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PhD fellow focus: Lukasz Cybulski

2 Feb

In this series, we meet our new PhD fellows to find out what they will be researching and what they hope to achieve.

Lukasz Cybulski started his PhD in September 2017. He has a background in research and mental health work with an interest in the synthesis of public health policy, the use of research findings in the ‘real-world’ and ways of increasing research transparency and reproducibility. The opportunity to combine these interests is what drew him to the projects at the Greater Manchester Patient Safety Translational Research Centre.

His PhD will focus on self-harm and suicide in children, adolescents and young adults. The epidemiology (the study of how diseases affect the health and illness of populations) of self-harm and suicide has not been extensively studied among registered primary care patients. The majority of people diagnosed with a mental health disorder, including conditions such as depression, anxiety disorders and eating disorders, are rarely referred to, or treated by, specialist mental health services.

Lukasz will investigate this topic using a nationally representative group of primary care patients,  linking with routinely collected clinical datasets and national mortality records. This will provide a unique platform for investigating people diagnosed with ‘mild to moderate’ mental health problems, their clinical management across healthcare sectors, and their subsequent risks of nonfatal and fatal suicidality and other causes of premature death. Epidemiological studies of this nature allow for the identification of populations at particular risk, and aid the development of clinical guidelines that maximise patient safety.

New research themes in the PSTRC

1 Feb

All-theme banner

The PSTRC will build on its existing themes of Safety Informatics and Medication Safety, and their specific focus on digital and diagnostic interventions and polypharmacy. However, the 2017-2022 PSTRC differs from its predecessor in having two new themes:

  • Safer Care Systems and Transitions
  • Safety in Marginalised Groups.

Safer Care Systems and Transitions will build on the centre’s previous work on multimorbidity to look at transitions and pathways of care. Transitions can be from one part of the NHS to another (e.g. hospital to primary care), between NHS and private care providers, between the health and social care sectors, or between other sectors and sites including the voluntary sector, self-help groups or “home.”  Most research and advances in patient safety are typically found within single discrete care settings, such as the emergency department. Less attention has been paid to safety between (transitional) primary, social and community providers and hospital care settings.

The second new theme is Safety in Marginalised Groups. Marginalised Groups include people that are excluded from mainstream social, economic and cultural life. This includes those with mental illness or at risk of suicide or self-harm, people living in nursing homes, the homeless, people with sensory impairment or who speak English as a second language. Such groups are at greater risk of experiencing adverse patient safety outcomes.

In all research themes, service responsibility and patient responsibility for patient safety go hand-in-hand. They are equal – it is a shared responsibility that requires co-design and partnership working, which is why the PSTRC has an involvement and engagement approach supporting all its research.

Self-harm in children and adolescents

1 Feb

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Self-harm is any act of self-poisoning or self-injury whether intentional or not. Self-harm is the strongest risk factor for possible future suicide, with suicide being the second most common cause of death before the age of 25 worldwide.

In recent years, there has been a rise in suicide rates in children and adolescents, as well as a marked increase in psychological distress. The purpose of this study was to identify how the rates of self-harm have changed, and how these changes compare in different genders, as well as among different age groups. The Clinical Practice Research Datalink (CPRD) database was used to identify 16,912 records of children or adolescents presenting to their GP after self-harming between 2001 and 2014. Researchers then looked at what proportion had been referred to mental health services and what drugs, if any, were prescribed in the 12 months following the self-harm.

The most notable trends were:

  • A 68% increase in incidence of self-harm in girls aged 13-16
  • Those who lived in socially deprived areas were 23% less likely to be referred in the 12 months following self-harm
  • Children and adolescents who self-harmed were at increased risk:
    • 9 times more likely to die of unnatural causes
    • 17 times more likely to die by suicide
    • 34 times more likely to die through alcohol or drug poisoning.

 Read more in the full paper in BMJ, or the plain English publication summary.

Safety in Marginalised Groups: Why a new theme for the PSTRC?

1 Feb

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Much of the work that took place in the first NIHR Greater Manchester PSTRC focused on involving patients and carers in its work. Examples of this were the James Lind Alliance Priority Setting Partnership, and public engagement events such as The Nest and More Than Just a Number.

In the second incarnation of the Greater Manchester PSTRC, one of the four themes, and a new theme for the centre, is Safety in Marginalised Groups. This research theme will focus on improving patient safety for marginalised groups of people, who are at a higher risk of harm within the healthcare system. The increased risk can be caused by a number of factors, for example, we know that Black and Minority Ethnic (BME) groups have poorer health outcomes, as well as poorer access to, and experiences of, healthcare services. People may also be marginalised because of stigma and poor access to services for specific conditions (e.g. mental health problems). Or they may be marginalised because of the circumstances or settings in which they live (e.g. living alone, caring for someone at home, living in a rural setting, in a care home or prison, or being homeless).

This theme has two main strands of research: the first on mental health and the second on patients and carers. Over the next five years, the Safety in Marginalised Groups theme researchers will work closely with researchers in other themes to explore a number of key issues, challenges and opportunities for improving safety in marginalised groups including:

  • communication
  • self-management: the co-design of tools to aid patients in their healthcare journeys
  • using mobile technology to monitor health.

A major component of the new theme will be mental health and it is particularly exciting that the PSTRC will be teaming up with the Centre for Mental Health and Safety. Some of the key safety outcomes in mental health involve suicide or self-harm. The proposed programme of work will look at the components of a ‘safe mental health service’ as well as investigating treatment gaps in the care of people who self-harm.

Find out more on our Safety in Marginalised Groups webpage.

What are Marginalised Groups?

1 Feb

Marginalised

You may not be familiar with the term marginalised groups. So what do we mean by marginalised?

The Oxford English dictionary definition of marginalisation is: “To render or treat as marginal; to remove from the centre or mainstream; to force (an individual, minority group, etc.) to the periphery of a dominant social group; (gen.) to belittle, depreciate, discount, or dismiss.” Within the academic literature, similar definitions have been used. For example, some simply state that marginalised groups are ‘populations outside of “mainstream society”’ (Schiffer K, 2008).

The term is increasingly replacing and/or being associated with other similar terms which you may be more familiar with, such as ‘vulnerable groups’, ‘seldom heard groups’ or ‘hard-to-reach groups’. Although each is different, all these terms include two main aspects. Firstly, there is a main/dominant/central individual or group, (e.g. the government) exerting power over another individual/group, with some sort of disadvantage occurring. In other words, the process of marginalisation leads to unequal outcomes.

Marginalisation is a dynamic process and people can move in and out of such groups. Many people can fall into one or more categories or groups simultaneously, meaning that it is a complex area to research.

In patient safety terms, people belonging to such marginalised groups are likely to experience more and perhaps different patient safety issues in relation to the general population. The truth is we simply don’t know as this is an under-researched area. What we do know however is that there are many barriers to accessing care for those considered to belong to marginalised groups such as migrants, the homeless, and people living in poverty and include issues relating to the way the health and care systems function. We want to understand the range of issues and people we ought to consider in our forthcoming research. This is why we in the Marginalised Groups theme are conducting a review of the published academic literature, identifying and analysing the existing literature on marginalised groups and patient safety in the United Kingdom. This will allow the theme to prioritise its patient safety research agenda over the coming five years.

Development of a resource to reduce self-harm

1 Feb

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Recent work led by The University of Manchester has developed and tested a brief theory-based psychological intervention (the “volitional help sheet” or VHS) that significantly reduces suicidal ideation and behaviour among people admitted to hospital following an episode of self-harm (Armitage et al., British Journal of Psychiatry, 2016).  However, it is not yet known whether the intervention is acceptable to, and effective in, preventing suicidal ideation and behaviour among the broader population.

The goal of this research is to translate these findings into a resource that will meet the needs of people at risk of self-harm and/or suicide who may not have been admitted to hospital with self-harm.

As people at risk of self-harm and/or suicide may present at any point in any care pathway, we will be investigating multiple physical and mental health conditions in both primary and hospital care. The focus of the research will be on understanding expressions of intent to self-harm and/or suicide and in gauging patient and health care professionals’ reactions to using the VHS as a tool to promote patient safety, with a view to refining and optimising the VHS.

Patient Safety: the way forward

8 Aug

by Stephen Campbell, Director of the NIHR Greater Manchester PSTRC

University campus

Seventy five percent of patient safety research is focused on hospitals. Less is known about patient safety outside hospitals, yet 85% of NHS contacts happen in these settings, mostly in general practice and in pharmacies. The scale of primary care in England is huge. There are 340 million general practice consultations annually, with 2% involving a patient safety incident, which means 6.8 million times each year where a patient is potentially at risk of harm. There are one billion prescriptions issued per year outside of hospitals, with 4.9% having an error – 49 million every year. And 20% of patients discharged from hospital will report an adverse event, which could lead to costly readmission to hospital. On 1 August 2012, the Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC) started, funded by the National Institute for Health Research (NIHR).  Our PSTRC has been a groundbreaking centre as it was the first patient safety centre to focus on primary care (general practice, community pharmacies etc.) as well as the interfaces with hospital care. The focus on primary care was intentional and needed.

We have achieved many improvements in primary care safety over the last 5 years. For example, we have developed a “Safer Prescribing” e-learning course for GPs, which has reduced prescribing errors.  We have developed a Medication Safety Dashboard as a “missed opportunity detector” that has resulted in fewer patients being at risk of potentially hazardous prescribing. We have used mobile technology such as smartphone apps to deliver safer healthcare. As an example, ClinTouch monitors symptom change in people with serious mental illness. We have worked in partnership with patients, GPs and pharmacists to create a Patient Safety Guide for general practice.

I am a health services researcher who has focused on the quality and safety of primary care for 25 years. Over that time there have been many advances in improving quality and safety but equally people are living longer, often with several health conditions requiring care from many different sources, in a world that becomes ever more complex with new digital technologies and “intelligent healthcare communities”. Most research and advances in patient safety are typically found within single care settings, such as the emergency department. Less attention has been paid to safety between (transitional) community providers and hospital care settings. Delayed diagnosis, incomplete patient information and medication errors are examples of problems, which may occur both within settings and across an interface. That is why we shall focus on primary care but also on transitional care settings in our second period of 5-years of funding from the National Institute for Health Research (NIHR), which started on 1 August 2017.

Over the next 5 years, our research will focus on:

  • Safety Informatics – developing technologies and behaviours that create safer care systems and to prevent diagnostic errors – working with the Health e-Research Centre
  • Medication Safety –developing safety management systems to ensure safer prescribing and treatment and to prevent medication errors
  • Safer Care Systems and Transitions – a new theme, to make care safer for patients moving between care settings
  • Safety in Marginalised Groups – a new theme – to enable patients and carers to take control of their care. There will be a key focus on patients and carers as well as mental health, working with the Centre for Mental Health and Safety

Service responsibility and patient responsibility for patient safety go hand-in-hand. They are equal. A member of the public seeking healthcare as a patient for themselves or a loved-one deserves the safest and best quality care possible. That is the duty of healthcare providers and professionals. Avoiding errors, or identifying and correcting them, is a high priority. Equally, patients can do much to keep themselves safer in terms of accessing care appropriately, taking medications as prescribed, self-managing a healthy lifestyle with sensible eating and drinking as well as exercising etc. This is the responsibility of each member of the public. It is a shared responsibility that requires co-design and partnership working, which underpins everything we do.

A key aspect of our work, and something which I think is crucial to the PSTRC, is capacity building and training people to be able to conduct and apply research. This includes recruiting PhD students, helping a group of pharmacists to work together on research projects in their own pharmacies, and training researchers as well as members of the public and patients. Healthcare isn’t just about a medical procedure or treatment option, it is about people, both those who deliver the care and those who receive it or work in partnership together. The PSTRC aims to be an interactive research centre working with healthcare professionals, the NHS, local authorities, industry and patients, carers and members of the public to make healthcare safer.

Much is happening in Greater Manchester that gives us opportunities to make a real difference. We will work across Greater Manchester’s newly-integrated Health and Social Care Partnership which serves 3 million people. The Connected Health Cities programme across the north of England will help us get our research implemented. We will continue to work in partnership with colleagues at the University of Nottingham, especially in the research on safer transitions and medication safety. We look forward to new collaborations with colleagues at the Christie NHS Foundation Trust and Central Manchester NHS Foundation Trust. There is much we can do using new digital technologies and behavioural interventions to improve safety and healthcare for the benefit of patients.

I want to thank everyone who has been involved with the PSTRC over the last 5 years. I look forward to working with everyone in the new PSTRC to continue our exciting, innovative and important research. The PSTRC has many outstanding and world-leading researchers and an excellent core staff. There is much to do but we will continue to build the capacity to make care safer.

The PSTRC has a strong involvement and engagement agenda working alongside members of the public and patients as well as healthcare professionals. If you would like to find out more about our research and how you can get involved then please email Zarina Saeed at zarina.saeed@manchester.ac.uk .