SPCR PhD Studentship

Major guidelines for the treatment of serious mental illness (psychotic illnesses and bipolar disorder) emphasise the importance of offering the annual physical health check to ensure that diabetes and risk factors for cardiovascular disease such as raised cholesterol are detected. This check is often conducted in primary care. Research to date has focussed on increasing provision of these checks, but there is very little evidence regarding whether attendance at the annual physical health check affects subsequent physical health outcomes.

A proposed plan for the PhD would be:

 Study 1: Systematic review of studies investigating facilitators and barriers to the provision of the annual physical health check.

Study 2: Longitudinal cohort study to investigate, in the Clinical Practice Research Datalink (CPRD) dataset, whether rates of adverse physical health outcomes (including cardiovascular events; amputations and renal failure due to diabetes; and mortality rates) differ between people with serious mental illness who have regularly attended the annual physical health check and people who have not.

 Study 3: Qualitative interviews with people with serious mental illness about the information they receive at the physical health check and how they perceive that this influences their lifestyle and health. This would include a diverse sample compared to previous research on this topic to explore how inequalities influence behaviour change following the checks.

Training: 

Training for doctoral students provided internally through doctoral school at QMUL.

Support in analysing large datasets and qualitative data collection and analysis from supervisors.

Support to attend external training courses and conferences to fit with students’ interests and training needs using training budget provided.

Support to publish findings and present them at a suitable conference.

Supervised by: Dr Natalie Shoham (QMUL), Dr Megan Armstrong (QMUL), Professor David Osborn (UCL).

The COVID19  pandemic increased health inequalities through higher deaths in poorer areas and minority ethnic groups. However, this is just the tip of the iceberg with inequalities likely to worsen more from subsequent economic impacts on employment, debt, housing, benefit cuts and education. These factors are what makes people healthy (or not). General practice is often the first point of call for people facing life challenges and also provides an opportunity to identify and signpost people facing crisis (e.g. uncontrollable debt or domestic violence). About a fifth of GPs time is already spent dealing with social problems.

 Despite the importance of social factors in making people healthy, this information is rarely elicited or added in a structured way to computer records in doctors’ surgeries to understand patients’ needs and target services. Having this information would allow practices to understand their patients better and provide targeted help, either within the surgery or via another organisation. The UK already lags behind many other countries in routinely recording social information in health records. For example, in the US there are 15 different tools to gather information on the social determinants of health.

The Index of Multiple Deprivation is often used as a proxy for individual socio-economic status, despite it being an area-based measure and independent of individual socio-economic status.

Proposed plan:

Working with a patient engagement and involvement panel, the aim of this PhD is to build the evidence base examining the collection and use of individual socio-economic status data in primary care. The anticipated objectives will be:

1. Undertake a review of the published and grey literature to identify and evaluate individual measures of socio-economic status in routinely collected health records (e.g. income, education, occupation, welfare claimants)
2. Assess the extent to which social information is currently coded in primary care using the Discovery database and identify opportunities for better coding and use of social information
3. Understand the views of practitioners and patients in collecting and using social information to assess socio-economic status in primary care through qualitative data
4. Develop recommendations for policy-makers and practices about how to collect and use social information

The PhD will use mixed methods and will focus on developing pragmatic, applied policy recommendations and solutions. The quantitative stage would use  deidentified primary care electronic health records including those extracted from the North East London Discovery Data Service which contains information from all the 285 practices across north east London.  The qualitative component will involve either semi-structured interviews or focus groups with patients and general practice staff to understand their views on collecting social information.  The student will work closely with policy makers, frontline primary care staff and patients to understand their needs and preferences. The objectives and methods will be developed to fit around the student’s interests and training needs.

Training: 

QMUL has an extensive professional development programme to support PhD students. At the start of the PhD, we will undertake a training needs assessment to build a formal training package to support the student. This may include This may include training in systematic literature reviews,  qualitative and/or  quantitative methods, and health inequalities metrics and methods.

The PhD will involve close working with the national NHS England primary care group with a possible internship. This partnership will help the student to understand how national policy is developed and the structure and function of different parts of the NHS. Dr Ford has worked at all levels of the NHS leading on health inequalities and the PhD would help the candidate to develop their understanding of policy approaches to health inequalities. 

Supervised by:  Dr John Ford

 

 

Potential for cross consortium networking and educational opportunities:

There are three main opportunities in this PhD. First, the topic area is under-researched but recognised as a policy priority, therefore there is a great opportunity to make a real difference through the research. Second, the PhD would sit alongside an NIHR-funded project examining equity-focused QI in secondary care. This means that there would be an opportunity to contribute to complementary research, be part of a wider team and leverage the learning from the evidence from a different context. Third, Dr Ford is embedded within the national NHS England primary care group. These policy links create opportunities to access a range of policy makers as well as an effective means of sharing the findings of the PhD. 

The NIHR funded project on EF-QI includes a collaboration with Oxford University, Cambridge University, THIS Institute and Health Foundation. These collaborations would complement any additional cross-SPCR networks designed around the student’s needs.

The PhD would be hosted in the Clinical Effectiveness Group (CEG) at QMUL. CEG is a centre of excellence for linking and using health services data to improve the quality of care. The centre has decades of experience in delivering quality improvement programmes in partnership with local primary care teams and using primary care electronic health records to deliver and evaluate these programmes. The student would be able to draw upon these networks and this wealth of experience.

Project description:

Quality improvement (QI) is a cornerstone of the NHS. Equity, the absence of inequalities in access, outcomes or experience, is included in many definitions of quality, such as the Institute of Medicine, but is often the most overlooked aspect of quality compared to safety, effectiveness and efficiency. We simply do not know the impact of QI projects on health inequalities; some are likely to have no impact on inequalities, and others may inadvertently narrow or widen them.

There are cautionary tales of QI projects that have inadvertently increased inequalities. The National Paediatric Diabetes Audit reports the quality of care in the paediatric diabetes unit. A 2017/18 analysis found that continuous glucose monitors improved the quality of care, reducing HbA1c by 2.6mmol/mol. However, this benefit was not equally distributed, with children from the least deprived areas experiencing a 5.7mmol/mol greater reduction than the most deprived areas.

 NHS England’s new health inequalities programme, CORE20Plus5, states that it will be “driven by QI methodologies to ensure measurable and sustained improvement” for disadvantaged groups. Currently, the UK lags behind other international countries in using QI methods to address inequalities.

There is currently a considerable evidence gap around the types of QI in primary care that increase or decrease inequalities and how equity-focused QI could be used to address inequalities in primary care. This PhD would focus on within practice inequalities (e.g.  inequalities across patients within the same practice) and local QI initiatives, rather than between practice inequalities (e.g. inequalities across different practices) and national QI initiatives (such as new QOF indicators).

Working with a patient engagement and involvement panel, the anticipated objectives of the research would be to:

1. Undertake a review of the published and grey literature on how equity-focused QI is used in primary care nationally and internationally
2. Generate theory to understand why equity is currently considered (or not) in QI projects in primary care through interviews, focus groups and case studies with practitioners and policy makers
3. Identify and evaluate a clinical area of interest to assess if improvements have been distributed equitably (choice would depend on the student’s interest, but may include hypertension case finding as part of the CORE20Plus5 inequalities programme, cervical screening, diabetes care, childhood immunisations)

 The PhD would use mixed methods and focus on impacting policy. An initial review will help the student to understand the existing literature and develop their knowledge. The qualitative component will focus on understanding why equity is included in QI in primary care (or not). The quantitative stage would use deidentified primary care electronic health records including those extracted from the North East London Discovery Data Service which include information from all 285 practices across north east London. This aspect of the project will be tailored around the needs of the individual student. We anticipate close working with NHS England and primary care colleagues.

Training and development provision by host

Informal training: The PhD will involve close working with the national NHS England primary care group with a possible internship. This partnership will help the student to understand how national policy is developed and the structure and function of different parts of the NHS. Dr Ford has worked at all levels of the NHS leading on health inequalities and the PhD would help the candidate to develop their understanding of policy approaches to health inequalities.

PPIE: Building effective PPIE relationships is really important to this PhD as understanding the lived experience of disadvantaged groups will be invaluable in informing each step of the PhD. QMUL is located in east London and the PhD offers the opportunity for building relationships with diverse communities in the east of London. The NIHR funded project (EQUAL-QI) has already a broad PPIE programme that the student would be able to draw upon, in addition to building their own relationships.

Supervised by: Dr John Ford Senior Clinical Lecturer in Public Health and Honorary Public Health Consultant NHS England with expertise in health inequalities research and policy.

Proposed supervisory team:                                    

Dr Laura Smith (Lecturer in Health Psychology, Queen Mary University of London (QMUL))
Dr Toby Ellmers (Sir Henry Wellcome Research Fellow, Imperial College London)

Potential for cross consortium networking and educational opportunities:

The PhD would be hosted in the Centre for Preventative Neurology at QMUL. The Centre has expertise in underrepresented populations, health records data, PPIE, and improving patient experiences through co-design. The student would be able to draw upon these networks and this wealth of experience.

The PhD also includes a collaboration with the Centre for Vestibular Neurology at Imperial College London, a world-renowned research unit and national NHS referral centre for dizziness. This collaboration will offer insights into the management of dizziness within the NHS and help the candidate to implement their research in clinical practice.

Collaboration with the Ménière’s Society, the UK’s leading charity supporting people with dizziness, is embedded across the PhD. The student will work with the charity to develop resources, recruit participants, conduct usability workshops, and disseminate study findings to improve public knowledge and awareness. The charity will also support the student to develop best practice around PPIE, considering the specific needs of people with chronic dizziness.

Project description: 

Dizziness is among the most common reasons people visit their general practitioner (GP). Thirty-percent of dizzy patients in primary care experience chronic dizziness which is a lasting sensation of dizziness or unsteadiness which can worsen in “visually busy” surroundings (e.g., supermarkets, crowded spaces). Although GPs regularly encounter people with chronic dizziness, they lack confidence diagnosing these patients, consider them difficult to manage, and are less likely to refer onwards. This is partly because there are multiple interacting causes of chronic dizziness, both physical and mental. Additionally, patients do not typically show any physical or ‘objective’ signs of abnormality on medical tests, meaning diagnosis relies on history taking.

Unravelling a patient’s history of dizziness is difficult because people use ‘dizziness’ to describe a range of sensations. Dizziness symptoms are challenging to verbalise, and patients and healthcare providers tend to assign different meanings to dizziness, creating language barriers. Factors such as culture, health literacy, and communication abilities create further health inequalities. Variations in intended meaning of dizziness can result in prescribing inappropriate medications, and long patient journeys. In around 40% of dizzy patients GPs were still unable to specify a diagnosis after one year of follow-up. Chronic dizziness leads to physical inactivity, disability, anxiety, and depression; therefore, delays to treatment represent a massive burden for patients, healthcare systems, and society. 

Guidelines are available to GPs to help classify patients’ dizziness symptoms into categories. However, these classifications use language which many patients are unfamiliar with. There is currently no framework for understanding dizziness that incorporates the patient perspective or covers how to discuss dizziness symptoms with patients. A recent survey showed GPs want practical guidelines, and printed information for dizzy patients to optimise care provision.

This PhD project will seek to address these gaps by developing a patient-centred framework of chronic dizziness and tailored resources for patients and GPs.

The proposed PhD will take the following structure:

Study 1: Qualitative interviews with people with chronic dizziness will explore patient language used to describe dizziness symptoms, appraisal of care received, relationships with healthcare professionals, coping strategies, and barriers to care. With consent, their healthcare records will also be accessed to understand how dizziness symptoms were recorded (and whether this reflects patients’ experiences), note any diagnoses, and map the patient care journey using theoretical frameworks. GPs will also be interviewed to understand their usual care practices and explore barriers and facilitators to the management of chronic dizziness in primary care.

Study 2: An e-Delphi study will be conducted with an expert panel including patients, their family members, clinicians, and charity professionals. Stakeholders will rate their agreement with descriptors of dizziness symptoms to form a patient-centred classification. They will also give their perspective on potential content for incorporation within tools to guide conversations in the clinic.

Study 3: Novel information resources to support patients with chronic dizziness, and toolkits for GPs on the evaluation and management of chronic dizziness will be developed. These will then be iteratively refined through PPIE, consultations with GPs, and two online multi-stakeholder workshops.       

Training and development provision by host:

QMUL has an extensive professional development programme to support PhD students. Based on the candidate’s training needs, a training programme will be developed. This will include training on literature reviews, PPIE, qualitative methods and analysis, and working with underrepresented groups. The student will also be invited to join relevant disciplinary working groups (e.g., health psychology, qualitative methods) and early career networks designed to foster knowledge-exchange and skill development.

Training in qualitative and e-Delphi methods will be provided by supervisors. Support to attend external training courses that align with students’ training needs will be provided using available budgets (e.g., Nuffield Department of Primary Care Health Sciences course in Analysing Qualitative Data).

Opportunities to publish findings and present them at a suitable conference (e.g., Barany Society International Meeting, British Society of Neuro-Otology Meeting).