:00 +0000

As UK general practices struggle with rising demand from patients, more work being transferred from secondary to primary care, and increasing difficulty in recruiting general practitioners, one proposed potential solution is a ‘telephone first’ approach, in which every patient asking to see a GP is initially phoned back by their doctor on the same day. At the end of this phone call the GP and the patient decide whether the problem needs a face-to-face consultation, or whether it has been satisfactorily resolved on the phone.

Two commercial companies provide similar types of management support for practices adopting the new approach, with claims that the approach dramatically reduces the need for face-to-face consultations, reduces workload stress for GPs and practice staff, increases continuity of care, reduces A&E attendance and emergency hospital admissions, and increases patient satisfaction.

Some of these claims are repeated in NHS England literature, including the assertion based on claims from one of the companies that practices using the approach have a 20% lower A&E usage and that “the model has demonstrated a cost saving of approximately £100k per practice through prevention of avoidable attendance and admissions to hospital”. Several Clinical Commissioning Groups have subsequently paid for the management support required for the approach to be adopted by practices in their area.

̽��ֱ��National Institute for Health Research (NIHR) acknowledged the need for robust and independent evaluation of current services and therefore commissioned the team led by Martin Roland, Emeritus Professor of Health Services Research at the ̽��ֱ�� of Cambridge. ̽��ֱ��results of the evaluation, which looked at data sources including GP and hospital records, patient surveys and economic analyses, are published today in ̽��ֱ��BMJ.

̽��ֱ��study found that adoption of the ‘telephone first’ approach had a major effect on patterns of consultation: the number of telephone consultations increased 12-fold, and the number of face-to-face consultations fell by 38%.

However, the study found that the ‘telephone first’ approach was on average associated with increased overall GP workload; there was an overall increase of 8% in the mean time spent consulting by GPs, but this figure masks a wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase.

Dr Jennifer Newbould from RAND Europe, part of the Cambridge Centre for Health Services Research, the study’s first author, says: “There are some positives to a ‘telephone first approach’; for example, we found clear evidence that a significant part of patient workload can be addressed through phone consultations. But we need to be careful about seeing this as a panacea: while this may increase a GP practice’s control over day-to-day workload, it does not necessarily decrease the amount of time GPs spend consulting and may, in some cases, increase it.”

̽��ֱ��researchers found no evidence that the approach substantially reduced overall attendance at A&E departments or emergency hospital admissions: introduction of the ‘telephone first’ approach was followed by a small (2%) increase in hospital admissions, no initial change in A&E attendance, but a small (2% per year) decrease in the subsequent rate of rise of A&E attendance. However, far from reducing secondary care costs, they found overall secondary care costs increased slightly by £11,776 per 10,000 patients.

Professor Roland adds: “Importantly, we found no evidence to support claims made by one of the companies that support such services – claims that have been repeated by NHS England – that the approach would be substantially cost-saving or reduce hospital referrals. This has resulted in some Clinical Commissioning Groups across England buying their consultancy services based on unsubstantiated claims. ̽��ֱ��NHS must be careful to ensure that it bases its information and recommendation on robust evidence.”

̽��ֱ��study was funded by the National Institute for Health Research.

Reference
Newbould, J et al. Tele-First. Evaluation of a ‘telephone first’ approach to demand management in English general practice: observational study. BMJ (2017). DOI: 10.1136/bmj.j4197

Telephone consultations to determine whether a patient needs to see their GP face-to-face can deal with many problems, but a study led by researchers at the Cambridge Centre for Health Services Research ( ̽��ֱ�� of Cambridge and RAND Europe), found no evidence to support claims by companies offering to manage these services or by NHS England that the approach saves money or reduces the number of hospital referrals.

̽��ֱ��NHS must be careful to ensure that it bases its information and recommendation on robust evidence.

Martin Roland

skeeze

Health/Medical

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Concerns over wasting doctor’s time may affect decision to see GP

cjb250 — Tue, 07 Feb 2017 09:11:57 +0000

In the study, published today in the journal Social Science and Medicine, researchers from the Cambridge Centre for Health Services Research report how the theme of ‘wasting doctors’ time’ arose so often during interviews conducted with patients about their experiences of primary care that they chose to study this topic in its own right.

“‘Am I wasting the doctor’s time?’ is a question that many patients ask themselves when deciding whether or not to visit the doctor,” explains Dr Nadia Llanwarne, who led the study. “We already knew that this worry existed among some patients, but this is the first study entirely dedicated to the subject that reports the existence of this worry among a variety of patients, young and old, healthy and sick, visiting their GP for a wide range of complaints.”

As part of the study, Dr Llanwarne and colleagues filmed patients’ consultations with their GPs and then interviewed 52 patients across GP surgeries in London, the east of England and south west England about their experience. It was in these interviews that the issue of timewasting arose.

̽��ֱ��researchers identified three threads common to the issue of timewasting present across patients’ narratives in general practice: the experience of a conveyor belt approach to care, the intimation that ‘other patients’ waste time, and uncertainty among patients over what is worthy of their doctor’s time.

̽��ֱ��authors consider the reasons why people appear concerned about timewasting. Patients spoke of the pressured context in which their consultations take place: the demand on services, the NHS’s limited resources, the lack of time, and busy doctors. Understanding the time pressures that doctors face, patients described how these challenges influenced their decision to see their GP.

In an overstretched NHS, time becomes all the more precious, and this has meant that public campaigns often refer to appropriate and inappropriate users. For decades, doctors have expressed frustration that too many patients visit unnecessarily. As a result of these judgments cast upon them, patients voice the pressure to consult only when necessary and speak openly of ‘timewasters’.

“Patients are keen to avoid this label, but neither the patients, nor the doctors, are able to clearly define what precise problems might attract such a label,” says Dr Llanwarne. “This is because some patients will present with what seems on the surface a minor problem, but once through the door of the doctor’s consulting room, they may open up about more serious complaints. With some symptoms it may be very difficult for the patient to know whether these are serious enough or not to need review by the doctor.

“Recognising this worry about timewasting among patients is important because it could influence whether a patient chooses to see the doctor or not. If a patient decided to hold off seeing the doctor for fear of wasting resources, this could have serious implications for their health.”

Dr Llanwarne adds: “It’s important for patients to not delay contacting their doctor simply because of worry about wasting doctors’ time. And it’s important for doctors to be attentive to the fact that many patients will be worried about this. Doctors can then ensure they allay patients’ concerns when they do seek help.”

̽��ֱ��study was funded by the National Institute for Health Research.

Reference
Llanwarne, N et al. Wasting the doctor's time? A video-elicitation interview study with patients in primary care. Social Science & Medicine; e-pub 18 January 2017; DOI: 10.1016/j.socscimed.2017.01.025

Worries over wasting their doctor’s time, particularly at a time when NHS resources are stretched, may influence when and whether patients choose to see their GP, according to a study carried out by the ̽��ֱ�� of Cambridge.

Recognising this worry about timewasting among patients is important because it could influence whether a patient chooses to see the doctor or not. If a patient decided to hold off seeing the doctor for fear of wasting resources, this could have serious implications for their health

Nadia Llanwarne

jasleen_kaur

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Keeping patients safe in hospital

cjb250 — Tue, 15 Nov 2016 09:39:09 +0000

In November 2004, Mary McClinton was admitted to Virginia Mason Medical Center in Seattle, USA, to receive treatment for a brain aneurysm, a potentially serious swelling in a blood vessel. What followed was a tragedy, made worse by the fact that it was entirely preventable.

McClinton was mistakenly injected with the antiseptic chlorhexidine. It happened, the hospital says, because of “confusion over the three identical stainless steel bowls in the procedure room containing clear liquids — chlorhexidine, contrast dye and saline solution”. Doctors tried amputating one of her legs to save her life, but the damage to her organs was too great: McClinton died 19 days later.

Nine years on, an almost identical accident occurred at Doncaster Royal Infirmary in the UK. Here, the patient, ‘Gina’, survived, but only after having her leg amputated.

Professor Mary Dixon-Woods is one of Cambridge’s newest recruits, and she is on a mission: to improve patient safety in the National Health Service and in healthcare worldwide. She has recently taken up the role as RAND Professor of Health Services Research, having moved here from the ̽��ֱ�� of Leicester.

It is, she admits, going to be a challenge. Many different policies and approaches have been tried to date, but few with widespread success, and often with unintended consequences.

Financial incentives are widely used in the NHS and in the USA, but recent evidence suggests that they have little effect. “There’s a danger that they tend to encourage effort substitution – what people often refer to as ‘teaching to the test’,” explains Dixon-Woods. In other words, people focus on the areas that are being incentivised, but neglect other areas. “It’s not even necessarily conscious neglect. People have only a limited amount of time, so it’s inevitable they focus on areas that are measured and rewarded: it’s an economy of attention as much as anything else.”

In 2013, Dixon-Woods and colleagues published a study, funded by the Wellcome Trust, evaluating the use of surgical checklists introduced in hospitals to reduce complications and deaths during surgery. ̽��ֱ��checklists have become the most widely used patient safety intervention in the world and are recommended by the World Health Organization. Yet, the evidence shows that checklists may have little impact, and her research found that in some situations – particularly in low-income countries – they might even make things worse.

“ ̽��ֱ��checklists sometimes introduced new risks. Nurses would use the lists as a box-ticking exercise rather than as a true reflection of events – they would tick the box to say the patient had had their antibiotics when there were no antibiotics in the hospital, for example.” They also reinforced the hierarchies – nurses had to try to get surgeons to do certain tasks, but the surgeons used it as an opportunity to display their power and refuse.

Problems are compounded by a lack of standardisation. Dixon-Woods and her team spend time in hospitals to try to understand which systems are in place and how they are used. Not only does she find differences in approaches between hospitals, but also between units and even between shifts. “Standardisation and harmonisation are two of the most urgent issues we have to tackle. Imagine if you have to learn each new system wherever you go or even whenever a new senior doctor is on the ward. This introduces massive risk.”

One place that has managed to break this pattern is Northern Ireland, which has overcome the problem of poor labelling of lines such as intravenous lines and urinary catheters

Even when an institution manages to make genuine improvements in patient safety, too often these interventions cannot be replicated elsewhere or scaled up, leading to the curse of “worked once”, as she describes it.

One place that has managed to break this pattern is Northern Ireland, which has overcome the problem of poor labelling of lines such as intravenous lines and urinary catheters. A sick patient may have several different lines attached to them; these were not labelled in any consistent way – if at all – so a nurse might use the wrong line or leave a line in place too long, risking infection. Over 18 months, the health service in Northern Ireland came up with a solution. Soon, whether you are in a hospital, a nursing home or a hospice, every line will be labelled the same way.

“I’m interested in how they managed to achieve that and what we can learn that can be used in the next place that wants to standardise their lines.”

Dixon-Woods compares the issue of patient safety to that of climate change, in the sense that it is a “problem of many hands”, with many actors, each making a contribution towards the outcome, and where it is difficult to identify who has responsibility for solving the problem. “Many patient safety issues arise at the level of the system as a whole, but policies treat patient safety as an issue for each individual organisation.”

Nowhere is this more apparent than the issue of ‘alarm fatigue’. Each bed in an intensive care unit typically generates 160 alarms per day, caused by machinery that is not integrated. “You have to assemble all the kit around an intensive care bed manually,” she explains. “It doesn’t come built as one like an aircraft cockpit. This is not a problem a hospital can solve alone. It needs to be solved at the sector level.”

Dixon-Woods has turned to Professor John Clarkson in Cambridge’s Engineering Design Centre to help. Clarkson has been interested in patient safety for over a decade; in 2004, his team published a report for the Chief Medical Officer entitled ‘Design for patient safety – a system-wide design-led approach to tackling patient safety in the NHS’.

We need to look through the eyes of the healthcare providers to see the challenges and to understand where tools and techniques we use in engineering may be of value
John Clarkson

“Fundamentally, my work is about asking how can we make it better and what could possibly go wrong,” explains Clarkson. It is not, he says, just about technology, but about the system and the people within the system. When he trains healthcare professionals, he avoids using words like ‘risk’, which mean different things in medicine and engineering, and instead asks questions to get them thinking about the system.

“We need to look through the eyes of the healthcare providers to see the challenges and to understand where tools and techniques we use in engineering may be of value. I have no doubt that if you were to put a hundred engineers into Addenbrooke’s [Hospital], you could help transform its care.”

There is a difficulty, he concedes: “There’s no formal language of design in healthcare. Do we understand what the need is? Do we understand what the requirements are? Can we think of a range of concepts we might use and then design a solution and test it before we put it in place? We seldom see this in healthcare, and that’s partly driven by culture and lack of training, but partly by lack of time.”

Dixon-Woods agrees that healthcare can learn much from how engineers approach problems. “Medical science tends to prioritise trials and particular types of evidence, whereas engineering does rapid tests. Randomised controlled trials do have a vital role, but on their own they’re not the whole solution. There has to be a way of getting our two sides talking.”

Only then, she says, will we be able to prevent further tragedies such as the death of Mary McClinton.

Healthcare is a complex beast and too often problems arise that can put patients’ health – and in some cases, lives – at risk. A collaboration between the Cambridge Centre for Health Services Research and the Department of Engineering hopes to get to the bottom of what’s going wrong – and to offer new ways of solving the problems.

Standardisation and harmonisation are two of the most urgent issues we have to tackle. Imagine if you have to learn each new system wherever you go or even whenever a new senior doctor is on the ward. This introduces massive risk

Mary Dixon-Woods

Toshiyuki Imai

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South Asian patients have worse experiences of GP interactions, study suggests

cjb250 — Thu, 15 Sep 2016 08:11:54 +0000

Patients’ evaluations of doctors’ interpersonal skills are used to assess quality of care. In both the UK and the US, certain minority ethnic groups report lower patient experience scores compared to the majority population. For example, the English General Practice Patient Survey found that South Asian groups report particularly low scores compared to the White British majority, with Bangladeshi and Pakistani groups providing the lowest scores.

Several potential explanations have been proposed for these lower ratings. These mainly relate to whether South Asian patients receive lower quality care, or whether they receive similar care, but rate this more negatively.

To explore whether the low scores reflect a genuinely poor experience, researchers at the Centre for Health Services Research, ̽��ֱ�� of Cambridge, showed 564 White British and 564 Pakistani adults a series of films showing typical clinical scenarios. They were asked to rate how good the GP was at various measures: giving sufficient time and listening to the patient in the the film, explaining the tests and treatment, involving the patients in decisions about care and treating them with care and concern.

Based on the participants’ responses, the researchers then gave a score out of 100 for how positively the participants had judged the GP’s performance in the vignettes. ̽��ֱ��results of the study, funded by the National Institute for Health Research, are published in the journal BMJ Open.

̽��ֱ��scores from Pakistani participants were typically higher than those from White British participants when they’d seen the same video. ̽��ֱ��mean communication score from Pakistani participants was 67 of 100, ten points higher than the mean score from White British participants. When adjusted for age, gender, deprivation, self-rated health, and video, the difference increased to 11 points. ̽��ֱ��largest differences were seen when participants were over 55 years old.

“Given that Pakistani adults tend to have a more positive take on the same vignettes viewed by their White British counterparts, we can only conclude that the low scores they give in national surveys do genuinely reflect worse care,” says Dr Jenni Burt from the Cambridge Centre for Health Services Research at the ̽��ֱ�� of Cambridge.

“To some extent, this may reflect challenges arising from language barriers and poorer health literacy, but this is unlikely to explain all of the variations in care. These findings very clearly show that there are major inequalities in care for minority ethnic groups.”

Professor Martin Roland, Emeritus Professor of Health Services Research at the ̽��ֱ�� of Cambridge, adds: “Understanding why minority ethnic groups often give poorer evaluations of care is critical to helping health services improve the services they offer to their patients. We need more research now that focuses on how factors such as language barriers, health literacy, discrimination and system-level failures that combine to create inequalities that affect South Asian people.”

Reference
Burt, J et al. Understanding negative feedback from South Asian patients: experimental vignette study. BMJ Open; 8 Sept 2016; DOI: 10.1136/bmjopen-2016-011256

Communication between doctors and South Asian patients is poor, according to national GP surveys, but a question has been raised about whether this reflects genuinely worse experiences or differences in responding to questionnaires. Now, a new study led by researchers at the ̽��ֱ�� of Cambridge has shown that it is in fact the former – South Asian patients do experience poorer communication with their GP than the White British majority.

Given that Pakistani adults tend to have a more positive take on the same vignettes viewed by their White British counterparts, we can only conclude that the low scores they give in national surveys do genuinely reflect worse care

Jenni Burt

Jasleen Kaur

Stethoscope

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