Tag Archives: GM PSTRC

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 .

 

Reflections on the power of a patients’ story and glimpses into the future

14 Jul

by Aneez Esmail, Director of the Greater Manchester PSTRC

Aneez_WhitePillsPinkPill_July14

One of the advantages of being the Director of the Centre is that occasionally I get asked to attend and speak at interesting conferences. One of these was the Patient Safety Congress, which is billed as the premiere patient safety event in England. This is a monster of a conference with hundred’s of NHS staff mainly from acute trusts attending. And of course the ubiquitous NHS managers who in my opinion are developing even more complex titles to describe what they do. Some no longer have safety in their title (patient experience is the new buzz word) and I am always asking people who are introduced to me – so what is it that you do? The sad thing is that I still don’t know after what is inevitably a 2-minute explanation- perhaps an interesting barometer of the NHS in 2014. It was also sad to see so little focus on patient safety in primary care, though there was a surprisingly good attendance from researchers and clinicians at the workshop that I was speaking at.

However the highlight for me was meeting Margaret Murphy who I first met when she gave a heart breaking account of how her son died as a result of a patient safety incident that had its origins in primary care. Listen to her presentation that she made at the final Linneaus Conference (a large European project on patient safety which I led). If you ever need reminding why patient safety is important, listen to Margaret and commit to doing something about it http://www.linneaus-pc.eu/frankfurt_conference.html (Look at the Video’s – Margaret Murphy –Importance of involving patients).

The other interesting conference was an invitation to the Health Service Journal Innovation Summit. This was supported by the NHS Innovation Unit and some private companies, who are already muscling in and making a pitch for the billions of funding that the NHS has. From the patient safety perspective there were some very interesting presentations made by companies developing apps for smartphones – many of which have a patient safety angle. So for example ‘apps’ which remind patients of possible side effects of medication, ‘apps’ that monitor patient bio data like mood, BP, pulse and blood sugar. I of course talked to them about how we can engage patients in primary care and they may be potential partners as we start work on some of the projects in the GP theme. There are many working in the area, one such company is www.uMotif.com

Interestingly there was also a company (doing very well apparently), which has directly used ideas that we developed on patient safety culture in Manchester (www.verita.net). They billed themselves an investigatory unit, working to improve things after disasters such as Mid Staffs and working with Boards to improve their resilience. Really what they are doing is assessing safety culture. So here is an interesting concept – they use publicly funded research to develop tools that they then repackage and sell back to the NHS! Brave New World. It did make me wonder whether we as academics are missing a few tricks here.

Ancient Egypt and the ‘hierarchy of evidence’

30 Jun

by Jonathan Stokes, PhD student in Multimorbidity theme

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One of the first things you learn when training in any sort of biomedical research is the ‘hierarchy of evidence’ (picture above), what counts as the ‘best’ type of evidence in our field. As you can see from this pyramid, randomised controlled trials (RCTs) – where a population is randomly split into two or more groups, an intervention is carried out on one, and the other acts as a ‘control’; results look at the difference between the two groups after a period of time – are at the very top (not counting ‘Systematic reviews’ which are simply compilations of many studies from the lower points of the pyramid). RCTs work so well, and are rated so highly in the hierarchy, because by definition and set-up they control for as much variation as possible. They control for variation both between the two groups involved, as well as between the settings they are subjected to. This is great from a statistical point of view, but stripping context and the variation naturally found in any population between individuals gives us extremely unnatural results i.e. the interventions assessed in this way don’t work in the same way when these are used in the much more complex, real world. And this is especially true when we look at more and more complex interventions e.g. integrated care, for more and more complex patients with multimorbidity – you can find more details on this specific issue in my personal blog page here. Not only do RCTs apply only incompletely to the actual context they’ll be used in, but they also cost an absolute fortune, and take years to do properly. Not always the most practical solution perhaps, particularly in assessing an intervention which has particularly low risk of harms for instance. This lack of real-world applicability can be a real problem, especially when working in a ‘translational’ research centre, where we try to focus on crossing the ‘translational gaps’ between evidence and actual practice. Surely, we want to create evidence here which applies and can be used in the ‘real world’. For this reason, I’d argue that the age old ‘hierarchy’ of evidence in biomedical research is as outdated as its architectural equivalent of the ancient Egyptians. By no means am I arguing not to use RCTs under any circumstances by saying this! RCTs are a great source of evidence in the appropriate circumstances, and for example, I wouldn’t want to be taking any medicine that hadn’t been thoroughly tested with one. But, we need to move away from the simplistic attitude that our evidence can sit neatly in a hierarchy. For starters, look how low down experiential, person-centred, qualitative evidence sits. This is an important area of understanding for the type of care we want to provide to patients! We have a new ‘multimorbidity’ disease paradigm. Our health system needs to adapt to this, and so does our research. Particularly in a time where budgets are being squeezed, if we can save money on a completely inappropriate RCT here and there, for instance, and can instead put some of the abundant routine data we have lying around to good use, we shouldn’t be afraid to do so because of some ancient paradigm.

GM PSTRC Newsletter – second edition now live

14 Apr

by Philip Hammond, GM PSTRC PPI Coordinator

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The latest edition of our newsletter is now available online.

With some key updates from the work of our research themes as well as other articles of interest including:

  • Learning materials for safer prescribing valued highly by GPs
  • MAXIMUM moves ahead, piloted by involvement
  • Healthcare hashtag project [#]
  • Closing the Gap
  • early details of our forthcoming Research Symposium
  • opportunities for people to get involved.

Make sure you don’t miss out on our free quarterly newsletter by signing up to become a Friend of the Centre at http://bit.ly/GMPSTRC

 

Exploring issues around our personal health data

3 Apr

by Cara Afzal, Vice-Chair of the GM PSTRC Research User Group and Matthew Sullivan, member of the GM PSTRC Research User Group Image

The Interface and Informatics theme cuts across all of the GM PSTRC research themes and is focused on developing information systems to allow access to and use of routine healthcare data. What does this mean – well it means that researchers, health professionals and other interested parties would like to look at our routine patient data to improve our care. Yet, public confidence in electronic patient records is at a low ebb. Stories in the press about international security services routinely harvesting data from internet and email traffic, stolen laptops, lost memory sticks and cyber-criminal hackers all fuel fears over what might happen to our healthcare data. Against this background, in February this year, the roll-out of care.data, the scheme to unify GP records with the Health and Social Care Information Centre (HSCIC), was delayed by at least six months. This seems to have been due to concerns from some GP and patient groups over security and privacy. If you have ever been in a hospital you may recall sitting through consultations and reeling off information about medications being taken, procedures completed, last time you/your loved one saw the GP etc and thinking how easy would be if clinical staff could just look at the patient record and get the information needed, without relying on us, the patient and/or carer to recall all of the information. Also, patient safety might be helped by allowing hospital data (Secondary care) and GP data (Primary care) information sources to be linked and accessible to staff involved in the delivery of our care. We enter into this debate with an open mind, if data access can improve patient care and save the NHS money then we need evidence to demonstrate this, which should reassure us, at least, that the benefits far outweigh the risks, but this evidence cannot be collected if access is not given. Some of us may recall that the NHS Connecting for Health Programme – designed to have a single patient record, accessible to the public – didn’t work and a lot of public money was wasted. As members of the user group we are asking ourselves how can the Interface and Information theme and the RUG gather evidence to evaluate the case for the introduction of care.data? There are two levels at which our work might be relevant.

  1. The first level for the I&I theme is the overall research project which is looking at some of the mechanics of combining records and building prescription alerting tools for GPs and primary care providers. However, in this blog we are introducing a second level:
  1. Understanding and addressing factors that affect individual patient confidence.
    1. The RUG I&I group have initiated two projects jointly with HeRC (Health e-Research Centre) that have different time scales. The first of these is a project to involve groups of the public in the use of mobile/wearable technology to monitor wellness indicators such as activity. The aim is to find what barriers to wearing these sensors might be and to see if this can be improved through personalization of the kit. This might seem somewhat removed from care.data, but it will enable us to explore issues around what data is and how we feel about sharing it when we have more ownership of its collection.
    2. The second project has a longer time scale and will look in more detail at patient involvement in access to their electronic records. Again, this could show how we might break down some barriers to sharing data.

We believe that access to patient data will continue to be a contentious area, until more work is done in engaging directly with the public on such issues. If we think back to when people were debating whether or not online banking was a good thing and now it’s become the norm – lessons can be learnt. It would be better if the debate for access to patient data is driven from the patients themselves and the public given a clearer stake in the decision making process for access to their data and a stronger case needs to be made for how such access will benefit patient care and importantly who will have access. It could be that the NHS considers limiting access to NHS and its affiliated organizations as a first stage and uses this learning to demonstrate benefit and consider the merits of allowing others to have access. Across all themes, the RUG can build patient trust through demonstrating improvement of safety in primary care and by collecting and explaining evidence for the benefits of sharing data

Quality and safety in community pharmacies: a complex business

17 Mar

by Denham Phipps, Research Fellow for Medication Safety theme Image “Hero pharmacist saved my life” was the headline that caught my eye in our local newspaper recently.  In the story, a customer recounted what happened when she went to her pharmacist with leg cramps.  “Going to him as the first port of call was the obvious thing to do.”  However, the pharmacist realised something was amiss when he heard her symptoms.  “He was very calm and told me to go to A&E immediately, which I did, but I had no idea I’d be diagnosed with deep vein thrombosis.  He saved my life.”1 In a previous blog (https://gmpstrc.wordpress.com/2014/02/11/the-earlier-the-better-why-visiting-your-local-pharmacy-sooner-rather-than-later-could-make-all-the-difference/), we saw that community pharmacies play a role in the vanguard of primary healthcare.  According to NHS England’s “Call to Action”, this role could become even more prominent as primary care faces increasing, and increasingly complex, demands.  How can pharmacies contribute to the management of long term conditions, to out-of-hospital care, and to the operation of other services such as general practices and hospitals?  Big questions, which we are invited to consider for NHS England’s consultation.  (If you wish to contribute your own views, then you have until March 18th to do so: http://www.england.nhs.uk/ourwork/qual-clin-lead/calltoaction/pharm-cta/). Meanwhile we in GM PSTRC, and our colleagues in Manchester Pharmacy School, have been studying the work of pharmacies.  In a recent study,2 we examined a sample of reports made by community pharmacies following a patient safety problem.  We found that most of the problems reported (about 92 percent) resulted in no harm to the patient, while the remainder resulted in varying degrees of harm; often minor or moderate.  Why did so few of the problems that occurred lead to any actual harm, and yet fewer to serious harm?  While luck may have a role to play, so too do the actions of pharmacy staff and service users to detect and correct problems.  It is important that these actions are not left to chance – pharmacies should be designed and managed in such a way to allow them to occur. What do the suggested changes to primary care have to do with this?  To answer that question, our study also looked at what pharmacies currently have to achieve.  We identified four main purposes for a pharmacy: supplying medication; supporting the use of medication; functioning as a business; and (as the opening story shows) promoting health.  For pharmacy staff, these purposes lead to a balancing act between cost-effectiveness, adherence to professional and legal standards, quality and safety.  Their day-to-day work involves keeping this balance, through whatever means they can, in the face of the demands on the pharmacy.  As demands change, or increase, pharmacies may have to work differently in order to maintain the balance. The challenge for quality and safety is to ensure that, as they adapt to changes in demand, pharmacies are still able to deal with the risks that arise in their work.  This is one of the topics for our ongoing research.  Our aim is to help ensure that the pharmacies of today, and of tomorrow, are ones that are fit for heroes. References: 1. “Hero pharmacist saved my life”, Manchester Evening News, 6th December 2013. 2. “Integrating data from the UK National and Learning System with work domain analysis to understand patient safety incidents in community pharmacy”, Journal of Patient Safety.  http://dx.doi.org/10.1097/PTS.0000000000000090

2MMs

6 Mar

by Brian Minor and Wendy Barlow, Research User Group members affiliated with Multimorbidity theme

MM RUG members blog photo

It’s nearly 12 months since we applied, were interviewed and subsequently invited to become members of the Research User Group (RUG).  Our first meeting was in April 2013 and since then there have been six meetings one of which was a full day at which we had a presentation on ‘Research? What’s it all about?’ Sometimes as RUG members we feel as if we haven’t moved forward or done very much, but when we look back over the past few months we realise just how much has been achieved i.e. developing/agreeing terms of reference for the group, developing/agreeing role descriptions for the Chair and Vice Chair, electing and appointing to these roles, reviewing theme documentation, developing reporting forms etc. As RUG members we are getting to know one another and starting to gel as a team, especially within our themes.  After the January RUG meeting the members went for a meal, which for those of us able to attend was a great opportunity to have a chat and find out more about each other in a social setting whilst enjoying a good meal. At the September 2013 meeting of the RUG we were asked to choose which of the five themes we would like to be assigned to and we were both fortunate in that we were aligned to the Multimorbidity theme which was our first choice. The multimorbidity research is aimed at patients with two or more long-term conditions i.e. an illness that at present can’t be cured but can be managed via medication and therapy.  These patients might need several sorts of medication and with a growing ageing population, there are a number of older people living with long term conditions who may be experiencing some form of memory loss.  This means that the patient is liable to make mistakes with his/her medicines by either taking too many or missing doses completely.  These patients are often under the supervision of several different clinicians, one of whom might prescribe medication that has an adverse effect on the prescriptions of another. The Research Team have welcomed us and provided us with a list of involvement opportunities.  We have reviewed some of the theme documentation and our input, particularly with feedback of the language used in documents resulted in changes being made.  This is not taking the ‘professionals’ to task, but as lay people we want to be able to read without being distracted by jargon or language that is not widely known outside the field of research. We are currently involved (after receiving training from Gavin Daker-White Research Fellow) in the thematic analysis and identifying themes from the results sections of published studies, and whilst this is a challenging task for us, as we don’t have research experience, we are relishing the opportunity to ‘have a go’ and hopefully our contribution will prove useful.  Brian is also looking forward to getting involved with interviewing participants as part of the research. Brian –  is retired and has a background is Sales and Marketing.  He has voluntary experience as Chairman of the PPI (Patient and Public Involvement) Forum set up at Salford Royal a few years ago and he also volunteers with the Local Community radio station and produces and presents four hours of radio each week. Wendy – up until a few months ago worked full-time at the University of Salford and is currently working part-time for the Big Life Centre as a Community Researcher looking at the development of a health and wellbeing website. She is also a registered volunteer with Salford Royal NHS Trust working with the Macmillan Cancer Support Services.