Chris Butler presentation WSPCR 2010

Our vision for Teaching and Research Public Health and Primary 

Care  

Chris Butler Head of Department of Primary Care and Public Health 

Cardiff University Director, Wales School of Primary Care Research 

This was my view from Llanedeyrn… 

Primary Care & Public Health South East Wales Trials Unit 

Wales Cancer Trials Unit  & Cancer RRG 

ParIcipant Resource Centre 

Epidemiology & Screening RRG 

Decision making laboratory 

Undergraduate teaching 

Postgraduate teaching 

Postgraduate research 

Wales School for Primary Care 

Clinical Epidemiology IRG 

Central PCAPH admin 

Neuadd Meirionnydd 

Mission statement Our mission is to promote well‐being and dignity by reducing the 

populaIon burden of disease and improving health care through high quality research, teaching, clinical service and innovaIon and engagement. 

 Our core aims are to:  •  Provide excellent educaIon and training for health care 

professionals •  Use our mulIdisciplinary, integrated research environment to: 

–  Promote healthier communiIes –  Develop relaIonship based, holisIc, cost effecIve individual care –  Contribute to the understanding and reducIon of health inequaliIes, 

parIcularly in Wales 

Achievements.. •  180 people •  165 teaching pracIces •  Best rated teaching in the curriculum •  65% 3* and 4* in RAE 2008 (=second best health submission form Wales) 

•  Research income since 2008 nearly £15M; highest of all groups in School of Medicine 

•  Total Value since 2008 £26.5M •  >50 ongoing studies •  Involved in winning infrastructure grants >£30M 

Theme 

•  Understanding unhelpful/harmful variaIon in the causes of ill health and health care delivery  

•  Developing and evaluaIng intervenIons  to address this with people/paIents are the centre 

•  Locally relevant, internaIonally applicable •  InternaIonally excellent 

Health stats… 

”A pathophysiology of disempowerment and degrada5on” 

Within the UK, over 95% of NHS clinical contacts are made in general pracIce and around 80% of health problems are managed at this level. Over 300 million general pracIce consultaIons take place in the UK each year; these encompass health promoIon, prevenIon and screening as well as acute and chronic care. 

Primary care  •  Helps prevent illness and death •  Associated with more equitable distribuIon of of health in a populaIon 

Primary care: four pillars 

1.  First contact for each new health need 2.  Long term (person‐(not disease) focused 3.  Comprehensive for most health care needs 4.  Coordinated care when it must ne sought 

elsewhere 

The evidence… 

•  Heath is beier in areas with more primary care physicians 

•  All cause mortality less •  Beier HRQL •  Less low birth weight 

•  People who receive care from primary care physicians are healthier 

•  The characterisIcs of primary are associated with beier health 

Mechanisms 

•  Greater access to needed services •  Beier quality of care •  Greater focus on prevenIon •  Earlier management •  PrevenIon of unnecessary and potenIally harmful specialist care 

Primary Care in 11 countries

Primary Care ranking

Expenditure per head

Health indicators

Medicines prescribed per head

Average rank for outcomes

US 11 11 8 7 8.5

UK 1 2 9.5 4 5.4

• Starfield B, Lancet 1994;3441129-1133

• 1 is best, 11 worst

IdenIfying unhelpful variaIon Sectional Proceedings of the Royal Society of Medicine Vol. XXXIpage 95 Soit'1219

$ectioII of Eptibemii0o[ogp anb !tate IDebiciniePresident-Sir ARTHUR MACNALTY, K.C.B., M.D.

[May 27, 1938]

The Incidence of Tonsillectomy in School Children

J. ALISON GLOVER, O.B.E., M.D., F.R.C.P., D.P.H.

THE rise in the incidence of tonsillectomy is one of the major phenomena of modernsurgery, for it has been estimated that 200,000 of these operations are performedannually in this country and that tonsillectomies form one-third of the number ofoperations performed under general ancesthesia in the United States. There are,moreover, features in the age, geographical and social distribution of the incidence,so unusual as to justify the decision of the Section of Epidemiology to devote anevening to its discussion.

HISTORYIt seems unnecessary to review the history of operative treatment of the tonsil,

and I will confine myself to pointing out that while it was natural that, in pre-anaesthetic and pre-Listerian days, the incidence of operation should be very small,it is astonishing to find how recent is the great vogue of the operation. For manyyears after the introduction of aneesthesia and aseptic surgery the incidence remainedlow. In 1885 that great physician Goodhart [14] said, " It is comparatively seldomthat an operation is necessary, and fortunately so, for parents manifest great repug-nance to it. Children grow out of it, and at 14 or 15 years of age the condition ceasesto be a disease of any importance ". These words were repeated in several subsequenteditions.

In 1888 I went to a preparatory boarding school of 50 boys, and then, in 1890, to apublic school of 650 boys. Though, as the son of a doctor and destined for theprofession myself, I took some interest in medical matters even then, I cannot recalla single boy in either school who had undergone the operation. Both schools stillflourish, but the percentage of tonsillectomized boys is now in both alike about 50%,and, as we shall see later, even this is nowadays a low figure for schools of these types.

Old photographs reveal little difference in appearance between the untonsillec-tomized fathers and the tonsillectomized sons, and although the latter seem to growtaller and heavier than we did, memory suggests that we were at least as resistantto infection.

EARLY ESTIMATES OF THE NEED FOR OPERATIONIt is difficult to estimate the number of operations previous to the introduction

of the School Medical Service. Any such estimate is derived either from estimatesof the number of children whose tonsils are said to " require immediate operations"or from hospital records.

In 1903 the Report of the Royal Commission on Physical Training (Scotland) gavethe age-and-sex grouped results of the examination of600 Edinburgh and 600 Aberdeenschool children, in tables, which showed well the two periods of physiological

AUG.-EPID. 1

Wales today 

MATCH Leaflet 

Shared decision‐making: a meeIng between experts 

•  InformaIon exchange is two‐way •  Clinician provides relevant informaIon about treatment opIons 

•  PaIent provides informaIon about their lived experience of the illness, their values, preferences, lifestyle and knowledge about the treatment 

Joint prescribing

decision

Butler C et al. JAC 2001; 48:435–440

University Research InsItute 

 Family Nurse Partnership Programme 

•  A structured, intensive home visiIng programme delivered by Family Nurses to pregnant teenagers 

•  Programme runs through pregnancy and unIl baby’s second birthday. 

•  Licensed programme developed and tested in the USA with fidelity measures to ensure replicaIon of original research  

Visi5ng Schedule 

•  1/week first month 

•  Every other week during pregnancy 

•  1/week first 6 weeks aner delivery 

 •  Every other week unIl 21 

months 

•  Once a month unIl age 2 

Outcome domain 

• Changes in prenatal tobacco use (maternal measure) • Birth weight (child measure) 

Pregnancy & birth 

Child health & development 

Maternal life course and economic self‐sufficiency 

• Emergency aiendances / admissions within two years of birth 

• ProporIon of women with a second pregnancy within two years of first birth 

• IntenIon to breaspeed • Prenatal aiachment 

• Injuries & ingesIons • Breast feeding (iniIaIon & duraIon) • Language development 

• EducaIon • Employment • Health status • Social support Paternal involvement 

Primary  Secondary 

Overview of the Trial Study Outcomes 

ImplemenIng an integrated vision… 

Previous Academic Fellows 

Academic Fellow Dates Continued as GP in Valleys?

Further Academic Post? Publication? Teaching? Post Grad. Qualification

Anne-Marie Cunningham 2001-03 MSc Pub Health

Liz Metcalf 2001-03 MSc Med Ed

Diane Owen 2002-04 MSc Pub Health

Josep Vidal-Alabal 2002-04 MSc Pub Health

Jo Davies 2002-05 Cert Med Ed

Kathy O’Brien 2003-05 Cert Med Ed

Nick Francis 2003-05 Fellowship App: PG Dip Epidemiology

Sandra Jones 2004-06 Cert Med Ed

Yolande Robles 2004-06 MSc Pub Health

Chantal Thomas 2005-07 Dip Med Ed

Jane Fryer 2005-07 MSc Med Ed

Della Williams 2005-06 Cert Med Ed

Naomi Cadbury 2005-07 Cert Med Ed

Rachel Andrew 2006 Cert Med Ed

Lisa Williams 2006-07 Cert Med Ed

Brechje Brocken 2007-08 Cert Med Ed

Jim Pink 2006-08 Cert Med Ed

Naomi Stanton 2007-08 Dip Pub Health

Lucy Morris 2007-09 Cert Med Ed DFSRH

Emma Melbourne 2007-09 Cert Med Ed

Nathan Francis 2008-2010 MSc Public Health -progressing

Bethan Stephens 2008- 2010 Cert Med Ed

On compleIon 

Glyncorrwg 

From this… 

To this.. 

Same old same old (but with  a beier view)? 

•  Not a: silo, outpaIent‐verIcal, QoF driven  model •  ConInuous, longitudinal integrated care, teaching and 

research for whole populaIon •  Truly mulIdisciplinary: nursing, admin, palliaIve care, 

learning disabiliIes, psychiatry, child health, obstetrics, minor injuries 

•  Integrated with voluntary sector, social services, social care and local authority, planning 

•  Begin with paIents problems •   Put on  strei‐strip, catheterize, make diagnoses •  24 hour care •  Community led/buy in 

Stoi and Davies revisited 

E Who can I teach? 

F What can I learn?  What data can be contributed?  

Three stage (triple diagnosis) model 

•  Biomedical •  Psychological  •  Social 

Five stage model 

•  Biomedical •  Psychological  •  Social 

•  Biomedical •  Psychological •  Social •  Environmental •  Spiritual 

Diolch yn fawr