Touch matters COVID-19, physical examination, and 21st century general practice - Department of Primary Care & Public Health - Imperial College ...
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Spring 2021 Department of Primary Care & Public Health
touch
matters
COVID-19, physical examination, and 21st
century general practice
Image by jcomp via freepik.com
Spring 2021
Many of the articles in this edition of our newsletter
discuss Covid-19 vaccination. This is now being rolled
out nationally and offers the best way for the United
Kingdom to bring the Covid-19 pandemic under
control, and allow a return to a more normal way of
living. We are very proud that many members of the
department, and also many of our medical students,
have contributed to the vaccination programme;
including working as vaccinators and addressing vaccine hesitancy in
marginalised groups. There is also a reminder in the newsletter that Covid-19
is a global pandemic and we won’t be truly safe in the United Kingdom until
vaccination programmes have targeted the
rest of the world’s population, in Professor Azeem Majeed
Head of Department of Primary Care and
particular, people in low income countries. Public Health
Imperial College London
Follow Prof Majeed on Twitter
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Copyright © 2021 Department of Primary Care & Public Health, Imperial College London
RETURNING TO PHYSICAL ACTIVITY AFTER A
COVID-19 INFECTION
Image: rawpixel.com
In an article published in the British Medical Journal, we
discuss returning to physical activity after a Covid-19
infection.
A risk-stratification approach can help maximise safety and mitigate
risks, and several factors need to be taken into account. First, is the
person physically ready to return to activity? In the natural course of
Covid-19, deterioration signifying severe infection often occurs at
around a week from symptom onset.
Therefore, consensus agreement is that a return to exercise or
sporting activity should only occur after an asymptomatic period of
at least seven days, and it would be pragmatic to apply this to any
strenuous physical activity. English and Scottish Institute of Sport
guidance suggests that, before re-initiation of sport for athletes,
activities of daily living should be easily achievable and the person
able to walk 500 metres on the flat without feeling excessive fatigue
or breathlessness. However, we recommend considering the
person’s pre-illness baseline, and tailoring guidance accordingly.
PROFESSOR MAJEED AWARDED LEADING HEALTH HONOURS
Six Imperial researchers, including Professor Azeem Majeed, have been appointed to
prestigious research positions by the National Institute of Health Research (NIHR).
They have been named as NIHR Senior Investigators – positions given to those who are
deemed to be the most outstanding leaders of patient and people-based research within
the NIHR faculty. They provide research leadership to the NIHR faculty, promoting clinical
and applied research in health and social care. They also act as a key source of advice to the
Department of Health and Social Care’s Chief Scientific Adviser.
FULL STORY
CONGRATULATIONS PROFESSOR KOSH RAY, YOU'RE A HIGHLY
CITED RESEARCHER ─ 2020
Each year, Clarivate™ identifies the world’s most influential researchers ─ the select few
who have been most frequently cited by their peers over the last decade. In 2020, fewer
than 6,200, or about 0.1%, of the world's researchers, in 21 research fields and across
multiple fields, have earned this exclusive distinction.
Prof Ray is among this elite group recognized for his exceptional research influence,
demonstrated by the production of multiple highly cited papers that rank in the top 1% by
citations for field and year in the Web of Science™.
AWARD FOR BEST PREMATURITY AND NEONATAL RESEARCH -
INTERNATIONAL CONFERENCE 2020
Dr Enitan Ogundipe was selected as the
‘Best Neonatal and Prematurity Research
with educational grant’ award. The work
was on improving the brain outcomes of
babies by optimising their mothers’
nutrition in a double blinded placebo-
controlled trial. The study was based on
work published in Prog Lipid Res 2018
which gave the first ever evidence of effect
of maternal ‘Brain Specific’ fatty acid
supplementation on their new-born
babies’ Brain volumes measured using MRI
scan.
ALERT TO SEPSIS WHOCC AND ROYAL COLLEGE
OF PHYSICIANS, EDINBURGH
Researchers have been awarded
JOINT FELLOWSHIP
over £800,000 to review the impact
of a digital alert system to monitor WHO CC and Royal College of Physicians,
patients with sepsis at NHS Edinburgh, have been working on a joint
hospitals Quality Governance Fellowship, which will
be launched in the latter part of the year.
Dr Kate Honeyford (Global Digital Health The fellowship will be based in London,
Unit) joined a group of national leaders on and applications will be open in spring.
26 Feb to provide a comprehensive seps More information to be announced on the
training day for nurses, paramedics, Centre’s website.
doctors and other healthcare
professionals. CHILD HEALTH UNIT
CHRISTMAS SOCIAL
Kate described the impact of digital sepsis
alerts at ICHT, how using data as part of a Child Heath Unit PhD Student, Tishya
learning healthcare system can improve Venkatraman, organised a Christmas
patient care and described the future Social Bingo for the Child Health Unit
work of the DiAlS NIHR project. before the college closure. We saw ugly
Christmas jumpers, learnt about each
Kate was keen to link robust statistical other’s strange food choices, heard a
methodology with improving patient clinician and lecturer sing his favourite
outcomes – which meant describing Karaoke song, and guessed each other’s
propensity score matching on a Friday and spirit animals. It was a lovely way to
afternoon! Although challenging, Kate end a trying year with some fun and
gave a clear and erudite description of the laughs.
approach. In addition, Kate spoke about
the need to appreciate the role, both
observational studies and natural
experiments, have in our understanding of
healthcare provision. Conference
delegates described the talk as
‘interesting but very complex and blew my
mind a little’, additional comments
included ‘so interesting to see how data
can be used to benefit quality
improvement’ and ‘pertinent to my digital
transformation role’. The positive VIVA SUCCESSES
response of delegates clearly
demonstrates that clear, relevant Congratulations to Shirin Aliabadi and
explanations of data and statistics are Federica Amati on passing their vivas.
received well by a range of audiences.
My gran has had both her jabs. It’s unlikely that employers could
Once lockdown has ended, can I go force you to get vaccinated, but
and see her? they could recommend vaccination
for staff who have public-facing
Once lockdown ends and the
roles that place them at increased
prohibition on people from different
risk of infection.
households mixing indoors stops,
including for the clinically extremely Everyone in my mum’s care home
vulnerable, you would be able to has had the vaccine. Should they
visit your grandmother. However, it allow relatives to visit without a
may be some time before this screen?
happens.
Relatives will continue to need to be
I’ve been shielding on my own. screened for now because the
Once I’ve had the vaccine will I be Covid-19 vaccines are not 100%
able to form a bubble with other effective even after two doses and
family members? some vaccinated people can still get
infected. The risk of serious illness,
You would need to continue to
complications and death is very high
follow any lockdown rules that are
in people living in care homes and
in place in your local area even after
we must be particularly cautious
you have had two doses of the
with this group.
vaccine.
Can I still be fined for breaking the
I’ve had my first vaccine – can I hug
rules if I show my vaccine card?
my grandchildren?
A vaccine card does not exempt you
One vaccination offers only partial
from following any local or national
protection. Two vaccinations are
rules that are in place; so yes, you
needed for maximum protection.
can be fined for breaking lockdown
Even after receiving two doses of
rules even if you have proof of
vaccine, you would still need to
vaccination.
follow any lockdown rules that were
in place in your local area. Once everyone has been
vaccinated, might there be places
Can my employer force me to get
those who have refused the
vaccinated?
vaccine aren’t allowed?
It’s possible that some places might It will take some time for research
implement this policy. For example, to establish this. We may find out
some cruise companies have said later in 2021.
they will require proof of
If one of my employees has been
vaccination from customers.
vaccinated, should I consider
Will I need to show proof of my him/her for a role that has a higher
vaccine to travel abroad? risk of infection?
It’s possible that some countries will Employers should risk assess staff
require proof of vaccination before before placing them in a specific
allowing you to travel there but this role. My view is that vaccination
will vary from country to country. should not be used as a reason for
placing potentially clinically
If I’ve had my vaccine will I still
vulnerable staff in high-risk roles
have to self-isolate if I’ve been in
that expose them to a greater risk
contact with someone who tested
of infection.
positive?
I’m a piano teacher. Can I advertise
If you have been in recent contact
for students using my proof of
with someone who has tested
vaccination to show I’m Covid free?
positive, you would still need to
self-isolate for 10 days because at Vaccination does not guarantee that
this point, we don’t know if you will be “Covid-free”. You would
vaccination stops you being need to continue to follow any
infectious. lockdown rules that are in place in
your local area.
When will we know if the vaccine
just stops you getting symptoms or
stops you getting infected?
Q&As about the AstraZeneca Covid-19 Vaccine
Should I really be worried about suffered from blood clots after
blood clots? receiving the vaccine but no causal
relationship has been found and the
The AstraZeneca vaccine has been
number of people affected is not
given to many millions of people
above what we would expect in the
across the world (over 10 million in
general population in people who
the UK). A few of these people have
did not receive the vaccine.
Image by vecteezy.com
How safe is the vaccine? Does your age affect the likelihood
of side effects? (For instance, do
The clinical trials in which the
younger people feel worse because
vaccine was tested showed it was
their immune systems are better?)
very safe, with a very low level of
serious side effects and this has Side effects can occur at all ages but
been confirmed subsequently in the tend to be less common in older
wider use of the vaccine in the UK people. This is thought to be
and elsewhere. because the immune system
gradually weakens with age, which
Why are so many countries
also leaves older people more
suspending it?
susceptible to infection.
When a possible side effect is linked
Won’t I still be protected if I refuse
to a drug or vaccine, some countries
the vaccine, because so many other
will temporarily suspend use of the
people have had it?
product until this has been
investigated further. This does not It’s important that as many people
mean that the vaccine is unsafe and as possible receive the vaccine. If
we would expect further review of many people are not vaccinated, we
the data to confirm its safety. will continue to see outbreaks of
Covid-19. The vaccine is not 100%
Can I reduce the risk of a blood clot
effective and children are not
by taking an aspirin?
currently being immunised, so there
It’s probably not advisable to use will be many people who can still
aspirin in this way athere is a small become infected.
risk of suffering a serious stomach
What’s the down side of not having
bleed after taking aspirin.
the vaccine?
What are the other possible side
If you don’t receive the vaccine, you
effects of the vaccine?
are at much higher risk of
The most common side effects of contracting a Covid-19 infection.
the vaccine are pain and tenderness These infections can be serious,
at the injection site, headache, leading to long-term complications
tiredness, generalised muscle pain, and death in many people. You may
shivering and a fever. These side also infect others, including elderly
effects usually resolve within a few relatives who may be at high-risk of
days. serious illness. Furthermore, the
more people who receive the
vaccine, the more likely we are to an end to the pandemic and the lockdown
measures it has led to.
In an article published in the Daily Mirror, Matt Roper and Prof
Azeem Majeed debunk some of the common myths and
misconceptions about vaccines.
Scepticism about vaccines has been growing throughout the
pandemic and a recent survey found that one in five British adults
may refuse to take a coronavirus jab – even though it is probably
our only hope of a return to normality.
1. MYTH: A vaccine produced Azeem Majeed is professor of
so quickly can’t be safe primary care and public health at
Imperial College London
Most vaccines take years to
develop, test and approve for public “Allergies to vaccines are very rare,”
use but, says Dr Majeed, a global says Dr Majeed. “They are given
effort has meant scientists have safely to millions of people every
been able to work at record speed. year.”
He says: “Covid-19 vaccines have to The odds you’ll have a severe
go through the same process of reaction to a vaccine is about one in
approval as other vaccines. Funding 760,000.
was made available immediately
Being struck by lightning next year is
and studies set up rapidly.
higher at one in 700,000.
“There have been a lot of
Most reactions are because of some
technological developments that
other component of the vaccine,
allow vaccines to be developed
such as egg protein, if the person is
much more quickly.”
severely allergic.
2. MYTH: I might be allergic but
3. MYTH: There haven’t been
won’t know until I get it
enough tests for people with
underlying conditionsDr Majeed says: “There are many contain a live coronavirus,” assures
vaccine trials taking place and they Dr Majeed, “and they therefore
are being tested in people with can’t give you a coronavirus
different characteristics, such as infection”.
age, sex, ethnicity and medical
6. MYTH: If everyone around
history.
me is immune, I don’t need a
“Results show they are safe in all vaccine
groups they have been tested in.”
“It’s essential to achieve a high
4. MYTH: Vaccines can overload vaccine coverage so we create herd
your immune system immunity,” says Dr Majeed. “If
people refuse to be immunised, we
In 2018 the myth was debunked by
will continue to get outbreaks of
American researchers who
Covid-19.
examined the medical records of
more than 900 infants from six “If you decline to be immunised,
hospitals. you may get infected and also infect
the people you come into contact
They found no link between
with.”
vaccines given before the age of
two and other infections in the 7. MYTH: It’s better to be
following years. immunised by catching Covid
“Vaccines do not overload your Dr Majeed says: “Vaccines have
immune system,” says Dr Majeed. been shown to be very safe,
“On the contrary, they generate an whereas illnesses such as measles
immune response that helps reduce and Covid-19 can lead to serious
the risk of infection, complications long-term medical complications.
and death.”
“Vaccines have saved many lives
5. MYTH: The vaccine could and prevented people from being
actually give me coronavirus left disabled.”
Some vaccines contain the germs 8. MYTH: Vaccinated children
that cause the disease they are experience more allergic,
immunising against, but they have autoimmune and respiratory
been killed or weakened to the diseases
point they don’t make you sick.
This is another unfounded claim
In the case of a coronavirus vaccine, that has led some parents to delay
“none that are in developmentor withhold vaccinations, says Dr syndrome, a rare neurological
Majeed. disorder.
Studies examining many vaccines Dr Majeed says: “Covid-19 vaccines
have failed to find a link with have been carefully tested in a large
allergies or autoimmune disease. number of volunteers and found to
be very safe.
“Vaccines protect against many
diseases and substantially reduce 11.MYTH: Vaccines cause
the risk of illness and death in autism
children,” he says.
The idea that vaccines cause autism
9. MYTH: Some of those taking has long been disproved but the
part in trials died claims have recently been doing the
rounds again.
Stories that Dr Elisa Granato, one of
the first participants in the human Last year a massive study from
trials of the Oxford vaccine, died Denmark found no association
shortly after being injected, were between being vaccinated against
shared millions of times. measles, mumps and rubella, and
developing autism.
The news was false, and she gave a
BBC interview saying she was It is the latest of at least 12 other
feeling “absolutely fine”. studies that have tried and failed to
find a link.
“Only one death has been reported
among people taking part in trials,” Dr Majeed says: “No evidence has
says Dr Majeed. ever been found that vaccines cause
autism in children.”
João Pedro Feitosa, a doctor in
Brazil, was given the placebo rather 12.MYTH: The Spanish Flu
than the vaccine and died of Covid- vaccine led to 50 million
related complications. deaths
10.MYTH: The swine flu vaccine During the 1918 pandemic, it was
left people with side effects, the fact there was no vaccine, that
so why would this one be caused it to infect a third of the
safe? world’s population.
A mass vaccination programme In the 1930s scientists found it was
against swine flu in the US in 1976 caused by a virus, with the first
led to increased chances of people vaccine developed a decade later.
developing Guillain-BarreImage by vecteezy.com
Image by jcomp via freepik.com
touch
matters
COVID-19, physical examination,
and 21st century general practice
By Paquita de Zulueta
The pandemic, not yet over, has already significantly
changed how primary care functions. GPs, typically
innovative and adaptable, swiftly switched to
‘remote’ consulting in March, with telephone and
video consultations the norm and face-to-face the
exception, albeit still available. GP’s express
concerns that the ‘flight to the virtual’ may lead to
losses, including the sapping of energy and joy and
an increase in health inequalities. But there is
another deeper issue at stake. The loss of touch in
our personal encounters threatens the wellbeing of
all of us and, in particular, for those who are
vulnerable and living alone. In the context of our
professional encounters, the physical examination,
aside from its diagnostic value, is an important mode
of communication and a skill that requires embodied
learning and practice — ‘body pedagogics’. We
should be wary of discounting its value.HUMAN SKIN AND THE ‘MAGIC’ OF TOUCH
Giles Dawnay in the BJGP posed the calming us by activating the
question: ‘Could our skin be far more than parasympathetic system, releasing
just a barrier to the elements?’ My oxytocin, serotonin, and endogenous
answer is a definite ‘yes’. Ashley Montagu, opioids, thus additionally acting as an
in his seminal book reminds us that the anaesthetic. Touch enhances cooperation
skin ‘is the oldest and the most sensitive and trust.
of our organs, our first medium of
communication and our most efficient And yet, despite this rich evidence from a
protector.’ The largest and most versatile variety of disciplines, touch is poorly
of our sense organs, it holds an researched in the medical field and
astonishing number of sensory receptors curiously lacking in medical and bioethical
for heat, cold, touch, and pain, giving us discourse.
an integrated sense of our bodies. When we are stressed and feeling
Montagu claims that touch is more vulnerable, we long for and need kind,
powerful than language and central to human touch. This is why the ‘social
human life, providing us with our most distancing’ imposed by this pandemic is so
fundamental means of contact with the cruel and dehumanising for all of us, but
external world. Research indeed confirms particularly for those who live alone, for
that the skin is a social organ, coding the vulnerable, the sick, the bereaved, the
interpersonal interactions and enabling us dying, for caregivers who are denied
to develop our sense of ‘felt security’ and access to their loved ones, and for
connectedness. Touch communicates healthcare professionals looking after
emotion in a ‘robust fashion’ and people patients with COVID-19 who fear to touch
can discern with a high degree of accuracy their partners and children when they go
anger, fear, sadness, and disgust, as well home.
as happiness, gratitude, sympathy, and
love. Research shows that touch — in We have all read or heard the harrowing
particular, affectionate touch — is also stories from caregivers and from those
key to relational, physical, and who have lost their loved ones in COVID-
psychological wellbeing in adults. 19 times.
Affectionate touch buffers one to stress,
THE PHYSICAL EXAMINATION
Abraham Verghese and Ralph I Horwitz
have made a passionate call for the
reinstatement of the physical
examination, arguing that it not only
avoids unnecessary tests but also helps to
develop trust, empathy, and relationship
building.
In my 35 years as a GP I have been
surprised by the revelations that have
Dr Paquita de ZuluetaImage: rawpixel.com via freepik.com
flowed from the many physical humane and authentic conversation than
examinations. This practice has often felt peering at a blood test or X-ray results on
as an almost sacred ritual eliciting trust a computer screen. This is not to
and information that bypasses the verbal disparage the usefulness of test results or
and visual. Yes, there were the diagnostic the telephone consultation and
surprises — the unexpected lump, the telemedicine. They may well be lifesaving
hidden bruises or scars, the unsuspected in some circumstances and do offer
breech, or perhaps a ‘secret’ tattoo or convenience, although not necessarily
body-piercing. But often the revelations speed.
were stories of pain and suffering —
sexual assault in childhood, torture in Visiting the frail elderly when working for
another country, a coercive or illicit the emergency service, I was struck by
relationship, an unmourned bereavement, their anguished loneliness. Yes, the carer
hidden fears. And as I percussed the had filled the dosset box, and checked
chest, or palpated the abdomen, or even that they had ‘taken their meds’ and had
undertook an intimate examination, I eaten (maybe), but what seemed to give
would hear ‘I have never told anyone them solace, to elicit a tentative smile or
about this, doctor.’ Touch became a door even tears of relief, was when I held their
to a hereto undisclosed inner world. hands, gnarled and trembling, in a firm,
warm clasp. They longed to have a chat,
I use the examination to further the to reminisce, to share a cup of tea. I would
dialogue, to hear more about people’s try to bring some humanity to the
lives, who they are, what they do, their encounter, but time pressures limited the
family, their hobbies. And this dialogue is scope for this.
conducted at two complementary levels
— with our speech and our bodies. The Phenomenology — a philosophy of
intimacy of contact encourages a more embodiment in which mind and body are
inseparable — offers us rich insights intotouch. Maurice Merleau-Ponty reminds us In the intimacy of the physical
that the lived body is reversible or examination we, as both patients and
‘double-sided’ in that it is both an clinicians, render ourselves more open,
experiencing subject and a material object more vulnerable. The etymology of the
in the world. This ‘dual existence’ as both word is relevant: the Latin intimus
consciousness and physical matter is signifying ‘innermost’, and intimare to
probably unique to humans. Touch brings ‘impress’, or ‘make familiar’.
us in contact with others, but also with
our own embodiment. When carrying out The avoidance of touch may be linked to
a physical examination we are observers the understandable fear of being seen as
and examiners, but also subjects who are invasive, of transgressing boundaries, or
responding to our patients’ responses and even being accused of sexual molestation
perceptions of us. It is a form of dynamic — but is there also an unspoken fear of
dialogue and we oscillate between our engagement, of getting ‘too close’ to our
subjectivity and objectivity. patients, of being ‘touched’ by their
suffering?
A TYPOLOGY OF TOUCH
Touch can help us as clinicians to discern, bodies. Leder describes how those in the
detect, and diagnose, but can also allow ‘kingdom of the sick’ yearn for the caring
us to express empathy, reassurance, touch: ‘Ultimately, healing touch is not
comfort, and presence. A study of GP’s something the clinician does or the
and patients’ perceptions regarding touch patient. Touch unfolds in the reciprocal
revealed that all patients and most space between the I-Thou relationship.’
doctors believed that ‘expressive touch’ This reciprocal touch is described in the
improved communication. literature as ‘relational’, ‘empathic‘,
‘compassionate’, or ‘caring’.
‘Healing touch’ has a long history dating
from classical times with the myth of From my lived experience as both patient
Asclepius, the Greek god of medicine. and doctor, I believe it is possible to use
Drew Leder describes the impersonal both kinds of touch concurrently — a
‘objectifying touch’, and the ‘absent ‘compassionate objectivity’. A study with
touch’ when technology displaces human- Canadian family doctors appears to
to-human interaction. Objectifying touch confirm this: the GP’s viewed the physical
— also described as ‘procedural’ or examination as practising good medicine
‘instrumental’ — is necessary, but if and that the ‘gnostic’ (intellectual,
unaccompanied by any form of empathy objective) elements were inextricably
or reciprocation can leave patients feeling linked to the ‘pathic’.14
bereft and alienated from their own
CONCLUSION
We are embodied social beings. We thrive key part of those relationships in everyday
on nurturing relationships. Touch forms a life but is also a powerful form ofcommunication for clinicians, allowing for ‘Losing touch’ threatens to undermine our
wordless dialogue, presence, and relationships with our patients, our
embodied empathy. ‘Touch hunger’, a professional practice, and a key element
term coined by Tiffany Field, threatens of our pedagogy. Clearly we are still in the
our sense of being-in-the-world, our midst of the pandemic and difficult
connectedness, growth, and flourishing. balancing acts are being made on a daily
This has been greatly exacerbated by the basis between avoiding potentially
pandemic-driven ‘social distancing’. Yet harmful, or even lethal, contagion and
the drive for a ‘contactless’ world had avoiding harm to social bonds and
been gathering pace well before the livelihoods (blandly called ‘the economy’).
pandemic. Our tactile poverty has been My fervent hope is that once we are ‘safe’
intensifying with the digitalisation of our again, the profession recognises the
lives and pervasive technophilia. Remote importance of touch in its healing
consultations may be seen as repertoire and pedagogy, and does not
advantageous: no risky physical eschew the physical examination as an
interactions, more efficient, more integral part of practice.
convenient.
The physical examination should remain a
‘touchstone’ of general practice.
This article is reproduced with kind permission from British Journal of
General Practice - Life
Image: Sarah Richter artPerspectives of GP Heads of Teaching on cultural diversity and inclusion in undergraduate primary care Imperial’s Medical Education Innovation and Research Centre (MEdIC) are currently involved in an exciting new collaborative qualitative study with researchers from the University of Dundee and the University of Glasgow. The study aims to explore and understand the perspectives of UK GP Heads of Teaching on cultural diversity and inclusion in medical education. In December 2020 five focus groups were conducted with 23 GP Heads of Teaching from across UK medical schools. Participants explored opportunities and barriers to cultural diversity and inclusion, discussed strategies to overcome to these challenges, and shared examples of best practice.
Image: grmarcstock via vecteezy.com The data is currently being thematically analysed by three researchers, and early results show there are both opportunities and challenges integrating diversity and inclusion within medical education at student, educator, and institutional levels. Deep structural inequities continue to exist in medical education, and medical schools must work collaboratively with faculty, students and other institutions, to strive to progress forwards with visible and sustainable change. This piece of work fits within MEdIC’s innovation and research theme on Diversity and Inclusion and links to the national working group MEdIC founded on Diversity and Inclusion in Medical Education.
Image: rawpixel.com via freepik.com
In January 2021, building on our relationships with local schools, Undergraduate Primary Care Education launched an exciting and innovative new module for year 2 Imperial Medical and Biomedical science students called I- Explore: Social Accountability in Action. This module was developed by our Community Collaboration Lead, Bethany Golding, together with Josh Gaon, Neha Ahuja, Arti Maini and Imperial StudentShapers Huriye Korkmazhan, Nadia Zaman & Ray Wang, with input from local schools and community partners.
Imperial students explore the Council, Mosaic Trust and Young
concepts of social accountability, Hammersmith and Fulham Foundation.
power and privilege through a real- We have been grateful to receive
world project developing and valuable input throughout from
delivering after-school STEMM-based Matthew Chisambi, a TeachFirst
sessions for local secondary school Ambassador, and the Innovation Lead
pupils in partnership with at Imperial College Health Partners.
schoolteachers. STEMM topics have
included a focus on the COVID-19 A key challenge this year has been the
pandemic context, including topical need to run the entire module,
issues relating to vaccine hesitancy including delivery of after-school
and equitable distribution of the sessions, virtually. As many will know,
vaccine. running an interactive session virtually
can be tricky even for the most
Imperial students have worked closely experienced of teachers. Our Imperial
with the participating schools in students rose to this challenge,
Hammersmith and Fulham (Fulham creating engaging and inclusive
Cross Academy, Phoenix Academy and material that brought their sessions to
Hammersmith Academy) to ensure the life.
sessions are engaging, inclusive and
relatable for the pupils. Through this The feedback from schools has been
real-life project work, our Imperial fantastic so far.
students are gaining invaluable A presentation event in March was the
experience of working in partnership culmination of the project, where the
with schools and with young people students showcased their work as well
from a wide range of backgrounds and as reflections and lessons learnt from
abilities as well as applying critical their teaching experience.
enquiry, creative thinking and using
problem solving skills. Although the pandemic has presented
us with many unforeseeable
To support this experience, we challenges, we have been encouraged
provided central sessions where and heartened by the ability of our
Imperial students learnt core inclusive students, faculty team, schools and
teaching skills and were supported to pupils, to navigate rapidly changing
explore concepts of social circumstances, and by the feedback we
accountability, including consideration have received. We hope that I-Explore:
of power and privilege, and reflect on Social Accountability in Action provides
how these principles relate to their an exciting example of how our faculty
future professional career and their and students can work in partnership-
role in society. These sessions were with local schools and communities to
built using inclusive material inspire our future generation, and we
developed in collaboration with the very much look forward to building on
three participating schools, and with this work.
Hammersmith and Fulham YouthFeedback from a teacher at Hammersmith Academy: “I just wanted to pass on my gratitude on behalf of our pupils for the sessions yesterday, and my praise for the Imperial College students who led them so well. They were both fantastic sessions and flowed very well, stimulating sophisticated, thought-provoking conversation. The information shared was relevant and accessible to our students and the guidance they gave in regard to higher education was most definitely inspiring. I have no doubt that our pupils left the calls, considering their potential and excited for the future”
EFFECTIVENESS OF MENTAL HEALTH WORKERS COLOCATED WITHIN PRIMARY CARE Mental health disorders contribute significantly to the global burden of disease and lead to extensive strain on health systems. The integration of mental health workers into primary care has been proposed as one possible solution, but evidence of clinical and cost effectiveness of this approach is unclear. In a paper published in the journal BMJ Open, we reviewed the clinical and cost effectiveness of mental health workers colocated within primary care practices. Fifteen studies from four countries were included. Mental health worker integration was associated with mental health benefits to varied populations, including minority groups and those with comorbid chronic diseases. The interventions were correlated with high patient satisfaction and increases in specialist mental health referrals among minority populations. However, there was insufficient evidence to suggest clinical outcomes were significantly different from usual general practitioner care. We concluded that while there appear to be some benefits associated with mental health worker integration in primary care practices, we found insufficient evidence to conclude that an onsite primary care mental health worker is significantly more clinically or cost effective when compared with usual general practitioner care. There should therefore be an increased emphasis on generating new evidence from clinical trials to better understand the benefits and effectiveness of mental health workers colocated within primary care practices.
Image by Tumisu from Pixabay
NEW RESEARCH Image by Adele Morris from Pixabay
We would like to congratulate Clinical Senior Lecturer, Cheryl
Battersby (pictured below), on successfully gaining a 5-year NIHR
Advanced Fellowship, entitled neoWONDER: Neonatal Whole
population data linkage to improve lifelong health and wellbeing of
preterm babies.
Cheryl’s cycle. These babies require
research will specialised care in neonatal units. At
link the present, we do not fully understand
National the longer-term impact of neonatal
Neonatal care and interventions (like feeding
Research and breathing support) or of social
Database and environmental factors following
(Utilising the hospital discharge. Therefore, a
National Neonatal Research better understanding of the longer-
Database | Faculty of Medicine | term impact would help improve
Imperial College London) to other neonatal care. However, this
health and education data to requires following up these
understand and improve the longer- children’s development, which can
term outcomes of babies born very be complex and costly. Finally,
prematurely. This final linked bringing together existing routine
dataset will include data for over data will help us understand how
100,000 babies born over the last these babies progress through their
14 years in England and Wales. childhood. As a result, we could
learn what neonatal unit
Each year in the United Kingdom
interventions and/or post-hospital
around 8,000 babies are born
social/environmental factors, may
prematurely less than 32 weeks of
have impacted on their
the normal 40-week pregnancy
development.
Please visit the study website if you would like to find out more about
neoWONDER.Image: Covid-19 by Richard Huňis – Public Domain
The Year 3 Medicine in the Community Apprenticeship (MICA) provides undergraduate medical students with an opportunity to do an 8-week placement in primary care. During this placement students are asked to work in pairs to develop a Community Action Project (CAP).
The CAP is a collaborative community-based quality improvement project where students are encouraged to think about issues affecting the local communities in which they are placed and design a project to address these. They are encouraged to work with the practice, community groups and patients. During Term 2, students were asked to focus on COVID-19 and the health and wellbeing priorities that have arisen due to the pandemic. The COVID-19 vaccine, including addressing local vaccine hesitancy was highlighted as a particular priority area. In the final week of their placement, students of the projects was excellent with students presented their projects in small groups and addressing vital local issues using a range of received feedback from their peers and innovative methods. primary care department tutors. The quality Some particular project highlights from this term include: • Nabeeah Ahmed and Jiwon Seo conducted a project aiming to explain COVID-19 to children. The students sent a survey to local primary schools to identify the local need and reviewed existing COVID-19 information resources aimed at children. They used this information to create a storyboard and video entitled ‘The Story of Mo and Coco’ (storyboard on opposite page), which aims to explain COVID-19 to 4-7-year-olds. These resources were then disseminated to local children and parents. Students received positive feedback on the intervention via a survey by over 50 parents. The video is available for children and parents to access on the GP practice website and has been sent to a local primary school. The GP team are hoping to distribute the resources more widely to other practices. • Ailin Anto and Arunima Basu explored COVID-19 vaccine hesitancy amongst care home staff. The students initially identified low uptake of the COVID-19 vaccine amongst staff at a local care home. They then asked care home staff to complete a survey exploring their vaccine concerns and met with the local Clinical Commissioning Group (CCG) to ascertain their understanding surrounding local vaccine hesitancy. The students created two videos aiming to increase vaccine uptake, which were shared with local GP practices, the CCG, Primary Care Network (PCN), the local council, the local authority, and an interfaith charity. Many of these organisations have placed the videos on their websites, shared them on social media, or disseminated to care homes and care providers. One video addressed the main concerns identified from their analysis using animation, and the second interviewed local community members who discussed their experiences of having the vaccine. In addition, the students conducted webinars with two local care homes showcasing the videos and discussing their personal experiences of receiving the vaccine. The videos and webinars were evaluated positively, particularly for the diversity of community members within the videos, and increased likelihood of vaccine uptake by participants was reported. The students plan to adapt the video with subtitles in different languages and disseminate more widely via other PCNs. As these projects demonstrate, the students currently analysing the projects to share worked collaboratively with community important findings and innovations with the partners and engaged meaningfully with the Department of Health and Social Care. community in their local area to positively Research is also being undertaken to ascertain impact upon health and wellbeing in student learning experiences from the innovative ways. The Medical Education projects. Innovation and Research Centre (MEdIC) are
Image: freepik.com
A PICTURE OF HEALTH By Sophie Coronini-Cronberg The COVID-19 outbreak has shone an unequivocal light on some of the stark inequalities in health and life chances people are living with every day, including the increase in domestic abuse reports, or children struggling to access home-schooling.
The challenge in starting to address inequalities is we need to understand the
local population’s demographic profile, along with their key health needs.
While public health information is routinely published for organisations such
as local boroughs, the same data does not exist for hospitals.
In large cities like London, there are 620,000 people, or 1 in 14 of London’s
multiple hospitals, local boroughs, primary population, who fall within the Trust’s
care providers and networks, and core catchment in two large areas, each
integrated care systems. Coupled with a broadly centred around one of the Trust’s
highly mobile population, this makes sites, West Middlesex University Hospital,
defining a hospital’s local population and Chelsea and Westminster Hospital. It
extremely difficult: simply describing the shows the catchment encompasses highly
attending population misses those who deprived and affluent areas, and an
cannot access services, do so elsewhere, ethnically diverse population. The
or are currently well. Yet, it is precisely population is also relatively young
this denominator that is critical to compared to England as a whole with 2 in
measuring equitable population health 3 (69%) aged 15 to 64 years.
outcomes.
A key public health concern is the impact
To try to address this, the Trust and that health inequalities, such as those
Imperial College collaborated to model associated with deprivation, disability and
and define a core catchment area; this ethnicity, are having on the lives of local
represents the area from which a people. We found significant variation in
significant proportion of people requiring health needs across our local community:
hospital treatment will access one of the people living in the most deprived parts of
Trust’s two hospitals. The work was in the catchment live at least 20 fewer years
part supported by a Health Foundation in good health than those in the most
grant. affluent areas
The model defines where people are most This work gives us a new perspective on
likely to come from if they need hospital the population that we serve. By
care and in turn allows us to describe the developing a better understanding of the
population’s size, geographical reach and local community that is likely to use one
basic demographic profile. Then of our hospitals, rather than just those
overlaying open-access datasets allows us who actually attend, we can make better
to estimate social and health indicators. decisions about how we plan and deliver
This starts to tell the story about the services, including COVID recovery, as well
community the Trust serves and helps as how we support local preventative
shine a light on potential priority areas for efforts to keep people healthier for
improving health and wellbeing, including longer.
through equitable access to services,
health outcomes and employment. The modelling was complemented by a
qualitative assessment consisting of key
In September, the Trust published its first stakeholder interviews to explore the
public health needs assessment of its core model’s utility in supporting service design
population. The report identifies around and delivery. This has given us insight intopotential areas of future focus. The trust is reached out and expressed interest in
also exploring applying outputs from this learning about and/or replicating this
work to support geographical model. Perhaps most notably, NHS
prioritisation of preventive outreach Providers have recently cited it as a ‘best
options and service integration, as well as practice case study’ in a framework
proportional resourcing for hospital-based document outlining the NHS should be
public health interventions such as alcohol addressing health inequalities during
harm reduction. COVID and beyond. Also, in March, it was
announced that the project has been
Since the publication of A Picture of shortlisted for an HSJ Value Award 2021 in
Health, a range of acute trusts, national the ‘Value Pilot Project of the Year’
and also third sector organisations have category.
Sophie Coronini-Cronberg is a Consultant in Public Health at Chelsea and Westminster NHS
Foundation Trust, Honorary Senior Lecturer at Imperial College London, and
Implementation Lead for NIHR ARC NWL.
For further information, please contact any of the following:
s.coronini-cronberg@imperial.ac.uk; l.lennox@imperial.ac.uk; j.clarke@imperial.ac.uk;
thomas.beaney@imperial.ac.uk; m.harris@imperial.ac.uk
Image: Our Core Catchment area –Chelsea and Westminster NHS Foundation TrustImage: freepik.com
DEMOCRATISING SELF-CARE WITH ONLINE SYMPTOM CHECKERS Online symptom checkers are becoming increasingly sophisticated and could help individuals with a health concern get a consultation outcome and a triage recommendation online. Once a consultation outcome is made, the end-user can learn more about the condition they may have to determine the best course of action. As online symptom checkers become more sophisticated, they will become more accurate at predicting the correct consultation outcome and can help the end-user determine if they need to see a GP, seek emergency care or simply self-care. An emerging and key benefit of these online tools is to promote an individual’s self-care capability for common and everyday conditions and ailments. This could be done by signposting individuals to relevant and quality assured self-care guidelines to promote self-care for specific self-treatable conditions. The widespread use of online symptom checkers can help promote health literacy levels and can even save precious NHS resources by promoting self-care for common conditions in the community setting where otherwise the end-user may book a GP appointment to get support. There are numerous free online consultation checkers currently available but no definitive way to benchmark their performance. To address this gap, Imperial College London Self-Care Academic Research Unit (SCARU) is collaborating with RCGP and Healthily on a study to assess the suitability of benchmarking the performance of online symptom checkers using a series of primary care vignettes. We are also conducting a systematic review on the safety and clinical accuracy of online symptom checkers. This would complement our ongoing qualitative research to understand extant barriers and drivers for the routine diffusion and adoption of online symptom checkers by members of the public and the impact this could have on health systems worldwide. We hope that this work will raise the profile of online symptom checkers as a key tool that can help democratise self-care in the new setting.
Image by rawpixel.com
Our new paper published in the Journal of the Royal Society of Medicine discusses whether the government should take ethnicity into account when establishing priority groups for Covid-19 vaccination as one component of a strategy to target health inequalities.
COVID-19 has disproportionately affected Black, Asian and Minority Ethnic (BAME) groups, resulting in higher rates of infection, hospitalisation and death. The COVID- 19 pandemic has also exposed the pre-existing racial and socioeconomic inequalities in the UK. However, the Joint Committee on Vaccination and Immunisation has omitted ethnic minorities from the top priority groups which include older age, frontline health and social care workers, and care home staff and residents. The invisibility of these vulnerable groups from the priority list and the worsening healthcare inequities and inequalities are putting ethnic minorities at a significantly higher risk of COVID-19 illness and death. The UK’s vaccine allocation strategies devastating impact lasting far beyond have the potential to further the end of the pandemic. exacerbate the pre-existing, persistent Controlling further outbreaks and, but avoidable, racial inequalities that ultimately, ending the pandemic will the COVID-19 pandemic and the wider require implementation of approaches governmental and societal response that target ethnic minorities as well as have harshly exposed and amplified. ensuring that vaccine allocation Dismissing the racial and strategies are effective, fair and socioeconomic disadvantages that justifiable for all. ethnic groups face may result in a Covid-19 vaccine hesitancy among ethnic minority groups In an editorial published in the British Medical Journal, we discuss the highly topical issue of Covid-19 vaccine hesitancy among ethnic minority groups. With mass Covid-19 vaccination efforts under way in many countries, including the UK, we need to understand and redress the disparities in its uptake. Data to 14 February 2021 show that over 90% of adults in Britain have received or would be likely to accept the Covid-19 vaccine if offered. However, surveys have indicated much greater vaccine hesitancy among people from some ethnic minorities. In a UK survey in December 2020, vaccine hesitancy was highest among black, Bangladeshi, and Pakistani groups compared with people from a white ethnic background. The legitimate concerns and yet to make up their minds about the information needs of ethnic minority vaccine. Covid-19 vaccination is one of communities must not be ignored, or the most important public health worse still, labelled as “irrational” or programmes in the history of the NHS. “conspiracy theories”. We need to Tackling vaccine hesitancy and engage, listen with respect, ensuring that vaccination coverage is communicate effectively, and offer high enough to lead to herd immunity practical support to those who have are essential for its success.
Image by Tumisu from Pixabay
The 2020/21 Widening Access To Careers in Community Healthcare (WATCCH) programme came to a close in February. WATCCH is a widening participation initiative for Year 13 students interested in pursuing a healthcare career. The 2020/21 programme consisted of a series of remote workshops, developed and run by Imperial medical students on the WATCCH committee, and the primary care team. The workshops are supported by medical student mentors recruited by Vision society. The programme covers varied topics large and small group sessions, as well as including interview skills, personal a truly insightful talk from a first year statement writing and reflection and Imperial medical student on her coaching. The WATCCH students also have experience of starting university during the opportunity to participate in a the COVID-19 pandemic. question and answer workshop with multi-disciplinary healthcare professionals Over the next few months, whilst students and attend mock interviews. For the final are awaiting interviews and university workshop students were given the offers, they can continue to access opportunity to suggest topics they would support from their Imperial medical like to cover. In response to their student mentors via Brightside, an online suggestions the WATCCH team developed mentoring platform. The WATCCH team a ‘Higher Education Tips’ session covering are currently planning for the programme key concerns such as finances, academic in 2021/22 where we hope to be able to study tips, university support services, and re-introduce primary care work the effect of the COVID-19 pandemic on experience opportunities. university life. The workshop consisted of
Cat Jackson on a
mission to run 60km
in 6 weeks, to raise
money for Leukaemia
UK
Cat Jackson, NIHR School for Public Health Research
Coordinator, set herself a challenge to run 60km over
6 weeks, in order to raise money for Leukaemia UK.
The charity was particularly pertinent to Cat as she
lost her mum, Pauline Coulton (pictured), to
Leukaemia in 1989 when she was 4. Tragically her
mum was just 27 when she died, after battling against
the disease for more than two years. This year marks
what would have been Pauline’s special 60th birthday,
and although the family haven’t been able to
celebrate her birthday in the traditional way, Cat
decided raising money for Leukaemia UK, was a fitting
way to honour her memory. Between February and
March, Cat ran 60km, a 10km run every weekend, until
her mum’s birthday on Saturday 20th March.
Unless you have been directly affected by Leukaemia, you may
not be greatly aware of it. It is a type of blood cancer and
someone in the UK is diagnosed with blood cancer every 16
minutes. Cat has raised money not only to celebrate her mum's
life, but also to make a small difference in the fight against
Leukaemia. Treatment options were quite limited back in the
1980s when Pauline was suffering with Leukaemia, but research
advancements are taking place all the time, and it is vital even
during these challenging times that this research continues.
Many charities and families are struggling financially at the
moment, due to the knock-on effect of COVID, but support in any
way has been very much appreciated, whether that was raising
awareness of the disease, helping to spread the word about the
fund-raising effort, donating or simply following Cat’s journey on
social media! Leukaemia UK have set up a designated fund
raising page, and Cat has setup the Instagram page, mumrun60,
logging her training progress, which includes profiles of her
weekly running buddy’s and coverage of the big runs each week.SELF-CARE SAFARI: POLICY MAPPING EXERCISE The WHO published the Consolidated Guideline on Self-Care Interventions for Sexual & Reproductive Health & Rights (SRHR) in June 2019. The guideline consists of 24 recommendations split across 4 categories: (1) improving antenatal, delivery, postpartum & new-born care, (2) providing high quality services for family planning, including infertility services, (3) eliminating unsafe abortion, and (4) combating sexually transmitted infections including HIV and other gynaecological morbidities. Two years on, and there is considerable interest to determine the extent that these recommendations are being implemented around the world. To this end, Imperial College London Self-Care Academic Research Unit (SCARU) is collaborating with Population Services International to conduct a policy mapping exercise in Kenya, Nigeria & Uganda. As there is no precedent for this, SCARU developed a mixed methods research approach to conduct the policy mapping exercise. The methodology includes desktop research to identify national policy documents, white papers and peer-reviewed studies relevant to the WHO Guideline, and primary data collection from a wide mix of stakeholders using an online tool (electronic survey) and personal interviews with key informants in each country. This baseline policy mapping exercise would signal the first step to objectively assess how each country is aligning with each of the 24 recommendations and lessons learnt would help inform the development of future policy mapping exercises earmarked for Senegal and other francophone countries in Sub-Saharan Africa. The work can also help inform country-specific advocacy tools for the consideration of policy makers. The WHO is currently finalising Supplement to the Self-Care Guideline. Austen El-Osta (SCARU) is a member of the WHO External Review Group and has built capacity in the Unit to help raise more awareness about the WHO Guideline on Self-Care Interventions and the formative Supplement earmarked for publication later this year.
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