LISS CASE funded PhD studentship
Applications are invited for a fully funded London Interdisciplinary Social Science Doctoral Training Partnership CASE studentship, starting October 2021.
The economic and social cost of type 2 diabetes by health inequalities
Professor Khalida Ismail, Professor of Psychiatry and Medicine, Psychological Medicine, King’s College London
Dr James Shearer, Senior Lecturer in Health Economics, King’s College London
Dr Alexandru Dregan, Senior Lecturer in Epidemiology, Psychological Medicine, King’s College London
Ms Nicola Morris, Assistant Director, SEL Analytics at NHS South East London Clinical Commissioning Group
Professor Paul McCrone, Professor of Health Care Economics, University of Greenwich
Professor Daniel Stahl, Professor of Medical Statistics and Statistical Learning, King’s College London
South East London Clinical Commissioning Group
Students will receive a stipend of £17,285 per annum and UK tuition fees (currently £4407 per annum) are paid.
Additional funding for research costs of around £750 per annum is also available. Opportunities to apply for additional funding for overseas students, overseas visits or student-led activities may also available (see London Interdisciplinary Social Science Doctoral Training Partnership for further details)
17.00, Friday 05 March 2021 with interviews to be held in second week of March 2021.
How to apply
Please submit the following:
- Your curriculum vitae
- Application form
- Maximum 1 page personal statement
- Applicants are asked to complete the Diversity Monitoring Form available only to LISS DTP for reporting purposes.
Please submit to firstname.lastname@example.org by 17.00 Friday 05 March 2021
The prevalence of type 2 diabetes is rising secondary to the obesity epidemic and aging population. Type 2 diabetes is a progressive condition and it can take 5-10 years before diabetes complications emerge. Despite effective lifestyle and pharmacological interventions around half of patients do not have effective blood glucose control. It was estimated that around 10% of the NHS’s budget is spent on managing diabetes and its complications. This estimate is now outdated and there is a lack of understanding as to how the trajectory of the cost of diabetes care changes over time, and whether health inequalities in particular ethnicity and socioeconomic deprivation accelerate the cost of diabetes. This study will first review the current literature on the prospective costs of type 2 diabetes. Second it will conduct a secondary analysis of a) routine primary care records and b) research cohort of incident type 2 diabetes patients who have now had their condition for over 10 years and identify subgroups most at risk of higher costs. Third, the student will undertake interviews with commissioners and patients with type 2 diabetes to understand the barriers and facilitators of diabetes care. These results will support population health integrated management systems to help target support to those at highest risk of developing complications.
Contact Professor Khalida Ismail or Dr James Shearer for further information.
Full project summary
The prevalence of type 2 diabetes (T2D) is rapidly increasing worldwide, secondary to the obesity epidemic and ageing population. In the UK is estimated to increase to 4 million by 2025, T2D typically progresses from a single condition to multiple conditions such as macrovascular (cardiovascular disease) and microvascular (retinopathy, neuropathy and nephropathy) diabetes complications as well as dementia and has a reduced life expectancy by 10 years. The cost of diabetes is estimated at £14 billion/year, or 10% of the NHS budget, mostly for the treatment of its complications such as strokes, blindness, foot amputations and renal dialysis. While there are many studies of (period) prevalence costs, only a few have studied the rate of progression of health care costs over time. These are predominantly set in insurance based North American systems. Even fewer have included the social care and employment costs of diabetes related disabilities or the effect of health inequalities such as deprivation, ethnicity and geography. Meanwhile innovative models of population health management are emerging as part of the NHS’s Long-Term Plan. These aim to integrate medical, social and community data at the individual level to improve health outcomes. Understanding the trajectory of the outcomes and their costs and of T2D, and the interaction between socio-economic and biological factors, is essential if these models are to effectively identify those patients at highest risk of diabetes complications.
This PhD will use a combination of methodologies (literature review, analyses of routine registers and research cohorts, and qualitative interviews) which together will i) estimate the health care costs over 20 years following the onset of T2D, ii) examine whether health inequalities are associated with faster progression of costs and complications of the disease, and iii) identify the barriers to T2D care.
This PhD is set within a multidisciplinary team of clinical academics, health economists, complex statistics and epidemiology providing a diverse and rich range of training and research skills acquisition opportunities.
The aim of Study 1 will be to synthesise and critique the current evidence. A systematic review will be conducted of observational studies reporting diabetes complications and costs with long-term follow-up (>5 years) using standardised guidelines. Data on outcomes will be synthesised using meta-analysis if homogeneity of studies allows including specifically the effect of health inequalities on the progression of costs. Included studies will be quality appraised using appropriate instruments.
Next, in Study 2, the student will develop a qualitative understanding of the patient’s and the commissioner’s perspectives of diabetes care. They will conduct semi-structured interviews and focus groups in purposive samples of people with T2D and commissioners from Sustainability and Transformation Partnerships (STP), which are emerging integrated care systems between the NHS and local councils. Topics will include the different perceptions of the cost of diabetes to the individual and society and the role of health inequalities in contributing to these costs. Thematic framework methods will be applied to analyse the contents of interviews.
The findings from Studies 1 and 2 will inform Study 3. Here primary and secondary care medical and cost data will be linked using the Clinical Practice Research Datalink (CPRD) to study the progression of costs in T2D over time and its interaction with health inequalities (www.cprd.com). The CPRD holds records on 5 million ‘active’ patients with an average follow-up of 9.4 years and can be linked to secondary care records held in Hospital Episode Statistics (HES) and to the mortality register. The student will derive a matched cohort of patients with and without T2D from the CPRD. Cases will be defined as first registration of T2D in primary care and controls defined as those without T2D during the follow-up, matched by surgery, age, sex and socio-economic status (Index of Multiple Deprivation (IMD)). The student will initially conduct analyses to quantify costs for each year following the diagnosis of T2D and assess the effect of age, sex and glycaemic control on these costs and the time to diabetes complications. Analyses will then explore the role of deprivation, ethnicity and geography, both directly and indirectly through their impact on glycaemic control, on the excess costs of diabetes and on health outcomes.
Study 4 builds on Study 3 by linking medical and cost data from primary and secondary care with data from statutory social care and community care services to understand how, and when, the progression of T2D leads to changes in social functioning such as i) increased formal social support (for instance housing and unemployment benefits; ii) reduced productivity. This study is set in a unique socioeconomic and ethnic diverse South London Diabetes (SOUL-D) cohort of T2D (n=1750) being followed up for 10 years after their diagnosis and included social support and productivity measures at baseline, years 1 and 2 of follow up. This cohort will be linked to the population health management e-system within South East London (SEL) Clinical Commissioning Group (CCG) (SOUL-D participants are also residents in the same CCG). The analyses will include describing the trajectory of diabetes complications and ‘whole systems’ costs of T2D to include the additive effects of social costs on health costs over 10 years since diagnosis, and the effects of health inequalities on these costs.
The student will be supported to publish each study in high impact journals. As this project involves a close partnership with the SELCCG, the findings will be directly used to inform local policies and forecasting budgets for T2D as well as help identify patients most at risk of worse outcomes and costs for informing the development of innovations for the secondary prevention of diabetes complications.
Year 1: Studies 1 and 2 conducted; set up of Study 3; contributing to data collection for Study 4.
Year 2: Study 3 analysis; data collection for Study 4.
Year 3: Study 4 analysis; internship; and thesis write up.
Developmental/training opportunities with the SEL CCG (non-HEI partner)
The concept of population health management is relatively new to the NHS so the student will be exposed to the cutting edge of translating policy into practice. South East London CCG covers 6 south London boroughs and is responsible for the health care for over 2 million residents.
The student will benefit from partnering with SEL CCG in the following ways:
- acquiring a deeper understanding of the similarities and differences between different costing models ie research methods versus commissioning methods
- access to the e-population health management systems to be able to derive ‘whole systems’ cost of diabetes with supervision from non HEI lead (Nicola Morris)
- knowledge of the strengths and limitations of routine medical and social care records
- networking with a range of professions in the NHS to guide own career aspirations including opportunities for mentoring
- training on how NHS Business Intelligence Units and Informatics operate
- office space and equipment use at non HEI site
- access to research participants
- opportunities to disseminate research findings to senior commissioners
- learning about how de-identified and identified data is used by NHS England to segment the local population according to care needs, and understanding who, within each segment, has the greatest risk of needing intense care such as a hospital admission.
- acquiring experience in preparing report writing and business cases
- opportunity to visit other NHS sites to compare different models of population health management eg other Sustainability and Transformation Partnerships (STP).
Further information about the supervisors
Khalida Ismail is Professor of Psychiatry and Medicine and is a national and international expert in the epidemiology of psychiatric disorders in diabetes and developing innovative complex interventions to improve diabetes outcomes. She leads the largest research unit in diabetes and mental health in the UK with around £20m funding over the past 15 years. She manages the South London Diabetes Cohort study which has contributed to 4 PhDs and 5 training fellowships and over 15 publications as well as over 20 BSc and MSc dissertations. Her research is strongly focused on social determinants in diabetes outcomes and this has led to the award winning services. For instance ‘3 Dimensions for Diabetes’ which integrated social and psychiatric care within a diabetes service won the BMJ Diabetes Team of the Year Award in 2014. She has supervised to completion 16 PhD (12 as first supervisor) and currently is second supervisor to 3 students.
James Shearer is an academic health economist with over twenty year’s experience in the UK and Australia. He holds a joint appointment as the Health Economics Methods Lead at the Research Design Service, London as well his own program of teaching and research as a Lecturer at King’s Health Economics in the Institute of Psychiatry, Psychology and Neuroscience. His relevant research interests include the economic modelling of disease progression where he has built patient based models to predict future costs and outcomes in opioid addiction, alcohol relapse, neurological disorders, and most recently diabetes prevention in young at risk adults in Sri Lanka.
Selected further reading
Moulton CD, Murray L, Winkley-Bryant K, Amiel SA, Ismail K, Patel A. Depression and change in occupational functioning in type 2 diabetes. Occup Med. 2019;69:322-328. doi: 10.1093/occmed/kqz072.
Ismail K, Stewart K, Ridge K, Britneff E, Freudenthal R, Stahl D et al. A pilot study of an integrated mental health, social and medical model for diabetes care in an inner-city setting: Three Dimensions for Diabetes (3DFD). Diabet Med. Published: Online First: Feb 1 2019. doi: 10.1111/dme.13918.
Stopford R, Winkley K, Ismail K. Social support and glycemic control in type 2 diabetes: A systematic review of observational studies. Patient Educ Couns. 2013;93:549-58. doi: 10.1016/j.pec.2013.08.016.
Shearer, J., Papanikolaou, N., Meiser-Stedman, R., McKinnon, A., Dalgeish, T., Smith, P., Dixon, C. & Byford, S., Cost-effectiveness of cognitive therapy as an early intervention for post-traumatic stress disorder in children and adolescents: A trial based evaluation and model. Journal of Child Psychology and Psychiatry. 2018; 59:773-780
Shearer, J., Green, C., Counsell, C. E. & Zajicek, J. P. The impact of motor and non motor symptoms on health state values in newly diagnosed idiopathic Parkinson's disease. Journal of Neurology. 2012: 259;462-468
Shearer, J. D., McCrone, P. R. & Romeo, R. Economic Evaluation of Mental Health Interventions: A Guide to Costing Approaches.., PharmacoEconomics. 2016: 34;651-664 https://doi.org/10.1007/s40273-016-0390-3
ESRC Core Training Requirements (+3 studentships)
If this studentship is to be awarded as a +3 (PhD only) the candidate must have covered at least two of the three major ESRC core research methods areas - social theory, qualitative methods and quantitative methods – in level 7 (master’s) modules or have a significant professional experience in at least two of these general areas. You can see more details regarding these ESRC’s core research training areas here.
ESRC Core Training Requirements 1+3 studentships
If the studentship is offered as a 1+3 (master's and PhD) then the student should undertake one of the master's programmes listed under the relevant pathway. These master's programmes meet the ESRC’s Core Training Requirements.