SPCR PhD Studentship

Project title: Moving beyond area-level measures of socio-economic status in primary care

Proposed supervisory team:

Names and areas of expertise to be included

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

Prof Carol Dezateux Professor of Clinical Epidemiology and Health Data Science has expertise in using linked routine electronic health records for research to understand health inequalities and to evaluate outcomes of quality improvement programmes.

Dr John Robson Clinical Reader in Primary Care Research & Development leads the Clinical Effectiveness group and has expertise in obtaining actionable insights from primary care data and delivering and evaluating quality improvement programmes working with primary care teams and commissioners to improve quality and equity of services. Potential for cross consortium networking and educational opportunities: There are a number of potential opportunities for cross-consortium networking and educational opportunities. The PhD will involve close working with NHS England policy makers and practitioners and will help the student build relationships with national policymakers.

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: 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. 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 and development provision by host:

Formal 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..

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.

Project title: Moving beyond averages – using quality improvement in primary care to address inequalities 

Proposed supervisory team:                                  

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

Prof Carol Dezateux Professor of Clinical Epidemiology and Health Data Science has expertise in using linked routine electronic health records for research to understand health inequalities and to evaluate outcomes of quality improvement programmes.

Dr John Robson Clinical Reader in Primary Care Research & Development leads the Clinical Effectiveness group and has expertise in obtaining actionable insights from primary care data and delivering and evaluating quality improvement programmes working with primary care teams and commissioners to improve quality and equity of services.

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.

 

 

 

 

Project title: Improving medication reviews from the inside out: a linguistic ethnographic study in general practice

Proposed supervisory team:   

Dr Nina Fudge (Queen Mary University of London): Social scientist and THIS-funded post-doctoral fellow with methodological expertise in ethnographic and participatory research approaches and experience of embedding patient and public involvement and engagement in research projects. Dr Fudge’s research interests explore the interrelationships between knowledge, expertise, and practice in complex healthcare settings.

Professor Deborah Swinglehurst (Queen Mary University of London): Practising GP with international profile as a qualitative researcher. Prof Swinglehurst conducts research at the interfaces between medicine, social science and linguistics, with a particular interest in the role of interaction and social relationships in primary health care settings.

 Dr Rebecca Barnes (Oxford) Dr Barnes is an NIHR-funded research fellow and an internationally recognised researcher and teacher of conversation analysis methods as applied to communication in health care settings. Rebecca’s research interests encompass the delivery of routine health care services and communication-based interventions in primary care settings.

Potential for cross consortium networking and educational opportunities:

This project is a new collaboration between supervisors at QMUL and Oxford which aligns with the supervisors’ ongoing interests in polypharmacy and deprescribing with a particular focus on Structured Medication Reviews as an intervention to reduce problematic polypharmacy.  

 The successful candidate will be based in the Wolfson Institute of Population Health Science at QMUL with access to formal (MSc modules) and informal (peer support groups, research seminars, discussion groups) educational opportunities - see the training and development section for more details. With a supervisor based at Oxford University, the candidate will have the opportunity to spend time as a visiting researcher at the Nuffield Department of Primary Care Health Sciences and to participate in Oxford Research in Conversation Analysis (ORCA) group data sessions.

Additional opportunities for enrichment and development will be made possible through the Faculty of Medicine and Dentistry, QMUL, with links to world-leading clinicians.

Background

In the UK the number of people prescribed five or more medicines, known as polypharmacy, is increasing. Sometimes polypharmacy is problematic. It can increase the risks of falls, hospitalisation, and adverse drug reactions. Problematic polypharmacy creates a burden of work for both patients and clinicians (e.g. processing prescriptions, assembling and organising medicines, managing medicines supplies). Some prescribed medicines may not be needed or taken, resulting in financial waste and environmental harm. Optimising the use of medicines in general practice is seen as a way to reduce the harms and risks of polypharmacy. Medication reviews are considered an evidence-based intervention to address the problems of polypharmacy: patient safety, the treatment burden, and environmental and financial waste.  Recently a new contract has been introduced in England which requires Primary Care Networks to deliver structured medication reviews (SMR) to patients at risk of problematic polypharmacy. The introduction of SMRs builds on recent initiatives to integrate clinical pharmacists into the general practice workforce, with an expectation that clinical pharmacists will undertake most of the SMRs.

The proposed PhD will be aligned with an existing project (PI Fudge, THIS) which is evaluating this policy and collecting audio and video data of consultations involving a SMR. This provides an ideal opportunity for a PhD candidate to:

1. develop advanced qualitative research skills, including microanalysis of clinical consultation data using the techniques of conversation analysis
2. contribute detailed analysis of SMRs as a reflexive tool within multidisciplinary workshops involving primary care clinicians
3. collaborate with researchers evaluating SMRs in primary care as an intervention to address problematic polypharmacy

Aims and objectives

The aim of this PhD is to understand, using techniques of conversation analysis, how and to what extent structured medication reviews address problematic polypharmacy with a view to recognising transferable strategies that can be employed within primary care settings. The specific focus of the study will be tailored to the student’s interest but may include one or more of the following areas:

• How do SMRs contribute to ensuring medication safety for patients prescribed multiple medications?
• How do SMRs contribute to reducing financial and environmental waste in terms of costs of unused and/or unnecessary medicines?
• How do clinicians and patients negotiate deprescribing within the SMR?
• How are patient preferences successfully incorporated into structured medication reviews?
• How do different health care professionals within primary care work together to deliver structured medication reviews and what does ‘successful’ collaboration look like?

Impact

The project has the potential to impact the delivery of health services in terms of identifying best practices for reducing instances of problematic polypharmacy, reducing impact of unnecessary medicines which lead to financial waste and environmental harm, and understanding collaboration between primary care health professionals. 

Training and development provision by host:

 Formal training:

The successful candidate will have access to an MRes level module on Qualitative Research Methods which is hosted in the Wolfson Institute of Population Health (WIPH) at QMUL. The candidate will also be encouraged to undertake training in conversation analysis techniques. Access to a short course in these techniques will be made available through the partner institution, Oxford University.

QMUL has robust monitoring arrangements to ensure students successfully complete their doctoral studies. The successful candidate will have regular supervisions with the supervisors (at least once per month, more frequent in the early stages of the PhD) which are documented through the MYSIS graduate student online system. The student will also complete PhD progression reports at 9 months, 18 months and 30 months of the PhD time. Progression at 9 and 18 months includes a viva voce. Progression reports will be read and assessed for progress and capability to complete the PhD by two panel members who are external to the PhD supervisory team and selected for their relevant academic expertise. The delivery of post graduate education is guided by robust academic regulations, with oversight of the implementation of these procedures by the Institute Director of Graduate Studies, and the support of the post graduate research administrator. PhD supervisors are required to engage in regular PhD supervision training, including mental health training.

Informal training:

Both institutions will provide the successful candidate with informal support and development. The successful candidate would become a member of the APOLLO social science team (led by Prof Deborah Swinglehurst) which meets weekly to provide discussion, support and development on individual team member’s projects.

The PhD student will have access to:

• monthly informal discussion groups where qualitative research methods, data analysis and application of theory are discussed with WIPH colleagues and researchers from other universities (Curiosity Workshop, Thinking Between the Lines)
• WIPH monthly research seminar where external guest speakers and Institute staff present their research; early career researchers and PhD students are encouraged to present their work at this seminar
• an active Early Career Researchers Group which meets monthly to discuss career development, support and development during the PhD and post-doctoral period
• WIPH’s annual showcase event where PhD students are encouraged to present their work and network with Institute researchers
• QMUL’s Student Services for (pastoral support and study needs)
• QMUL Academy delivering university-wide support and development for education and research

Additional opportunities for enrichment and development will be made possible through:

• WIPH and Nuffield Department of Primary Care Health Sciences networks with links to national and international collaborators
• the Faculty of Medicine and Dentistry, QMUL, with its links to world-leading clinicians.

PPIE:

PPIE activities (focus group discussions with people who are prescribed multiple medications, discussion with health care professionals about the study design and questions) have been undertaken in preparation for the project from which the PhD data set will be drawn. The successful candidate would be encouraged to establish their own PPIE advisory group to help refine and develop the research going forward. The candidate may also want to consider approaching existing groups for PPIE support such as GP Patient Participation Groups and the Wolfson Institute of Population Health’s Public Advisory Panel.