The Royal College of GPs' James Mackenzie Lecture 2021

PRSB Chair, Professor Maureen Baker, gave the annual James Mackenzie lecture at the RCGP’s AGM in November.

If you looked at your phone right now, you would be able to monitor your BPM, sleep schedule and daily step count in little more than two clicks. In this sense, we are all already self-directed patients, meaning that we are using electronic wearables and handheld devices to track our health in our everyday lives and from the comfort of our own homes.

Last week, I had the honour of delivering The James Mackenzie Lecture to my colleagues at the Royal College of GP’s AGM, on the topic of the self-directed patient and the future of medical wearables for self-management of health. On researching the work of the eponymous GP, Sir James Mackenzie, I discovered that the cardiologist invented the first polygraph and used the device to record his own atrial fibrillation. In this sense, medical self-management is not new.

Today, however, the methods and tools used for self-management look very different. Over 80% of the world’s population now has a smart phone, which means that concurrently, most of us own a health wearable that can track various elements of our well-being. We all have the capacity to be self-directed patients by using existing devices that we are already well-versed in, which has many potential benefits and risks for both the individual and society.

There are many benefits to medical wearables. They have the potential to democratise healthcare, empowering patients with the information and knowledge needed to become an active participant in their own care. For the individual, this means understanding how to self-care where appropriate and control chronic conditions without having to wait to see a doctor. For wider society, the prevalence of health wearables could result in a healthier population more in tune with its lifestyle choices and their impact. For clinicians, wearables could help us to detect disease earlier.

However, many in the profession would be right to raise concerns over the reliability and validity of results from smartphones and consumer electronics for medical analysis. It is also possible that the use of health wearables could lead to an overdiagnosis based on an abundance rather than quality of numbers and observations, which side-lines the person and their individual needs and priorities in favour of metrics.

The answer to these concerns cannot be to reject wearables entirely. Indeed, the first wearable medical device has already been authorised: Withings ScanWatch is the first FDA approved medical wearable and monitors the user’s heart rate, ECG, sleep and blood oxygen. Whether we like it or not, wearables are here to stay and it is up to GPs to put forward our case for their safe regulation and use for the benefit of patients. If we fail to do this, the medical wearables market will continue to grow without medical input.

As people gain greater access to their own medical data, we need to ensure that they also have ability to turn the information they receive into knowledge. It is not enough to know the facts about your own condition, people must be able to analyse and assess those facts through observation and true understanding. Mobile devices, such as symptoms checkers, are critical here as they allow the user to input details of symptoms together with other relevant information such as age and then return possible conditions related to the user’s symptoms. In 2021, the ideal self-directed patient has access to high quality information that allows them to know when to seek professional help. 

When it comes to medical devices, GPs are on the frontline. We are the first port of call for patients when they record an unusual heartrate or are failing to get 6 hours of sleep a night, and we will be the clinicians monitoring and managing medical wearables. It is imperative that we take on this responsibility and begin to dig deeper into the risks and benefits of medical wearables so that we can make a clinical case for their use and continue to provide safe care for patients in the information age.

Watch Maureen’s lecture in full here

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Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.