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"Marshall, Martin"
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The power of trusting relationships in general practice
Relationship based care remains a fundamental feature of safe, effective practice
Journal Article
Development and validation of the Cambridge Multimorbidity Score
Health services have failed to respond to the pressures of multimorbidity. Improved measures of multimorbidity are needed for conducting research, planning services and allocating resources.
We modelled the association between 37 morbidities and 3 key outcomes (primary care consultations, unplanned hospital admission, death) at 1 and 5 years. We extracted development (n = 300 000) and validation (n = 150 000) samples from the UK Clinical Practice Research Datalink. We constructed a general-outcome multimorbidity score by averaging the standardized weights of the separate outcome scores. We compared performance with the Charlson Comorbidity Index.
Models that included all 37 conditions were acceptable predictors of general practitioner consultations (C-index 0.732, 95% confidence interval [CI] 0.731–0.734), unplanned hospital admission (C-index 0.742, 95% CI 0.737–0.747) and death at 1 year (C-index 0.912, 95% CI 0.905–0.918). Models reduced to the 20 conditions with the greatest combined prevalence/weight showed similar predictive ability (C-indices 0.727, 95% CI 0.725–0.728; 0.738, 95% CI 0.732–0.743; and 0.910, 95% CI 0.904–0.917, respectively). They also predicted 5-year outcomes similarly for consultations and death (C-indices 0.735, 95% CI 0.734–0.736, and 0.889, 95% CI 0.885–0.892, respectively) but performed less well for admissions (C-index 0.708, 95% CI 0.705–0.712). The performance of the general-outcome score was similar to that of the outcome-specific models. These models performed significantly better than those based on the Charlson Comorbidity Index for consultations (C-index 0.691, 95% CI 0.690–0.693) and admissions (C-index 0.703, 95% CI 0.697–0.709) and similarly for mortality (C-index 0.907, 95% CI 0.900–0.914).
The Cambridge Multimorbidity Score is robust and can be either tailored or not tailored to specific health outcomes. It will be valuable to those planning clinical services, policymakers allocating resources and researchers seeking to account for the effect of multimorbidity.
Journal Article
Promotion of improvement as a science
An agreed curriculum is needed to achieve this education. [...]academia needs to break out of rigid and unhelpful departmental silos and work in interprofessional research and practice teams; incentives are needed to encourage this cooperation. [...]funding is needed to establish and support centres for improvement science, and bring together diverse academic and clinical disciplines within discrete health economies.
Journal Article
Moving improvement research closer to practice: the Researcher-in-Residence model
The traditional separation of the producers of research evidence in academia from the users of that evidence in healthcare organisations has not succeeded in closing the gap between what is known about the organisation and delivery of health services and what is actually done in practice. As a consequence, there is growing interest in alternative models of knowledge creation and mobilisation, ones which emphasise collaboration, active participation of all stakeholders, and a commitment to shared learning. Such models have robust historical, philosophical and methodological foundations but have not yet been embraced by many of the people working in the health sector. This paper presents an emerging model of participation, the Researcher-in-Residence. The model positions the researcher as a core member of a delivery team, actively negotiating a body of expertise which is different from, but complementary to, the expertise of managers and clinicians. Three examples of in-residence models are presented: an anthropologist working as a member of an executive team, operational researchers working in a front-line delivery team, and a Health Services Researcher working across an integrated care organisation. Each of these examples illustrates the contribution that an embedded researcher can make to a service-based team. They also highlight a number of unanswered questions about the model, including the required level of experience of the researcher and their areas of expertise, the institutional facilitators and barriers to embedding the model, and the risk that the independence of an embedded researcher might be compromised. The Researcher-in-Residence model has the potential to engage both academics and practitioners in the promotion of evidence-informed service improvement, but further evaluation is required before the model should be routinely used in practice.
Journal Article
Bridging the ivory towers and the swampy lowlands; increasing the impact of health services research on quality improvement
Decisions about how to organize and deliver health services are often more complex and seemingly less rational than decisions about what clinical care to provide. The concept of 'Evidence-Based Management', or what might more appropriately be termed 'Evidence-Informed Improvement', does not seem to have captured the hearts and minds of the people responsible for managing health-care provision. Organizational decision-making is more likely to be influenced by political, ideological and pragmatic factors, and by the personal experience of the decision-makers, than by science. Whilst some people would regard the messiness of management decision-making as inevitable, most would accept that decisions could be improved by making greater use of the established health service research evidence, and through a stronger commitment to developing new evidence. Over the last two or more decades the evidence base created by Health Service Researchers has grown in quantity and in quality and yet much of it remains invisible to the people who most need to use it. This paper explores how the disconnect between the traditional 'producers' of research evidence in academia, and the managerial and clinical 'consumers' ofthat evidence, has contributed to the challenge of embedding an evidence-informed approach to service improvement. The advantages of a closer working relationship between academia and health services are outlined and three approaches to evidence creation and utilization are described which attempt to maximize the influence of scientific evidence on managerial practice.
Journal Article
Transforming community nursing services in the UK; lessons from a participatory evaluation of the implementation of a new community nursing model in East London based on the principles of the Dutch Buurtzorg model
Background
Buurtzorg, a model of community nursing conceived in the Netherlands, is widely cited as a promising and evidence-based approach to improving the delivery of integrated nursing and social care in community settings. The model is characterised by high levels of patient and staff satisfaction, professional autonomy exercised through self-managing nursing teams, client empowerment and holistic, patient centred care. This study aimed to examine the extent to which some of the principles of the Buurtzorg model could be adapted for community nursing in the United Kingdom.
Methods
A community nursing model based on the Buurtzorg approach was piloted from June 2017–August 2018 with a team of nurses co-located in a single general practice in the Borough of Tower Hamlets, East London, UK. The initiative was evaluated using a participatory methodology known as the Researcher-in-Residence model. Qualitative data were collected using participant observation of meetings and semi-structured interviews with nurse team members, senior managers, patients/carers and other local stakeholders such as General Practitioners (GP) and social workers. A thematic framework analysis of the data was carried out.
Results
Implementation of a community nursing model based on the Buurtzorg approach in East London had mixed success when assessed against its key principles. Patient experience of the service was positive because of the better access, improved continuity of care and longer appointment times in comparison with traditional community nursing provision. The model also provided important learning for developing service integration in community care, in particular, how to form effective collaborations across the care system with other health and social care professionals. However, some of the core features of the Buurtzorg model were difficult to put into practice in the National Health Service (NHS) because of significant cultural and regulatory differences between The Netherlands and the UK, especially the nurses’ ability to exercise professional autonomy.
Conclusions
Whilst many of the principles of the Buurtzorg model are applicable and transferable to the UK, in particular promoting independence among patients, improving patient experience and empowering frontline staff, the successful embedding of these aims as normalised ways of working will require a significant cultural shift at all levels of the NHS.
Journal Article
The future of general practice in England
The Health and Social Care Committee shows leadership where government has failed to act
Journal Article
Media attacks on GPs threaten the doctor-patient relationship
Criticisms of GPs commitment and professionalism are undermining patients’ trust and confidence in their doctors
Journal Article
“Our plan for patients”—neither bold nor a plan
Politicians need to understand that we need urgent action to protect general practice, writes Martin Marshall
Journal Article