Prognosis, the periodical of the Harley Street Medical Area

The periodical of the Harley Street Medical Area Issue 09 / 2022

Research lights Insights from one of the charities that helps fund and shape vital pancreatic cancer research The big interview Professor Dame Anne Johnson on epidemiology and behaviour Optical coherence tomography The secrets of a technique that has revolutionised retinal medicine Healthcare in the climate crisis Steps towards a sustaniable NHS

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Prognosis is owned by The Howard de Walden Estate 23 Queen Anne Street London W1G 9DL 020 7580 3163 hdwe.co.uk Estate contact Annette Shiel annette.shiel@hdwe.co.uk

42 A healthy heart Julian Best of The Howard de Walden Estate and Dr Brian Donley of Cleveland Clinic London discuss how the Harley Street Medical Area has become a global healthcare hub of sufficient reputation to draw one of the USA’s most influential clinics into its ranks

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Publisher Lusona Publishing lusonapub.co.uk Editor Viel Richardson info@lusonapub.co.uk Editorial consultant Mark Riddaway mark@lscpublishing.com Contributers Jean-Paul Aubin-Parvu, Ellie Costigan, Clare Finney, Orlando Gili, Julia Price, Christopher L Proctor, Kaite Welsh Design and art direction Em-Project Limited 01892 614 346 mike@em-project.com

Prognosis – 1

04 HSMA update Julian Best of The Howard de Walden Estate on how the HSMA has responded to the challenges of the past year 09 News New arrivals, developments and events 10 Crystal ball The evolution of treatments for post-surgical spinal pain 11 Harley Street hero Sophia Jex-Blake 12 How does it work Optical coherence tomography 14 Thinking aloud The thoughts of Dr Dejan Dragisic of Wimpole Street Dental Clinic 16 Profile of a pathogen Marburg virus 18 How to The treatment of floaters 20 A day in the life Dr Paul Ettlinger of The London General Practice 24 Best of both worlds Shams Maladwala of The Royal Marsden Private Care, on the Trust’s integrated model of private and NHS care 26 Healthcare in the climate crisis A sustainable NHS

30 The big interview Professor Dame Anne Johnson on the behavioural aspects of epidemiology 36 Research lights Progress in the detection and treatment of pancreatic cancer 42 A healthy heart How the HSMA has become a global healthcare hub 48 Q&A Professor Michael Gatzoulis on the treatment of a serious heart condition 52 Patient experience Susan Bridgman on how revision knee replacement freed her from severe pain 56 Stronger together A rehab programme that bridges the gap between doctors and fitness specialists

60 My Marylebone Dr Adrian Whiteson, GP and co-founder of Teenage Cancer Trust 62 What’s on Cultural events near the Harley Street Medical Area 63 Five Places for a bowl of soup in Marylebone 64 The guide Marylebone memorial sculptures

This job is a combination of academic work and practical work. You are constantly learning, constantly developing.

You get to meet new people all the time, and we work in a team. It’s a great job.

Dr Dejan Dragisic of Wimpole Street Dental Clinic

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2—Prognosis

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Prognosis—3

HSMA UPDATE Julian Best, executive property director at The Howard de Walden Estate, on how the Harley Street Medical Area has responded to the challenges of the past year

Welcome to the latest issue of Prognosis.

It is wonderful to see the magazine back in print after two digital issues. Its return reflects our belief that the light at the end of this long tunnel is finally getting brighter. While the digital editions did an excellent job of keeping the community informed about the Harley Street Medical Area, we know from past experience that many people have a greater emotional attachment to the physical magazine.

This is why it’s so nice to once again enjoy the feeling of flicking through its pages.

It is almost two years since COVID-19 began to impact our lives, and while there has been remarkable progress in the development of vaccines and treatments, the pandemic is still having a major impact on us all. While the HSMA has not been, and still isn’t, exempt from these issues, the past year has been 4—Prognosis

a busy one for the area. Having been delayed by the onset of the pandemic, Cleveland Clinic London finally opened its doors to patients in September 2021. It’s a fantastic facility, which by the end of the year had already seen 10,000 patients – an incredible achievement. Another new entrant to the area is The Royal Marsden Private Cancer Care at Cavendish Square, which has also seen significant demand for its services. The Royal Marsden brand has huge international reach and always comes high up on the list when people are looking for world-class oncology services.

The success of these two openings has shown that patients are returning to the area in significant numbers. But this increase in patient demand has served to highlight one of the less positive things to come out of the past year. A message that we are hearing from many of our

The WHO estimates there will be a global shortfall of 18 million health workers by 2030. This is not a short-term or localised issue and, because of the impact it has on operational capacity, it’s on the minds of a lot of people.

Clevelend Clinic London

Prognosis—5

28°-50° By Night, Jason Court

operators is one of acute staff shortages.

Nurses, theatre staff and support staff are all in short supply and the problem is felt across all hospitals, clinics and support organisations. The World Health Organisation estimates there will be a global shortfall of 18 million health workers by 2030. This is not a short-term or localised issue and, because of the impact it has on operational capacity, it’s on the minds of a lot of people.

At the moment, we are talking to several HSMA operators as we consider sustainable ways to tackle the issue.

These are very early preliminary chats, and we will have to see where they lead, but it is something we cannot ignore if we want the area to continue to grow. This is one of the reasons why The Howard de Walden Estate started several years ago to offer key-worker accommodation to nurses and support staff who were putting in the long hours required while commuting significant distances.

Another field we are continuing to explore is the link between hospitals, universities and medical research.

We are doing this by looking at space requirements for enablers of medical technology and life sciences, and perhaps even providing some laboratory space.

The HMSA is uniquely placed to make a real contribution, hosting as it does this incredibly diverse and specialist medical ecosystem. After all, if we can provide some of the infrastructure for greater collaboration, learning and innovation, it will contribute to London’s ongoing success. There is a growing number of facilities in places like Oxford, Cambridge and Stevenage, but there remains an acute shortage of laboratory space 6—Prognosis

Looking back over the year, I think that the success of The Royal Marsden and Cleveland Clinic London really do underscore that the HSMA is a place where high-quality health providers want to be.

for research and innovation in central London where the biggest talent pool exists. It is a matter of getting the balance right between providing the laboratory facilities themselves, the ancillary services they need and dedicated accommodation for the staff. The idea of housing complementary businesses in the HSMA is very exciting and seems like an obvious step to take. You could have a consultant practicing in the area, perhaps being connected to a university which is undertaking research around the corner.

One piece of good news that goes beyond the HSMA was the successful ballot to establish the Harley Street Area Partnership Business Improvement District (BID). This gives a voice to the diverse occupiers of Marylebone to pursue tangible improvements to

the public realm and transformative projects for long-term, sustainable development. Marylebone is a wonderful place, but there is always room for improvement and the establishment of the BID definitely places key projects and decision making in the hands of our community.

Looking a bit further afield, the wider Marylebone area has not been standing still over the past year. We have welcomed many new businesses into the area. Ottolenghi’s latest restaurant has come to Marylebone Lane; Bloobloom, a niche eyewear retailer, has opened a premises on Marylebone High Street; Fursac, a contemporary French menswear label, has also arrived; and 28°-50°, which has been a popular restaurant on Marylebone Lane for many years, has opened 28°-50° By Night on Jason Court, offering late night dining alongside live jazz and blues.

Looking back over 2021, I think that the successes of The Royal Marsden and Cleveland Clinic London really underscore that the HSMA is a place where high-quality health providers want to be. We are already in discussions with another major health provider that wants to open premises in the area because of the existing expertise already based here. The HSMA is now firmly on the global healthcare map and when companies are looking to establish new premises, Harley Street is generally at the very top of their list.

The Howard de Walden Estate 23 Queen Anne Street London W1G 9DL 020 7580 3163 hdwe.co.uk

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NEWS Mayo Clinic Healthcare – the London subsidiary of Mayo Clinic, the American not-for-profit academic medical centre – and the health insurer Bupa have announced a two-year agreement to deliver care to Bupa’s customers. The agreement enables Bupa’s UK health insurance customers to access care at Mayo Clinic Healthcare’s Portland Place facility, including consultations, diagnostics, endoscopy, MRI and CT services. The clinic, which opened in 2020, will also provide a secondary clinical review for Bupa customers who might benefit from CAR-T cell therapy, a pioneering treatment which uses a patient’s own immune system cells to tackle a small number of advanced cancers. mayoclinichealthcare.co.uk Mayo Clinic Healthcare

Green Door Clinic, the specialist mental health clinic, is trialling a revolutionary machine-learning tool that tracks voice changes.

Affect.AI – developed by Imperial College students Woochan Hwang and Alice Tang and data scientist Dr Wun Wong – uses machine learning, along with formal assessments made by a clinician, to determine the changing characteristics of an individual’s voice over time. While the symptoms of depression can be hard to recognise, it is known that vocal traits such as pitch and volume can act as biomarkers. The tool can pick up on subtle differences in tone and help clinicians track patients over time by comparing the data with their own baselines.

King Edward VII’s Hospital has opened a new outpatient and diagnostic centre. The Kantor Medical Centre, situated opposite the main hospital on Beaumont Street, spans seven floors, offering 28 additional consulting rooms. The centre’s facilities include a 3T MRI, CT scanner, two x-ray facilities, two ultrasound machines and two minor procedure rooms. The ground floor hosts a waiting area and pharmacy, while other floors are dedicated to expanding the hospital’s outpatient services. As well as expanding the hospital’s offering within musculoskeletal, women’s health, urology and digestive health, the Kantor Medical Centre will host centres of excellence in other specialities such as ophthalmology, dermatology and ENT.

greendoorclinic.com

kingedwardvii.co.uk

Schoen Clinic London has become one of the first UK hospitals to take possession of a set of Microsoft HoloLens smart glasses. The device’s mixed reality capabilities will allow the clinic’s surgeons to connect with remote experts around the world, call up patient data and consult MRI images at the point of care. The smart glasses can be an invaluable tool in the field of orthopaedics thanks to the OptiVu Mixed Reality Solutions platform for orthopaedic surgery, which has been developed by the medical device company Zimmer Biomet in collaboration with Microsoft.

The Kantor Medical Centre

schoen-clinic.co.uk/london

A new oral and maxillofacial centre of excellence, in which seven leading consultant maxillofacial surgeons work together in a state-of-the-art unit, has opened in the Harley Street Medical Area. Occupying the entire first floor of the new Harley Street Specialist Hospital (HSSH), the Centre for Oral and Maxillofacial Surgery contains consulting rooms, an operating theatre, and a suite of diagnostic tools including cone beam computed tomography (CBCT). The team, led by the pioneering oral and maxillofacial surgeon Mr Luke Cascarini, also has access to on-site 3D printing, used in the planning of complex facial reconstruction and the correction of facial deformity. hssh.health Prognosis – 9

I can also see the software improving to the point where it senses activity in the nerves and automatically delivers the appropriate level of current at a frequency calculated to negate those signals and stop any pain.

CRYSTAL BALL

Post-surgical spinal pain Dr Nigel Kellow on the evolution of treatments for post-surgical spinal pain and nerve injuries

State of play It is increasingly common for people – particularly the elderly population – to undergo structural spinal surgery.

After surgery, some patients find they have the same pain they had before the procedure, or that a new pain has appeared.

The most important thing for us at this point is imaging. After any spinal surgery, you typically need to combine MRI and CT scans to exclude any issues that require another surgical solution.

If the problem appears to be tissue based, such as a swollen nerve, we can administer targeted injections of steroids. If nerves aren’t swollen but have been damaged, we would traditionally start with nerve pain drugs such as amitriptyline or gabapentin. If the symptoms don’t respond, we would 10—Prognosis

move on to spinal cord stimulation.

When a nerve has been damaged, abnormal signals can be sent from the spine up to the brain, causing pain. If we attach electrodes to that part of the spine, then stimulate those electrodes at a very high frequency, the current dampens down the abnormal signals to the point of almost blocking them, and the brain no longer registers those signals as pain.

On the horizon When I started spinal cord stimulations, the intention was to give the patient a feeling of buzzing in the area where they felt the pain. We would steer the electrodes into a particular part of their spine and stimulate them at 50 Hertz. This worked well for a while, but the benefit wore off after a year or two. We found that higher frequency stimulation was much more effective, and effective for much longer periods.

Now we use 10,000 Hertz.

For me, advances in spinal cord stimulation and other forms of neuromodulation remain the way forward for treating this kind of pain.

While the technology does exist, it is still a niche treatment that is inaccessible to a large majority of people suffering such pain, which is unfortunate. The treatment is not as widely known as it should be, and the devices and implants are quite expensive. I’d like the technology to become cheaper and much more widely used. In the time I have been prescribing spinal cord stimulation there has been real progress in both the hardware used and the effectiveness of the treatment, and no doubt that will continue.

In the distance As time goes by, I expect to see the devices we use evolve from the present rods with electrodes wrapped around them into more mesh-like structures.

These would be put in place through a needle, then deployed sideways and lengthways inside the spinal canal.

Such meshes would greatly increase the effectiveness of the interface between the electrode and the nerves while using less power, therefore needing much smaller, longer-lasting batteries.

I can also see the software improving to the point where it senses activity in the nerves and automatically delivers the appropriate level of current at a frequency calculated to negate those signals and stop the patient from feeling any pain at all. Done well, this could create a feedback loop without any intervention from a clinician, providing truly personalised pain relief at the moment it is most needed.

Finally, I’m hoping we will eventually see some kind of advance in the material science of the structural support hardware we use. At present, spinal surgery often involves titanium implants. This causes problems because the metal implants are completely rigid, while our bones are a little softer and want to flex a bit. New materials that provide the necessary support but offer more give than titanium would be hugely beneficial.

UME Group 17 Harley Street London W1G 9QH 020 7467 6190 umehealth.co.uk

HARLEY STREET HERO

Sophia Jex-Blake 1840-1912 Physician and campaigner Words: Kaite Welsh

In 2020, despite her contributions to medicine, English Heritage rejected a request to commemorate Sophia Jex-Blake with a blue plaque on Harley Street. The request was made by Queen’s College, the Marylebone school where Jex-Blake had both studied and taught prior to beginning her medical education. She enrolled at the school in 1858 and the next year, while still a student, was offered a role as maths tutor. Since her parents refused to allow her to be paid for teaching – a job would be far too unladylike – she worked for free while living in the Finchley home of fellow Queen’s student (and future social reformer) Octavia Hill and her family.

This rejection by English Heritage wasn’t the first time Jex-Blake’s achievements had been overlooked. It wasn’t until 2019 that she was awarded her medical degree from the University of Edinburgh – over 150 years after she successfully campaigned for women to be admitted to the institution. She had first applied in the spring of 1869, shortly after her essay advocating for female participation in medicine appeared in the early feminist campaigner Josephine Butler’s book, Women’s Work and Women’s Culture. JexBlake may have captured the zeitgeist, but Edinburgh turned her down nonetheless, stating that its centurieslong tradition of male-only education couldn’t possibly be overturned for one solitary woman.

So Jex-Blake did what any enterprising woman would do: took out an advert in the Scotsman newspaper calling for other women to join her, and together they successfully petitioned

the university to allow them to sit the entrance exam, before matriculating in March 1870. They took separate classes to the male students for the sake of propriety, and the ‘Edinburgh seven’ as they were known spent the next few years cloistered in a small room in 15 Buccleuch Place, soaking up all the knowledge they could get.

Not everyone was happy, though.

When the women sat their November exams, the male student body made their feelings known. When the women were due to sit their anatomy examination at Surgeon’s Hall, they were met with a crowd of several hundred protestors who managed to stop traffic on South Bridge for a full hour. A group of drunken male students hurled abuse and rubbish at them, blocking their way into the building. .

Only three of the male students were fined – £1 each – and when Jex-Blake argued that they had been encouraged in their ‘protest’ by a teaching assistant at the medical school, he sued her and won. In contrast, she had to pay £915.

In 1872, still determined to make the case for female doctors, Jex-Blake published Medical Women: A Thesis and History. But progress came to a disappointing halt when, in 1873, the University of Edinburgh refused to award the women their degrees.

If the traditional institutions weren’t going to train female doctors, the women would have to do it themselves.

In 1874, after returning to London, Jex-Blake joined forces with several other equally passionate women, including Elizabeth Garrett Anderson, to found the London School of Medicine

for Women in Bloomsbury. Two years later, the UK Medical Act removed the previous restrictions and allowed both sexes to qualify as doctors. Jex-Blake was finally awarded her MD in Berne and then the Licentiate of the King’s and Queen’s College of Physicians of Ireland, meaning she could at last be registered with the General Medical Council, becoming the third registered woman doctor in the UK. Spurred on, Jex-Blake returned to Edinburgh to open an outpatient clinic and finally practice medicine as a fully qualified doctor. By 1885, the clinic moved to larger premises and became the Edinburgh Hospital and Dispensary for Women. But Jex-Blake’s ambitions didn’t stop there. With women still not permitted to study medicine at Edinburgh, she opened the Edinburgh Medical School for Women.

When, in 1892, the University of Edinburgh officially opened its doors to female students, it was the culmination of decades of campaigning by Jex-Blake, but one of the consequences of this success was to render her own school increasingly irrelevant, forcing it to close soon after. Jex-Blake continued practising medicine at her home in Bruntsfield Lodge, which would eventually become the Bruntsfield Hospital.

Jex-Blake died in 1912. There is a plaque dedicated to her in the archway of the old medical buildings at the University of Edinburgh, and it seems fitting that the institution that was so reluctant to admit her has finally embraced her contributions to medicine and the world. It is a shame that similar recognition could not be afforded her on Harley Street.

Prognosis—11

The key thing about optical coherence tomography is the way it is increasing our understanding of the pathophysiology – the physiological processes – associated with these conditions.

HOW DOES IT WORK?

Optical coherence tomography Consultant ophthalmic surgeon Mr Shafiq Rehman on a technique that has revolutionised retinal medicine Interview: Viel Richardson

12—Prognosis

Optical coherence tomography (OTC) is a technology that allows us to image various parts of the eye using electromagnetic radiation – light – and to see its internal structures in exquisite detail. The eye is particularly well suited for this type of scan as the cornea, a natural lens, allows light to enter the eye in ways that are well understood.

The scanner first projects a beam of light into an optical splitter, which divides the beam into two streams.

One is a reference stream, allowing the scanner to precisely analyse the phase of the beam projected; the other stream is sent to the eye. These electromagnetic waves go through the cornea, hit the retina and bounce back.

The key to OTC is that each returning wave arrives back at the scanner modified in a slightly different way depending on the properties of the structure it encountered. This means the returning waves will have slightly different phases to the ones they had when projected. The scanner records and analyses these changes in phase, in relation to the reference beam, to create an initial map of the structures the light waves encountered in the eye.

These are then fed through very sophisticated computer algorithms which interpret the information and create an artificial image, which is a reflection of the real structure of the retina. This type of scanning can be incredibly detailed, highlighting features almost down to the cellular level. Some of the machines can see structures in the eye that are only 3-4 micrometres across. To give you a sense of what that means, a red blood cell is about 7-8 micrometres in diameter.

Unlike sound waves, which can penetrate deeper into human tissue, light waves are really only transmissible when the structure is largely transparent. For example, there is a structure called the retinal pigment epithelium, a dense layer of cells that regulates the transport of nutrients and waste products to and from the retina.

While it is very reflective, we can still see some details behind it. But then we have a structure called the choroid. This is intensely infiltrated by blood vessels and represents a kind of barrier. Some devices using longer wavelengths and higher energy levels can get a bit below the choroid’s surface, but not very much.

It is important to stress that OCT scans are not diagnostic in themselves, unlike those produced by some other scanning technologies. We still rely on clinical examination, talking to the patient and running other tests, but OCT is an absolutely core part of the evaluation of a patient.

If I see a patient in their seventies with deteriorating eyesight, such as blurring and distortion of images, there is a strong possibility that the patient is suffering from dry or wet macular degeneration. Dry macular

Macular Part of the retina with a very high concentration of photoreceptor cells, responsible for the the fine vision required for reading.

Choroid A highly vascular, pigmented tissue which covers most of the eye behind the retina.

Diabetic retinopathy A complication of diabetes where high sugar levels damage blood vessels in the light-sensitive tissue at the back of the eye which make up the retina.

Optical coherence tomography

REFERENCE BEAM

REFERENCE BEAM

Reference mirror

Optical splitter

DIAGNOSTIC BEAM TO EYE

DIAGNOSTIC BEAM FROM EYE

Patient

Light source REFERENCE BEAM

DIAGNOSTIC BEAM FROM EYE

Detector

degeneration is basically wear and tear.

Like with any other part of the body, tissue in the eye can atrophy as we get older and lose some of its effectiveness.

Wet macular degeneration is very different. Here, abnormal blood vessels grow through the retinal pigment epithelium behind the retina. These blood vessels then explode, causing bleeding and scarring which can lead to a very rapid deterioration of the patient’s vision. They can go from having normal eyesight to very poor eyesight within a matter of days. This type of macular degeneration clearly needs to be addressed as quickly as possible. OCT scans are extremely good at differentiating between those two types of macular degeneration, making it an absolutely essential tool.

Another condition this technology

helps to diagnose well is a macular edoema, a very specific syndrome which is part of a complex disorder called diabetic retinopathy. With macular edoema, fluid accumulation in the retina leads to swelling of the macula, the central part of the retina. When a person looks at an object, the image falls onto the macular, so any changes in the macular structure will have a significant impact on the person’s visual acuity. OCT technology is not only good at highlighting this, but it can also measure the level of swelling, allowing us to quantify the syndrome’s progress. This allows us to develop age and genderbased normative reference databases, against which we can compare a patient’s condition. These images let us see the impact our treatment is having on those swellings and therefore how successful

the treatment is being. This really helps personalise the treatment we can offer.

One of the really exciting things about OCT is that it allows us to treat conditions we could not treat before. For many years a condition called vitreomacular traction syndrome (VMT) was extraordinarily hard, if not impossible, to spot. The vitreous gel is a sort of inert structure sitting in the space between the cornea and the retina. As we get older it can partially pull away from the retina.

This is known as posterior vitreous detachment (PVD) and it is extraordinarily hard to visualise, and therefore diagnose, with the naked eye. In a patient with symptoms of mild vision disturbance you can spend three or four minutes examining the area in detail through a microscope and see little or nothing suggestive of PDV. On an OCT scan, it stands out very clearly, looking like a separate line that is pulling the retina forward. This means we can diagnose VMT quickly and accurately.

Fifteen years ago we could only postulate a diagnosis. We could asses the symptoms and surmise that the patient may be suffering from VMT, but we could not be absolutely sure. Now we can even chart the effectiveness of any treatment in real time. It represents remarkable progress.

Another condition we can now diagnose and treat quickly is called a macular hole. Again, it can be quite hard to see a very small macular hole as it is starting to develop, but on OCT it’s immediately obvious. You can see the altered structure and decide how to manage it very early in the process.

Each one of these is a wonderful advancement, but the key thing about optical coherence tomography is the way it is increasing our understanding of the pathophysiology – the physiological processes – associated with these conditions. We now understand much more about the mechanisms by which these conditions develop and progress. This means we are better informed about how to manage and treat them.

It’s remarkable how much OCT has revolutionised the field of treating retinal disorders. Fifteen years ago, OTC scanners did not exist; now there isn’t a department in the country that would want to work without one.

Optegra Name Address 25 Queen Anne Street Telephone London W1G 9HT website 020 7509 5400 optegra.com Prognosis—13

THINKING ALOUD

Dr Dejan Dragisic Oral surgeon at Wimpole Street Dental Clinic Interview: Ellie Costigan Portrait: Christopher L Proctor

The training to be an oral surgeon is long – it took me 11 years – so you need to like it, particularly as there’s not much else you can go into afterwards! I started in dental school, then did almost four years of medical school as well before going into specialist training. That was more than 20 years ago. I’ve never regretted it.

Medicine is in my blood: the wider family includes dentists, vets, a gynaecologist, a paediatrician, and my brother is an ophthalmologist.

I grew up with it.

I offer specific types of treatment that a lot of dentists don’t do. I’m lucky because I get these patients referred to me. We have several hundred practitioners in the Harley Street Medical Area, so there is a really nice exchange. If I have a patient who needs a filling or a crown, I know where to send them to get really good treatment.

Google can be dangerous. Patients form an opinion before they come in sometimes, which is quite often misleading, so I prefer when they don’t know much about the treatment we are going to provide. We can always point them in the right direction, give them links to good literature, to publications and peer-reviewed articles.

Treatments have changed a lot in the past 20 years, though not always for the better. It has become more financially driven. There’s much more cosmetic treatment, which is something I’m not involved in. I think the biggest advance has been in dental implantology, which has got better and safer. Knowledge and seminars are more accessible too, because of digitisation.

This job is a combination of academic work and practical work. You are constantly learning, constantly developing. You get to meet new people all the time, and we work in a team.

It’s a great job.

The mouth is an intimate area. Because of that, dental work or surgery can cause anxiety for a lot of patients. Much of my work is invasive and can be unpleasant – extractions and cyst removals, implants – so you need to guide the patient psychologically. It can be intense: I talk a lot during treatment, to reassure patients.

It was always the plan to set up a practice in Marylebone. The buildings in Marylebone are beautiful. It’s also central, which is useful for patients as they come from both within and outside London, as well as abroad.

We were lucky; the practice that we acquired about six years ago was in a terrible state, so we could design it the way we wanted to.

Patients expect a high level of service and that begins with our reception and our nurses, how they talk to patients, how they explain things, how pleasant the waiting room is – even the smell of a surgery. Music is an important factor, as is making sure that you don’t make people wait. I like to get my patients in straight away.

We had to close in March last year until June, which was a disaster.

It has created a lot of problems because patients didn’t have any access to dental and medical treatment, so certain conditions we could’ve treated with simple intervention have become much more major. Since re-opening, it has been full-on.

14—Prognosis

Wimpole Street Dental Clinic 55 Wimpole Street London, W1G 8YL 020 3745 7455 wimpolestreetdental.clinic Prognosis—15

PROFILE OF A PATHOGEN Marburg virus

This is one of those viruses that keep people awake at night. The Marburg virus (MARV) causes Marburg haemorrhagic fever (Marburg HF).

Haemorrhagic fevers cause the patient to bleed profusely from the body’s orifices and Marburg HF is an extremely severe form. Though the first known crossing of the virus from animal to human was via monkeys, the host of this particular virus is the African fruit bat, Rousettus aegyptiacus, which show no obvious signs of illness when infected.

Marburg HF is a filovirus belonging to a group of viruses called Filoviridae, which cause severe haemorrhagic fever.

It is fatal in both humans and nonhuman primates. So far, three genera of this virus family have been identified: Ebola virus, Cueva virus and Marburg virus.

It was first encountered in Germany and 16 – Prognosis

part of Yugoslavia, which is now Serbia, in August 1967. Thirty-one people were admitted to hospitals in Marburg, Frankfurt and Belgrade, suffering fever symptoms. The first patients were laboratory assistants who had been handling African green monkeys imported from Uganda but were soon followed by some of the medical personnel and family members who had cared for them.

The hospitals soon determined that they had a type of haemorrhagic fever, but every test for pathogens known to cause the disease returned negative.

Clinicians realised they were dealing with an unknown virus and after seven of the 31 died, the investigation was moved to more specialised laboratories.

One of two Marburg viruses, A and B, that cause illness in humans, was isolated in November the same year.

The incubation period is between five to 10 days, with the first symptoms being a high fever, chills, headache and muscle pain. At around the fifth day, when most people would expect to start feeling better, another raft of symptoms begin to arrive. These include a maculopapular rash, which looks like red bumps on a flat red patch of skin, nausea, vomiting, abdominal pain, chest pain, a sore throat, and often diarrhoea. The symptoms become increasingly severe and can include jaundice, inflammation of the pancreas, severe weight loss, delirium, shock, liver failure, multi-organ dysfunction and the massive bleeding from various parts of the body that gives this kind of fever its name.

The main mode of transmission is through person-to-person contact, which can happen in several ways:

direct contact to droplets of body fluids from infected people or through contact with equipment and other objects contaminated with infectious blood or tissues. Historically, the people at highest risk include family members and hospital staff who care for patients infected with Marburg virus, often without the proper barrier nursing techniques available to them. Particular occupations such as veterinarians and laboratory or quarantine facility workers who handle non-human primates from Africa may also be at increased risk of exposure to MARV. The nature of the disease means that the mortality rate is very dependent on where you are when contracting the disease. Modern medicine is very good at keeping very sick people alive and eventually returning them to health.

Even so, with the best care delivered in a timely fashion, the mortality of Marburg HF is 30%, which is high. However, in cases of poor care – or none at all – mortality rises to 90%.

The problem is that there is no specific treatment for Marburg haemorrhagic fever. All clinicians can do is support the body through the worst of the disease through processes like balancing the patient’s fluids and electrolytes, maintaining oxygen levels, keeping blood pressure stable, replacing lost blood and blood clotting factors, and treating any complicating infections. Experimental treatments are showing some promise in non-human primate models, but as yet none have been tried in humans.

Marburg haemorrhagic fever remains, for the foreseeable future, an extremely distressing and dangerous disease.

Haemorrhagic fever A general term for a severe illness, often associated with bleeding, that can be caused by a number of viruses.

Barrier nursing A set of stringent infection control techniques used to protect medical staff against infection by patients.

Blood clotting factors A group of proteins found in the blood that are essential to blood clot formation.

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HOW TO...

Treat floaters Miss Louisa Wickham, chief surgeon at Moorfields Private Eye Hospital

Floaters

What are floaters?

Floaters occur when collagen condenses in the vitreous jelly that sits at the back of your eye. When you’re born, this jelly is very firm, but as you get older it becomes more liquid. The collagen begins to change in nature, becoming thicker and forming into clumps, which then begin to move around. It’s a bit like when you shake a snow globe and the little snowflakes move around—as your eye moves, these clumps of collagen are agitated, and as they move around they catch the light and disturb your vision.

How common are floaters?

Very common. Around 75% of patients will say that they’ve had them at some point. Certainly, floaters become much more prevalent with age. They can also get much worse quite suddenly. For example, vitreous detachment—where the vitreous jelly changes its position in the eye—is a common condition among patients in their fifties and sixties, and this can suddenly cause the appearance of floaters to increase considerably in a short period of time before settling back down again.

What does someone with floaters actually see?

You might see little black dots moving across your eye—I’ve heard floaters described as being like little flies. Other people might see them as a big clump.

They might notice, for example, that when they’re reading, a large floater will gradually drift into their central vision, causing them problems. They can seem worse in certain lighting conditions, so if your job requires you to look at lots of white screens, for example, you might notice floaters more commonly.

The same is true if you live in a very sunny country. There is also evidence to suggest that people who are either very short-sighted or long-sighted tend to notice floaters more than those who aren’t. The symptoms are usually transient, so floaters are not always experienced in the same way or in the same place. And if you went to an optician for an eye test, it would often come back as normal, because although the quality of vision is affected, your ability to see letters on a chart is likely to be entirely normal.

Can they become a serious problem?

Floaters can be very annoying and can significantly affect your quality of life, but in the vast majority of cases they don’t indicate any disease of the eye.

But if there’s a sudden increase in the number of floaters—as happens with vitreous detachment—then that could be indicative of a wider issue that needs to be checked out by an optician or ophthalmologist.

18 – Prognosis

Are there treatments available?

In the vast majority of cases, floaters will only be visible for a while before settling down. That’s not because the floaters have gone away—they don’t get broken down or absorbed in some way—but because your perception of them changes. After a while, the brain understands that the floaters are insignificant and will begin to fade them from your vision, except in particular lighting conditions where they might become visible again.

Where floaters are causing a significant issue with a patient’s quality of life or preventing them from doing their

job effectively, there are treatments available.

What are these treatments?

The one that I would strongly discourage patients from pursuing is the YAG Floater Lysis laser treatment, which targets and disperses floaters.

Very often, the floaters are dispersed into smaller ones, making those patients more symptomatic than they were beforehand. Also, you’re introducing a lot of energy into the eye in a fairly unregulated fashion, and this can cause retinal injuries. To my mind, this treatment is neither regulated nor controlled enough to deal with the issue.

The second treatment is called a vitrectomy. This keyhole surgery is a very effective and controlled way of removing the floaters, but it is not entirely risk-free. There’s around a 3-5% risk of complications that could cause permanent visual reduction not correctible with glasses.

What should we do if floaters become a problem?

In the first instance, you should see your optician, so they can check whether there’s anything untoward going on.

Once you know your eyes are healthy, the floaters will often settle down. But if they don’t, then your next course of action would be going to see your GP and asking them to refer you to a consultant for an expert opinion.

Moorfields Private Eye Hospital 8 Upper Wimpole Street London W1G 6LH 0800 328 3421 moorfields-private.co.uk

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A DAY IN THE LIFE

Dr Paul Ettlinger, founder and lead clinician at The London General Practice Interview: Jean-Paul Aubin-Parvu Images: Orlando Gili

I am a great believer in the importance of personal care during this modern technological age. This means guiding and helping patients through the avenues of private medicine with a real human touch, but with all the available up-to-date facilities, technologies and clinical guidelines, ensuring that they get the very best medical care.

We will look after absolutely anyone who wants to have private medical care, from people who live locally through to patients flying in from all over the world.

We look after various companies and do a lot of executive health screenings. We also look after several embassies and many of the five-star hotels in London.

Claridge’s and The Connaught, for example – we are their doctors.

20—Prognosis

As founder and lead clinician, I look after and supervise the medical management of the practice to make sure we’re maintaining excellent standards, but I still see patients on a daily basis. I am also one of the lead medical officers for the entertainment insurance industry and as such I’m often asked to review cases – for example, to assess the risk for medical underwriting for performers and film actors.

I tend to get up between 6.30am and 6.45am. I am someone who gets up instantly rather than lying there hitting the snooze button. I must have a very strong internal body clock because I often wake up just one minute before the alarm is due to go off. Depending on the weather I will either cycle to work

Prognosis—21

It’s been nearly two years now since the COVID pandemic began and its impact on our daily operations has been significant. A huge part of that has been dealing with COVID itself.

on a hire bike or arrange for a cab to pick me up. Sitting in the back of the car gives me a great opportunity to catch up with emails and review any results that may have come in overnight.

I arrive at the practice by around 7.30am, but I won’t usually see my first patient until nine o’clock. I always tell my patients that this is a good time to phone me if there’s an issue. I might tell them to pop in and see me at 8.30am. I can even do a visit on my way into the office if the patient isn’t well enough to travel.

We tend to finish the clinical work at about 7.30, 8pm. We have a number of doctors consulting at the practice each day and so we also have clinical meetings together. Then there are our practice meetings and clinical governance meetings. We are very strong on our clinical governance structure.

For us, it’s all about striving to give each patient the very best personal care – that’s the philosophy throughout our practice. We also provide a 24-hour visiting service. Our phones are always answered, and if it’s out of hours then the call is automatically transferred to the on-call doctor, who can assess whether the patient requires a visit.

The beauty of working in Harley Street is if a patient needs a scan, for example, you can ask them to sit in the waiting room while you arrange the investigation and then get that patient to come back to you straightaway with the report, so you can make a diagnosis instantly. You can get laboratory tests really quickly. You can walk round to the laboratory and have the results back within the hour. I don’t think you can do 22 – Prognosis

that anywhere else in the UK, actually.

This is what the Harley Street Medical Area offers.

It’s been nearly two years now since the COVID pandemic began and its impact on our daily operations has been significant. A huge part of that has been dealing with COVID itself. The number of general inquiries about the disease and people requesting tests has led to a dramatic increase in our usual daily intake of calls. There has been talk in the press about it being some kind of financial windfall for GPs and clinics, but I can assure you, from our perspective this is certainly not the case. The admin and organisation surrounding it is extremely labour intensive and has also led to the need for more staff.

COVID is still a large part of our daily operation. In early 2020, we introduced COVID testing, which is a service we continue to offer. We are also still offering the COVID assist service. With this, we send the patient a home kit with an O2 oximeter, thermometer and blood pressure monitor. A doctor then makes a five-minute telephone call each day for seven days to review test readings and check that the patient has no new symptoms. We have had patients admitted to hospital who hadn’t realised that their condition was deteriorating and the situation was becoming quite dangerous.

Sadly, another thing we are seeing is the impact of the pandemic on people’s mental health. I think whatever sphere of society you look at, the pressures of living with COVID have had a big impact on people. There is much more anxiety, insecurity, lack of clarity. We are seeing much more depression, alcoholism and

other stress-related conditions. Then there are those who have actually had COVID, some of whom are dealing with memory changes, the COVID fog, or the fatigue of long COVID. Alongside this, all the other physical and mental issues patients were contacting us with have not gone away, and in some cases they have been exacerbated, so there has been a significant increase in the practice’s workload.

There has been another effect of the pandemic which runs a little deeper. We have always been a pretty technically savvy practice, ensuring we make use of available technology to find the best ways to serve our patients. Working in the pandemic, especially in the early days when video consultations became necessary, we were forced to interact even more intensely with the technological world. The last two years have made me much more aware of medical resources, both informational and technological, that are available to us as a practice. Keeping up with the constant discussions about the viruses, protocols and government guidelines have led us to review the way we integrate technology into all areas of the practice. The pandemic has been one of those moments where everyone has been forced to re-evaluate how they do things. As a result, our relationship to and use of technology is one area where we have moved things forward.

The London General Practice 114a Harley Street London W1G 7JL 020 7935 1000 thelondongeneralpractice.com

A BUSINESS IMPROVEMENT DISTRICT FOR THE HARLEY STREET AREA You may recall from the last edition that the Harley Street Area Partnership had been established to promote the area from a medical perspective along with representing a wide mix of businesses in the footprint.

In November 2021 the business community were invited to vote in the ballot to develop a business improvement district and we are delighted that there was an overwhelming “yes” for a BID to be established from the businesses. The BID term will run from April 2022 to March 2027. With the investment that will be made through the BID this provides opportunities to deliver projects across the key themes which are set out below.

WHAT HAPPENS NOW Our next steps involve identification and project delivery, looking at key priorities and setting our steering groups with key partners. Our 4 steering groups are set out below and we will have a specific medical group to ensure we acknowledge and deliver opportunities for all businesses.

PUBLIC REALM AND WAYFINDING

INTERNATIONAL MARKETING

BUSINESS SUSTAINABILITY AND CONNECTIVITY

SAFETY AND BUSINESS RESILIENCE

KEEP IN TOUCH If you would like more information on the newly developed business improvement district please do not hesitate to contact Nicki Palmer. Email: nicki@hsmapartnership.com.

BEST OF BOTH WORLDS

Shams Maladwala, managing director of The Royal Marsden Private Care, on the Trust’s integrated model of private and NHS care and its new Cavendish Square facility Interview: Ellie Costigan

As managing director of The Royal Marsden Private Care, I‘m responsible for the governance and management of private patients within the framework of the Trust, including operational, clinical and commercial aspects. Ours is an integrated model; it’s the best of both worlds, private and NHS. In practical terms, it means we have distinct areas within the Trust – the NHS side and the private care side – but it is very much a symbiotic relationship. There are also areas that are shared between NHS and private patients, such as surgery and the ICU. It is much more efficient and a betterquality experience to have a shared resource for these clinically key areas.

The integrated model works on a number of levels. It works for patients, most importantly, because they get the safety assurance and governance that 24—Prognosis

is so important in private healthcare. It works for sponsor groups, insurers and embassies, because they are assured that whatever pathway is taken, it will be evidence based. When drugs are prescribed, they are prescribed within the context of a multi-disciplinary team.

It works for consultants, because they can carry out their private and NHS practice within the confines of one organisation, alongside the Trust teams they’re used to working with on a dayto-day basis. This leads to more time spent with patients and a better quality and continuity of care.

And, fundamentally, this integrated model also works for the Trust. All revenue generated via the private care division goes back into the Trust. This enables further investment into our teams, our kit, our staff, our research, and that benefits

all patients. I believe this model has been a contributor to the fact that the private care side has doubled in size in the past five years. We also have an outstanding CQC rating. These results are testament to the success of our integrated model. Other Trusts have similar arrangements, but The Royal Marsden is the largest of these private patient units in the country.

The fact that we are research-led is another very big differentiator of The Royal Marsden. It means patients can access the very latest and most innovative treatments in oncology. We have clinical trials happening all the time.

We work in partnership with the Institute of Cancer Research, so we really do offer cutting-edge treatments: whether it’s the latest genetic tests, CAR T-cell therapy, or the latest type of MR imaging. Having access to that, whether you’re a private

Being research led means patients have access to the very latest and most innovative treatments happening in oncology.

Having access to that, whether you’re a private or an NHS patient, is, I believe, the basis for outstanding care.

Our new Cavendish Square site is an embodiment of that.

or an NHS patient, is, I believe, the basis for outstanding care. Our new Cavendish Square site is an embodiment of that.

The new centre is all about enabling us to diagnose cancers faster and earlier.

Cavendish Square has a full diagnostic imaging suite on hand, including MRI, CT, x-ray, mammography and ultrasound, plus nasoendoscopy and colposcopy.

Chemotherapy is available and there are very clear pathways to and from The Royal Marsden. There is on-site pathology and pharmacy and patients have fast and direct access to The Royal Marsden’s world-leading diagnostic and researchactive consultants. It really gives patients and referrers assurance that The Royal Marsden, as Europe’s largest cancer centre, is providing a comprehensive set of services – and it’s all backed by research.

We are making a statement about our

ability to deliver the kind of service we think is right. On the same day, they can have a consultation, diagnostics, bloods and get the results. That speed is key.

While COVID-19 has presented challenges, I’m pleased to say we have managed to create, in partnership with the independent sector and with the government’s support, a cancer hub to ensure that patients have access to life-saving surgery and other treatments in a protected environment. There are also several things we’ve found through the pandemic that help drive efficiency and those are things that we’re going to look to retain. For example, virtual consultations are a great way to minimise the time patients spend in a hospital while also maximising consultants’ time. We are also developing our home-based services, such as at-home chemotherapy.

Over time, a greater number of international patients have sought to access The Royal Marsden’s treatments from all over the world, not just the traditional health markets. We’ve found through virtual technology – not just consultations, but the ability to provide training and education in those markets – that there are ways we can give those patients better access to treatment.

With Cavendish Square, there is even greater opportunity to offer all our patients, both domestically and internationally, treatments and rapid diagnostics of the very highest quality.

The Royal Marsden Private Care 19a Cavendish Square London, W1G 0LP 020 7811 8111 royalmarsden.nhs.uk Prognosis—25

HEALTHCARE A SUSTAINABLE IN THE NHS the fight against CLIMATE CRISIS In climate change, the NHS

The global impact of climate change on healthcare – and vice versa – is vast.

In this series, experts from within the diverse community of the Royal Society of Medicine offer their unique perspectives

26 – Prognosis

aims to reduce its direct greenhouse emissions to net zero by 2040. For emissions produced by its supply chain, the aim is to reach net zero by 2045. Dr Nick Watts, the NHS’s first chief sustainability officer, and Professor Linda Luxon, who recently organised a Royal Society of Medicine series exploring the intersection between healthcare and climate change, talk about why the task goes far beyond electrifying the ambulance fleet

Dr Nick Watts: As chief sustainability officer, anything that falls under the umbrella of sustainability arrives on my desk – single-use plastics, vehicle air pollution, sustainable supply chains, the list goes on. At the moment, we’re focused on how all that comes together in the NHS net zero commitments. With 1.3 million employees, the NHS is the largest employer in Europe and the fifth largest in the world. Our emissions are roughly 5% of the UK total, so while tackling that may seem daunting, the scale is what makes it exciting. Get this right and we can make a real difference.

Prof Linda Luxon: We have known the need for something like this for decades. In the 1970s and 80s, scientific evidence was beginning to accumulate about the health impacts of climate change. We had known for years about the health impacts of air pollution, but we were beginning to understand how this huge thing called ‘climate change’ was impacting on our health at a very local level. When I worked at the Royal College of Physicians, the academic vice-president, Tim Evans, asked me to lead a project called The Future Hospital Initiative. The aim was to identify ways to make healthcare more effective and one of the areas we looked at was climate change. That’s when I really began to research the area properly. I appointed two clinical research fellows and we produced a report in which we highlighted not only the health impacts of climate change, but also that the practice and provision of healthcare needed to change as it was a major contaminator of the environment.

Dr Nick Watts: We knew we had a problem, so the first priority was to find

w Prognosis – 27

Focussing in on what people can do in the here and now is incredibly important.

People are aware of climate change, but they still see it as something that is only going to impact upon us in the UK at some unspecified future point, that the present urgency lies elsewhere. The urgency is here and now.

out where we’re generating emissions.

My team spent most of 2020 building a full footprint of the system. We worked with several independent analysts to ensure the data we were gathering was robust enough for us to have real confidence in it. I can tell you how our emissions break down by medicines, by buildings, by region and by other metrics, but at the level of a specific ward in a specific hospital, the data is not quite good enough yet. But we have good enough sense of where we are to start making effective recommendations.

We’re not yet in a position to empower every individual to know their own carbon emissions – that’s what we’re working on over the next two years.

Prof Linda Luxon: I think focussing on what people can do in the here and now is incredibly important. Most people are aware of climate change, but I get a sense that they still see it as something that is only going to impact upon us in the UK at some unspecified future point, that the present urgency lies elsewhere.

But the urgency is here and now. Most people in the wider community accept the connection between air pollution and lung disease. But what they may not realise is that a quarter of cardiovascular diseases are initiated or made worse by air pollution. Strokes are the same: approximately a quarter are initiated or exacerbated by the increased air pollution. The data is also showing a correlation between climate changedriven environmental changes and increasing levels of gastrointestinal disorders, skin disease and infectious diseases. There isn’t a medical discipline that isn’t affected in some way, and this is a message we really have to get across.

28 – Prognosis

Dr Nick Watts: The danger is that the problem seems so enormous that it’s disempowering. People think, what can an individual do? In truth, individuals can make all the difference.

An organisation is a collection of people making individual decisions.

The key is communication. We act as a central point for identifying issues and co-ordinating responses. Take ambulances, for example. By 2030 we need to have a zero-emission ambulance infrastructure in place, as buying fossil fuel replacements will be banned. So, I talk to the teams in charge of our ambulance fleet and together we devise a strategy to help hit that target. It is the same for our commercial directors. We’ve been very clear that within a decade the NHS will no longer purchase from any supplier that does not meet or exceed our standards on net zero. But it’s not just a case of chucking a new rulebook at them. We are currently working with manufacturers on the development of zero emission ambulance prototypes, which is a very complex task.

Prof Linda Luxon: The great thing is that this is part of a growing international consensus on the direction healthcare needs to take in its approach to climate change – one in which both treatment delivery and disease prevention play a key role. Here at the Royal Society of Medicine, we recently ran a 10-part series on the intersection between climate change and health that was introduced by HRH The Prince of Wales. The series attracted a wonderful range of international speakers, real high-fliers from a wide range of specialties, all talking about climate change from their perspective and

suggesting possible solutions. The series left me in no doubt that the medical field is really beginning to understand the problem across the globe. The key is translating that into government action.

This is why the NHS net-zero project is so important; it is about the health sector taking a significant and highly visible role in tackling the problem here and now.

Dr Nick Watts: This is about making sure that everyone across the whole system understands that a lot of what we want to do is perfectly aligned with improving public health.

People get on board very quickly when they realise this. Maybe they can’t achieve the end result tomorrow, but given time, they will. I think my job is 50% operational, 50% engagement and managing cultural change. Do people understand the direction we’re heading in, what is going to be the hardest part, where are the success stories? I believe a lot of what we need to do will sell itself if we can get those messages across.

Prof Linda Luxon: For this to work, the NHS is also going to need help from other sectors in getting the message across.

Professor Chris Rapley, a professor of climate science at University College London, recently gave a lecture about society’s approach to cause and effect.

The COVID pandemic has raised serious questions about the balance between health and the economy. For centuries, our leaders have had the approach that if you improve the economy, better public health will automatically follow.

He showed this isn’t quite correct – while the two are intertwined it’s not a bi-directional phenomenon. There are many other factors at play. The NHS has a part to play, but it has to be part of a wider coordinated approach.

Dr Nick Watts:There’s not a single doubt in my mind we can do this.

It’s going to mean a lot of sleepless nights. But what an exciting thing for the NHS to achieve. We were the world’s first universal health care system, we rolled out the world’s first national vaccine programme, the first heart and lung transplant, the first COVID vaccine. The NHS has so many impressive firsts, if any health system in the world can be the first to achieve net zero, it’s us.

Royal Society of Medicine 1 Wimpole Street London W1G 0AE 020 7290 2900 rsm.ac.uk

THE BIG INTERVIEW Best behaviour Professor Dame Anne Johnson, president of the Academy of Medical Sciences and professor of infectious disease epidemiology at University College London, established an international reputation with ground-breaking research into the behavioural aspects of epidemiology during the HIV outbreak in the 1980s. She looks at what lessons that pioneering work has for those battling the current COVID pandemic Words: Viel Richardson

30 – Prognosis

w Prognosis – 31

Most people of a certain age will remember the tombstones. Set to apocalyptic music and filmed in gloomy black and white tones, a workman, seen only by his arms, chiselled a tombstone out of black granite. As the tombstone crashed to the ground, John Hurt – in gravelly Voice of God tones – implored us not to “die of ignorance”. It was the late 1980s and the HIV-AIDS pandemic, which had been quietly raging through marginalised populations across the globe, was finally being forced into the wider British consciousness by the UK government. The myth of AIDS being a ‘gay plague’ was killing heterosexuals in their droves, and the authorities had finally decided that something needed to be done.

“HIV was a very different type of pandemic, operating on a different timescale, and it remains a major problem today, but as with all major infectious disease outbreaks there are lessons to be learned which can be applied elsewhere,” says Professor Dame Anne Johnson. The HIV-AIDS pandemic, which began in the 1980s, was the last disease outbreak that had anything like the global impact of SARS-CoV-2. It was a very different disease and appeared in very different circumstances, but it was deadly, fast-spreading and cloaked by a fog of misinformation and fear.

“In 1986 I went to San Francisco.

They had discovered a huge problem of hidden HIV infection,” Prof Johnson explains. “People were contracting HIV and not getting any symptoms. When they investigated properly, the city suddenly found that up to 50% of men in the gay community were infected. These

32—Prognosis

were really high rates. I remember doing a lot of media work in the early days about how important it was that the gay community had got themselves organised. In the end, they were the ones who drove a lot of the behaviour change.

Their response was central to lowering the infection rates in their community.”

This was the start of a career in which Prof Johnson would specialise in studying the role played by behavioural sciences in controlling infectious disease outbreak. Since then, there have clearly been enormous advances in disease biology; the question is, has there been parallel progress in understanding the psychology of a population in the face of a widespread disease outbreak?

“That’s a very interesting question.

I’m not sure there has,” she replies.

“As we have seen in this pandemic, there has, quite rightly, been a huge focus on understanding the biology of the disease. We had the gene sequence of the virus very early on and we have the techniques to identify it quickly.

Using the PCR test, we can measure the variability in the amount of virus that is being transmitted. We can do large-scale studies and understand what is going on with transmission. Miraculously, with new scientific tools,we’ve been able to develop effective vaccines, which are playing a key role in fighting the spread and impact of COVID-19. None of this was available in the early days of the AIDS epidemic. We had antibody tests for HIV by about 1985, but it wasn’t as easy to do as it is today, and the PCR technique hadn’t been invented. It meant that we had to lean heavily on understanding how people’s behaviour

was driving transmission in order to find ways to combat it.”

Prof Johnson’s early research looked at heterosexual transmission of HIV. Her team studied couples where one person was HIV-positive to find out what proportion of their sexual partners were also infected, which turned out to be about 30%. But the study revealed that while some people with the disease appeared to be highly infectious, others appeared to be hardly infectious at all. Some partners in the study had been repeatedly exposed to the virus in a long-term relationship and never caught it, others had been infected the first time they’d had sex.

It became clear to her that there were differences in people’s infectiousness and possibly in people’s susceptibility

HIV Human immunodeficiency viruses (HIV) are two species of Lentivirus. They can cause acquired immunodeficiency syndrome (AIDS), a condition in which progressive failure of the immune system allows life-threatening infections and cancers to thrive.

AIDS The most severe phase of HIV infection. People with AIDS have such badly damaged immune systems that they get an increasing number of severe illnesses.

PCR test Polymerase chain reaction is a test to detect genetic material from a specific organism, such as a virus.

Wellcome Trust A global charitable foundation established in 1936 with legacies from the pharmaceutical magnate Henry Wellcome to fund research to improve human and animal health.

Ebola A rare and deadly haemorrhagic fever virus. Ebola can lead to internal bleeding, causing inflammation and major tissue damage.

The problem we faced with HIV-AIDS was that people were much less interested in studying behaviours or understanding which behavioural patterns were driving infection.

w Prognosis—33

to infection. It had long been known that environmental and behavioural changes impacted disease infection rates, but this data was vital for developing the kind of targeted advice that could be used to drive a significant reduction in HIV infections.

“The problem we faced was that people were much less interested in studying behaviours or understanding which behavioural patterns were driving infection,” continues Prof Johnson. “In 1990, when we undertook the National Survey of Sexual Attitudes and Lifestyles (Natsal), it was the first large-scale investigation into the sexual attitudes and behaviours of the British population, and it was regarded as somewhat politically unacceptable.”

At the time, as well as limited knowledge about the virus itself, British public health authorities had very limited data on which to base their public health campaigns or create models predicting the disease’s spread.

The then prime minister Margaret Thatcher declared that prying into people’s sex lives was not the business of the government and ordered that no public money be spent on the project.

“Fortunately, the Wellcome Trust stepped in with the funding and we gathered some ground-breaking data. We were able to demonstrate a massive change in sexual behaviour, with condoms becoming much more widely used, alongside a reduction in the number of people’s sexual partners.

We were then able to map these shifts in behaviour against changes in infection rates and show that there was a correlation between behavioural changes and a significant fall in

34—Prognosis

infections. Further studies showed that people went back to having more partners once effective treatments had become available. Infection rates then stayed steady for quite a long time, having reached a balance between the behaviours which were driving infection and the medications that were slowing it down and stopping severe disease.

Everybody wanted to discover a cure, but at the end of the day, just as with COVID, we were incredibly dependent on people’s behaviour to contain the spread. While the government campaigns such as the one featuring the tombstones were much criticised, they were in fact very successful.”

The Academy of Medical Sciences, of which Prof Johnson is currently president, has been heavily involved in studies considering the best ways to tackle the ongoing COVID pandemic.

One of their key findings has been the need to provide the public with clear and consistent messaging, with any changes clearly laid out and explained.

“I think as the messaging has changed over the course of this pandemic, people have become very confused,” Prof Johnson says, with a look of genuine concern. “Take mask wearing as an example – we haven’t managed to sustain that and unfortunately it seems to have become politicised, which is a real problem. One of the things masks do most effectively is protect other people, which is hugely important when you are trying to slow the spread of an infection.”

Prof Johnson points to another disease outbreak to emphasise the importance of communication in tackling an infectious disease outbreak – the 2014-16 Ebola outbreak in west

COVID has been a real shock to the system.

I hope we will learn real lessons. We need to rebuild strong, robust public health systems, which have been starved of investment for years.

Africa. “One of the ways Ebola was being transmitted was through local burial practices, but simply swanning in from the outside and telling people to abandon very important aspects of their culture just wouldn’t work,” she explains.

“Unless you got the community leaders, the elders, on board you wouldn’t gain people’s trust and persuade them to take the necessary actions to stop Ebola spreading. That is just one example of the key role of community engagement.

The same is true with COVID. We’ve seen that in those communities where English isn’t the first language or where there are different cultural notions of acceptability around how health services are delivered, the messaging may not be being delivered in ways and through channels appropriate to the community, leading, for example,

to higher levels of vaccine hesitancy.

We have seen better outcomes in areas where local public health organisations have worked with their communities to get messages across through trusted voices. Some of the vaccine hesitancy we are facing is caused by people either not trusting science or not trusting government.”

COVID has also focused a spotlight on health inequalities. People living in overcrowded housing suffer increased household transmission.

Poorer people often work in jobs with more interpersonal contact or with less ability to work remotely. When we talk about the need for increased ventilation or going outside to meet family, that’s much easier if you have a garden or live in an area with green space. This makes it harder for people lower down the income scale to live, work and socialise in a safe manner.

Last year, the Academy of Medical Sciences produced a report called COVID-19: Preparing for the Future.

In it, concerns were raised about the longer-term socio-economic and cultural impacts of the pandemic based on factors such as geography, age and profession. “We have to think about the indirect and longer-term consequences of COVID. What is the impact of increasing waiting lists on mortality from cancer and heart disease or on employment?” asks Prof Johnson.

The aftermath of COVID will last for years. What will the impact be on young people’s mental health or that of exausted, traumatised healthcare workers? What are the impacts on the babies who didn’t socialise in their first

Sexual Attitudes and Lifestyles AJ Johnson, K Wellings, J Field, J Wadsworth (Blackwell, 1994) Epidemics and Society: From the Black Death to the Present FM Snowden (Yale University Press, 2020)

year, or the children who missed out on education? As the general transmission levels of COVID are reduced, how can we ensure certain groups of the population are not left behind?

“We know that one of the biggest predictors of a person’s health outcomes is their educational attainment,” Prof Johnson explains. “The inequalities in access to computers and quiet spaces to study when the schools were closed will impact students. If you’re in a crowded space with several children sharing one computer, it is easy to fall behind those who have their own bedroom and computer. We need to be proactive in dealing with these impacts, we can’t just sit back and see what happens before coming up with a plan.”

The real test of any system is how it deals with a crisis. Does it rise to the occasion or collapse under the pressure? Does it have the ability to respond or is it mired in inertia and unable to change course? It will be years before we can truly assess the quality of the world’s response to SARSCoV-2. There have been examples of exceptional cooperation between and within nations in finding ways to tackle the virus, yet large swathes of the world’s poorer citizens have yet to set eyes on a single vial of vaccine, giving the virus fertile ground in which to mutate before returning to assault the defences of the wealthier nations.

“This has been a real shock to the system. I hope we will learn real lessons.

We need to rebuild strong, robust public health systems, which have been starved of investment for years. We need to tackle the circumstances that drive epidemics – areas like the interface between animal

and human health. We need to think about the problems of globalisation exposed by the pandemic and start building more resilient societies, which happen to also be fairer societies,” Prof Johnson says with passion. “We need to be thinking in terms of global health, not just national health. There’s a tendency for us each to deal with our own national crisis, but the response to COVID has shown us what amazing progress we can achieve through co-operation.”

It was in 1980 that the US Center for Disease Control received a report from San Francisco of the first American AIDS sufferer in a pandemic that was engulfing the globe. Forty years later, the world was introduced to the name SARS-CoV-2. Advances in medical technology have unquestionably meant that many lives that could have been lost have been preserved, as vaccines and new treatments have developed at a wonderous pace. But it is questionable as to whether the social sciences have received as much attention as their medical counterparts. The initial reaction to HIV was characterised by ignorance, misinformation, fear and unequal access to medication, which between them caused lives to be unnecessarily lost. Forty years later, assessing the public health response to COVID, the question could again be asked of whether we have paid enough attention to the different voices and needs of our complex and interconnected community. We know what needs to be done; it is a case of having the will to do it. If we don’t, new generations of epidemiologists will be forced to commission 21st century ways of imploring us not to “die of ignorance”.

Academy of Medical Sciences Professor Dame Anne Johnson is president of The Academy of Medical Sciences. The Academy, based on Portland Place, is an elected fellowship of medical researchers. It has over 1,300 fellows, about half of whom are clinically qualified, the other half being laboratory scientists in a range of disciplines. The Academy, which seeks to promote excellence in research,influence policy to improve health, promote careers in medical research, and foster links between academia, industry and government, is a registered charity that relies on philanthropic funding. To support its work and make a donation please visit: acmedsci.ac.uk/support

Prognosis—35

36—Prognosis

RESEARCH LIGHTS A diagnosis of pancreatic cancer is among the most crushing that any patient can receive, but significant progress is being made in its detection and treatment.

Prognosis hears from one of the charities that helps fund and shape pancreatic cancer research and one of the hospitals at the cutting edge of its application Words: Viel Richardson

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Founded in 2003 by Sue Ballard, Pancreatic Cancer UK aimed to tackle the lack of progress in a condition that was then languishing in the backwaters of cancer research.

At the time, the feeling was that pancreatic cancer was – and would remain – a ‘put your affairs in order’ diagnosis.

Ballard aimed to change this perception by raising research funding and channelling it into the areas where it was most needed.

While a great deal of progress has since been made, figures surrounding pancreatic cancer still don’t make particularly good reading. According to figures from Cancer Research UK, for the years 2013-17 only 7.3% of people diagnosed with pancreatic cancer would survive their disease for five years or more. Between the early 1990s and 2018, pancreatic cancer incidence rates increased by 17% in females and 14% in males. Research conducted in 2014 predicted that rates would rise by 6% by 2035, and the intervening years have produced few reasons to lower that number. There has been some progress, especially in the realm of early detection, but those early detections are usually the result of investigations into other conditions.

In such cases outcomes can improve greatly, but pancreatic cancer remains a diagnosis for which the prognosis is poor.

There is, however, a determined push to reverse this unhappy trend. “One of the things that has happened in the past four to five years is an increasing coordination in the pancreatic cancer research community,” says Chris Macdonald, head of research at Pancreatic Cancer UK. “Compared with other cancer research, the funding is still quite low, but it’s on the increase, and the coordination and coherence within the pancreatic cancer community is getting a lot better.”

In 2003, pancreatic cancer research accounted for 1% of total UK research spend, while patients and carers were reporting the worst NHS experience of almost any cancer patient group. It was going to take a series of well thought-out and executed plans to improve the situation.

“We were, and still are, the only dedicated research funding team in pancreatic cancer in Europe,” Macdonald continues.

“That means we have developed deep networks throughout the community. We reflect that connection in our strategies.

We’re very collaborative and responsive, so we listen closely to what the community has to say.”

38—Prognosis

That community is a broad one. “It includes scientists doing the lab work, the research funding organisations and clinicians working with patients. We also talk to the patients themselves and their loved ones. It’s crucial that our research activities truly meet the needs of all those impacted by pancreatic disease,” Macdonald says with feeling. “But our main stakeholders are the researchers.

This could be people working on ways to translate research into treatment methodologies, it could be lab-based researchers in the initial discovery phase. We work with teams involved in clinical research or those within the NHS delivering treatments, testing or trialling diagnostics and delivering supportive care.”

With its ear so close to the ground, the organisation knows that aside from funding there are other fundamental issues in the field of pancreatic cancer research. “We have our finger on the pulse of what challenges the community faces and the actual mechanisms being used to overcome them, and more often than you would think, handing over extra money is not the answer. It might be opening up access to networks, datasets and resources.”

One of the biggest challenges is simply having enough people to do the work. Researchers, quite understandably, tend to follow the funding, as doing so gives them the chance of a viable career. Leukaemia, for example, has nearly four times as many researchers dedicated to finding a cure, due to higher levels of funding. One of the key areas for which Macdonald is developing strategies is attracting researchers to the field and then keeping them there once they’ve arrived. Attracting good people for the long term involves writing cheques, but there’s much more to it than that: the infrastructure and culture also need to be right.

Channelling scarce resources effectively is also vital.

In the complex world of funding applications, Pancreatic Cancer UK can sometimes act as an objective broker, assessing the needs of competing projects, helping to avoid research duplication and suggesting areas where more effort is needed. To these ends, Macdonald and his team work closely with other organisations in the research-funding community. Their partners include large pan-cancer charities like Cancer Research UK and organisations that fund medical research but are not

The problem with pancreatic cancer is that by the time patients start suffering from symptoms, things are already quite advanced, and the cancer has often spread to other organs like the liver, the lungs or the veins.

tied to a particular condition, including the UK government and the Engineering and Physical Sciences Research Council.

“We generally work with like-minded, similar-sized charities. This way we learn from one another and develop programmes that have research support. The aim is to help as many researchers as possible,” Macdonald explains.

“Taking a broader view, we are part of the funding community committed to providing resources and financial support for those contributing to the endeavour of forging our understanding of these conditions and how to treat them.”

As the research base grows, so too does the range of treatments available. At The London Clinic, a new form of treatment from the field of nuclear medicine is being prepared to welcome its first patients. Dr Zarni Win, chief of service of nuclear medicine at the Imperial College NHS Trust and a consultant radiologist and nuclear medicine physician at The London Clinic, has set up a clinical trial for a pioneering pancreatic cancer treatment called OncoSil, making The London Clinic the

first hospital in the UK to offer the treatment. It is the latest stage of a long journey that began in 2018 when Dr Win was part of the first team in Europe to work with OncoSil on a research basis.

“The problem with pancreatic cancer is that by the time patients start suffering from symptoms things are already quite advanced,” Dr Win explains. “There may be some abdominal pain, some weight loss, but by the time they consult their doctor the cancer itself will have definitely grown locally and has often spread to other organs like the liver, the lungs or the veins. At this stage the therapeutic options are quite limited. The conventional treatments are chemotherapy and radiotherapy to the pancreas, but unfortunately the survival statistics are not great, with the average survival time being about 12 months.

However, in about 10% of patients this conventional treatment shrinks the tumour. This is great news because the tumour can then often be removed by surgery. In those cases, the patients’ chances of longer-term survival increase greatly.”

OncoSil, Dr Win explains, is radioactivity delivered in a liquid form. All radioactive substances decay and as they do so they emit rays such as x-rays, radioactive particles, or both. The OncoSil treatment uses a radioactive substance called phosphorus 32, which as it decays emits beta particles which travel less than 2mm and kill any cell in their path. The radioactive material is bound to carbon-type molecules, which allows it to be stored in a liquid form. During the procedure, the clinician uses an endoscope to gain access to the tumour and injects the dose of phosphorus 32 directly into the middle of the tumour, where the beta particles kills the tumour cells.

“We usually deliver our nuclear medicine therapies in a tablet form. This should be the first time where a product has been injected directly into a tumour. That’s why we set up Oncosil here at The London Clinic – a forward-looking hospital that has the resources, but more importantly also has the culture of engaging with new and innovative treatments,” Dr Win tells me. “So far, the studies are showing that we can accurately calibrate the size of the dose to the size of the tumour delivering a very high radiation dose while almost eliminating damage to surrounding healthy tissue.

At the moment, we can treat a maximum tumour size of 7cm.”

Prognosis—39

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Chemotherapy A drug treatment that uses powerful chemicals to kill fast-growing (often cancer) cells in your body.

It is most often given as an infusion into a vein.

Radiotherapy The use of ionising radiation (high energy) that destroys the cancer cells in the treated area by damaging the DNA of these cells. It can be delivered by implants inside the body (internal radiotherapy) or from machines outside the body (external radiotherapy).

Pancreas A gland, about 15cm long, located in the abdomen.

It is a vital part of the digestive system and has a critical role in controlling blood sugar levels.

Beta particles High-energy, high-speed electrons or positrons that are ejected from the nucleus of atoms that are inherently unstable.

Phosphorus 32 A radioactive isotope of phosphorus obtained by neutron bombardment of stable phosphorus atoms.

WE MUST NEVER LOSE SIGHT OF THOSE PEOPLE WITH LIVED EXPERIENCE OF PANCREATIC CANCER. WE MUST ENSURE THEIR VOICE IS HEARD. THEY ARE WHY WE EXIST IN THE FIRST PLACE AND WHILE IT COULD BE EASY TO GET TUNNEL VISION OPERATING IN SUCH A COMPLEX AND DIFFICULT LANDSCAPE, THAT IS SOMETHING WE WILL NEVER FORGET.

40—Prognosis

For patients on whom you can operate, there is a really significant increase in survival time, so being able to get so many more people into the operating theatre would represent a huge step forward in pancreatic cancer treatment.

There are many other radioactive products that emit beta particles but not all are predictable and controllable enough to be injected into a person. Factors include the strength of the radiation, how far the particles travel and how fast they decay. “The half-life of phosphorus 32 is around 14 days. You don’t want something with a half-life of 20 or 40 years, which will retain the ability to kill cells for several lifetimes.”

The OncoSil process is a single-dose treatment. It is used in conjunction with chemotherapy, which kills any cancer cells in the vicinity that were not in the tumour, such as those often found in nearby lymph nodes.

“We use the chemotherapy to sterilise any microscopic cancer cells in the surrounding area. It will act on the primary tumour as well, so there’s a bit of a synergistic effect,” Dr Win says with a smile. “Before and after the phosphorus-32 is delivered to the primary tumour, the patient will go on four to six weeks of chemotherapy.”

Not everyone can be treated this way. “Unfortunately, we can’t treat people where the cancer has spread to organs like the liver or into bone. At the moment, trials show that

about 30-40% of pancreatic cancer patients may be eligible for this treatment,” Dr Win explains. But for that large constituency of potential patients, the prospects are highly promising. “What is so exciting about this treatment is the increased incidence of downstaging – shrinking – the tumour, for potential curative surgery. Whereas with conventional treatment 10% of the patients might go on to surgery, with this treatment a recent Australian study saw about 43% of patients’ tumours downstaged to the point where they were offered surgery. For patients on whom you can operate, there is a really significant increase in survival time, so being able to get so many more people into the operating theatre would represent a huge step forward in the treatment of pancreatic cancer.”

OncoSil and treatments like it represent a step-change in the treatment of pancreatic cancer. They offer a sign that the situation in the field is definitely improving.

They also demonstrate clearly the importance of well-funded research. “The field is in a much better place than it was when Pancreatic Cancer UK was founded,” Chris Macdonald tells me. “It’s a complex picture, but we can see that progress is being made.”

Despite the daunting complexity of the field, the ultimate aim of everyone involved in the fight against pancreatic cancer is a simple one: to improve the lives of people who receive that most unsettling of diagnoses.

“We must never lose sight of those people with lived experience of pancreatic cancer,” Macdonald continues. “We must ensure their voice is heard. Their views need to inform the decisions we take, the projects we fund and the way we approach what we do. They are why we exist in the first place and while it could be easy to get tunnel vision operating in such a complex and difficult landscape, that is something we will never forget.”

The London Clinic 20 Devonshire Place London W1G 6BW 020 3613 4413 thelondonclinic.co.uk Pancreatic Cancer UK pancreaticcancer.org.uk Prognosis—41

Julian Best of The Howard de Walden Estate and Dr Brian Donley of Cleveland Clinic London discuss how the Harley Street Medical Area has become a global healthcare hub of sufficient reputation to draw one of the USA’s most influential clinics into its ranks Words: Clare Finney

A HEALTHY HEART 42 – Prognosis

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There aren’t many streets in Britain as rich in cultural and historical references as Harley Street. Like Fleet Street or Abbey Road, the name alone conjures up a colourful array of associations, from the art of JMW Turner to the Oscar-winning film The King’s Speech.

Some of the great pioneers of modern medicine lived or worked on this street. Yet while this extraordinary heritage is as much a part of the fabric of the street as its beautiful buildings, in the past 10 to 15 years Harley Street has been quietly cultivating another reputation that could not be more forward-looking in its conception: being at the heart of one of the most revered and respected private healthcare hubs in the world.

“This is now the largest concentration of medical premises in Europe,” says Julian Best, property director at The Howard de Walden Estate, which oversees the Harley Street Medical Area (HSMA).

“It may not have that sprawling sense of scale you see in the hubs of Boston, Massachusetts, for example, but the number and quality of medical providers is growing all the time.” The reasons are, for the most part, obvious. “As part of a triangle with Cambridge and Oxford, London is a global player now in the life sciences sector,” Best continues. “That, together with first-class university teaching hospitals, has really boosted London on the medical front. The presence of so much technological innovation and groundbreaking medical research has helped build up the area’s reputation.” Then there’s London’s status as a truly global city, with its transport links, international businesses and a dynamic, richly diverse population that has also given rise to some of the best cuisine and culture in the world. And then there’s the NHS. “The NHS is the bedrock of the experience and the skills that many of the consultants working on Harley Street have gained over the years, and it’s the place that many of them still consider home.”

Last year, Harley Street became home to yet another world-leading medical institution, Cleveland Clinic, which opened its first medical outpatient centre at 24 Portland Place in advance of the arrival in 2022 of its London hospital in Belgravia. The American clinic’s London CEO, Brian Donley MD, believes “there is a lot for us to learn from a place like London, which has such a long and rich tradition of healthcare research and innovation”.

44—Prognosis

“For a long time, London has had outstanding research institutions, great medical training, and hospitals – and the NHS has done great things,” he says, recalling his experience with the health service 15 years ago. “I was an orthopaedic surgeon before I was running this project, and I was fortunate enough 15 years ago to spend six weeks touring NHS trusts around the country. Every three days we’d go to a different trust around the UK and it was a phenomenal experience, seeing the excellence of care, the passion of the staff – and the culture, which I felt at the time was very similar to the one we have here at Cleveland Clinic, where strong teamwork enables focus to be placed on the patient’s best interest.”

A key link between the HSMA and Cleveland Clinic is their historic status. “Cleveland Clinic is 100 years old. Harley Street has been famous

Cleveland Clinic is 100 years old.

Harley Street has been famous for medicine for even longer

for medicine for even longer. Both have heritage and both are about constant innovation,” says Dr Donley. “There is a great synergy between the two brands.” While it is hard to draw a direct comparison between UK private care sector and the US healthcare systems, Dr Donley continues, “the parallel between Harley Street and Cleveland Clinic is the focus on improving the experience and life of the patient. Enhancing the expression of empathy between the physician or the nurse and the patient – that is at the core of what we’re trying to do.”

Another key similarity between the HSMA and Cleveland Clinic, and one of the main reasons for their continued growth, is a constant striving toward innovation. “Harley Street cannot sit back and think about the last 100 years – any more than we can,” says Dr Donley. “We have to focus

on the next century: how we can continue to be great at giving care.” Harley Street’s venerable status might be well known in this country, “but it’s not really known internationally outside of certain medical circles,” says Best. Of course, the distinctive beauty of the period buildings will always give them an aesthetic appeal that goes beyond that of the more generically modernlooking healthcare centres – but one should not overestimate the extent to which Harley Street’s history influences the perception international patients and medical providers have of the area today.

Indeed, the historical component can occasionally work against the area. “There are still some people who associate Harley Street with less scientifically robust practices or the poorerend of cosmetic surgery, which were prominent Prognosis—45

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in the area for parts of the 20th century,” says Best. Then there are the sheer logistics of trying to accommodate 21st century medicine into 18th and 19th century buildings. It is one thing to create, from scratch, a purpose-built oncology clinic and lab. It is quite another to adapt a former townhouse-come-GP surgery into an oncology unit that attracts some of the world’s best practitioners. “We need to ensure the buildings we have remain relevant and focused on improving and streamlining the medical pathway for patients,” he continues. “Harley Street is a conservation area, and over 30% of the buildings are listed. It is costly and time consuming – but we have become pretty adept over the years at planning buildings into new, interesting, exciting uses, that are best for medical occupiers.”

Part of the magic of Harley Street is that 46—Prognosis

its buildings are in a way a mirage; behind those pillar-clad Georgian facades is a wealth of research labs, stores, wards and medical apparatus of an intricacy and scale no one merely idling along towards Oxford Street could possibly fathom. “Most recently, we’ve converted two listed buildings and listed mews to create space for the first linear proton beam treatment unit, for Advanced Oncology therapy, with the support of Westminster City Council.

That is a great thing to have been part of.”

There is undeniably merit in having an area as beautiful as Harley Street, and Marylebone generally. “It gives us an edge,” says Best, but for him the real aim is to “continue to raise the bar in medical standards, and get the right balance of hospitals and clinicians. Oncology is well covered; cardiovascular is well covered; we have really

more pertinently, should be going forward. “It is the entire gamut of all that is needed: nurses, consultants, allied health professionals and so on. “It’s creating a market that continues to attract the best people to practice the best medicine,” Dr Donley continues, “and for that nucleus to be there and to keep going, you need continual innovation.” Welcoming an institution like Cleveland Clinic to join what Best describes as the area’s “anchor tenants: The London Clinic, HCA, Royal Brompton, Schoen Clinic, King Edward VII’s Hospital and Phoenix” means bringing together “people with a similar passion and top talents, but with unique perspectives and diversity of thought,” says Dr Donley – “and that is how innovation flourishes.”

We’d love to have lab space for life sciences, and we’ve always wanted a rehabilitation or ‘step down’ facility

good diagnostic capabilities – and by bringing in international operators like Cleveland Clinic, it keeps the domestic ones on their toes.”

Of course, one of the HSMA’s key assets for practitioners looking to move there permanently is that it does not exist in a vacuum, but in a village – one of the real few villages left in central London. “Marylebone is a village in its truest sense,” says Best, “because it can sustain itself.

You can, and many people do, work here, shop here, live here. There are 11 schools on the estate; good food and retail; and the medical is the jewel in the crown. It’s a community, within a large city environment,” he continues. “I think Marylebone as an entity plays an important role.”

There is a neat parallel between Marylebone as a complete entity, and Best and Dr Donley’s shared vision of what Harley Street is now and,

“I think what we can learn from London as well as help to develop is continued innovation around the model for healthcare – like our digital healthcare experience,” says Dr Donley, by way of example. “We have digital integrated patient medical records, which means that patients can access their records wherever they are, in real time; and the doctors can access them in real time. There’s complete transparency there, and transparency is critical to driving improvements in medical safety, efficiency and quality.”

Best’s plans for furthering the comprehensiveness of Harley Street’s offering include “complementary businesses: we’d love to have lab space for life sciences, and we’ve always wanted a rehabilitation or ‘step down’ facility, so that patients who have knee or hip replacements have an environment in which to recuperate.”

By creating this microcosm of complete, end-to-end healthcare within the beautiful environs of Harley Street, it is his hope – and that of Cleveland Clinic’s – that “we will do things that will inspire and push others, beyond Cleveland Clinic and Harley Street and around the country,” says Dr Donley. “That is good for society, for London, and for all 70 million people in the UK.” Cleveland Clinic London clevelandcliniclondon.uk The Harley Street Medical Area harleystreetmedicalarea.com

Prognosis—47

Q+A Tetralogy of Fallot Professor Michael Gatzoulis, consultant cardiologist at Royal Brompton and Harefield Hospitals, on how the treatment of a serious congenital heart condition is rapidly evolving Interview: Viel Richardson Portrait: Christopher L Proctor

What is congenital heart disease?

It’s a broad range of conditions, not a single entity. There can be holes in different parts of the heart, the valves regulating the blood flow can be narrow or completely closed, there can be abnormally small chambers – we’re talking about an entire spectrum of defects. At one end, very severe disease presents itself immediately after birth, or in some cases during foetal life; at the other end, some conditions only present symptoms in adulthood.

What is tetralogy of Fallot?

It is a series of structural defects of the heart that together cause oxygen-poor blood to flow out to the rest of the body.

Pulmonary valve stenosis is a narrowing of the valve that separates the lower right chamber of the heart – the right ventricle – from the pulmonary artery, which is the main blood vessel leading to the lungs. This valve regulates the flow of blood to the lungs, and the narrowing reduces this flow. It might also affect the muscle beneath the pulmonary valve, causing problems with its performance, known as pulmonary atresia.

Ventricular septal defect is a hole in the wall – the septum – that separates the two lower chambers of the heart, the left and right ventricles. This hole causes oxygen-poor blood in the right ventricle to mix with oxygen-rich blood in the left ventricle. In tetralogy of Fallot, the body’s main artery 48—Prognosis

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– the aorta – is in the wrong position, lying directly above the hole in the heart wall. As a result, it receives this mix of oxygen-rich and oxygen-poor blood from both the right and left ventricles. The typical presentation for these patients is a blue-ish colouration of the skin, caused by cyanosis.

Can it be diagnosed before birth?

In the UK, there’s very good infrastructure for foetal screening, so we can now routinely look for problems with the heart. If a clinician sees, for example, that there is a potential hole, showing a risk of tetralogy, or evidence of blockage on the way to the lungs, they can make the diagnosis during foetal life. That means we’re prepared to receive the newborn and provide whatever treatment is necessary.

Is the solution always to operate immediately after birth?

Not always. We are talking about a new-born child, which weighs around three kilos. Imagine the size of the heart – the size of a chestnut, maybe – and then the size of the vessels. Depending on the complexity of the defects, the approach used to be some palliative procedures, perhaps using medication, to open up the arteries. We would then carry out the full operation to repair the heart when the child was between the ages of two and five. But with modern precision surgical techniques we are now in a better position to offer surgery very soon after birth if necessary.

What does the surgery involve?

The procedure is called a repair of tetralogy. Because of the complex nature of the condition, you may need to perform different procedures on different patients to get the desired outcome. The key aim is to close the hole in the heart and repair any constrictions to ensure the correct blood circulation to and from the lungs. This way, fully oxygenated blood is then pumped to the body. It is essentially a bypass operation that ensures the correct working of two separate circulatory systems.

How do you close the hole?

If the hole is small, we can use direct stitches, but in this condition the hole is usually too big for that. If that’s the case, we use a surgical-grade Gore-Tex material, which the 50—Prognosis

body does not reject. Occasionally you can use skin from around the heart, but that’s not as hard-wearing and so is not normally the preferred choice. After that, you remove some muscle from underneath the pulmonary valve.

The condition often causes the muscle to become abnormally thick – hypertrophic – and that is often the main source of obstruction to the blood flowing to the lungs. After that, there is usually some delicate surgery required on the valve itself, because it is also not working properly and is therefore contributing to the obstruction.

As you can see, it can be quite a complex procedure.

Does this completely cure the patient?

That’s an interesting question because thinking on that has changed over the years. In fact, it is the reason I started specialising in treating adult patients. We used to be very aggressive and take away a lot of tissue in order to relieve the obstruction of the pulmonary artery. That induced a leakage of the pulmonary valve – there wasn’t really an effective valve left. Infants tolerated this very well.

But from research we carried out, primarily here at the Brompton, we showed that being so aggressive with the first operation was not in the patient’s long-term interest.

What was the problem?

Because of the damaged pulmonary valve, blood was leaking into the right pulmonary chamber. The chamber had to expand to accommodate this extra blood. Over the years, this progressive dilation of the right pulmonary chamber began to cause problems. Patients could have arrhythmias, some of which could be life-threatening. There was also a weakening of the heart muscle, which could lead to heart failure. The thing is that there was very little knowledge about the adult patients. That was the incentive for me to leave paediatric cardiology and start treating adults with congenital heart disease. The good thing is, you can still successfully treat the condition in adults.

So how has the approached changed?

Surgeons now take a much more precise and conservative approach to relieving the obstruction. During that first procedure, they remove much less tissue. The aim is now to maintain the competence of the valves as much as possible.

I think there are some universal principles that we can all adhere to, but with these patients – who have this background of structural heart disease and major surgery, with the prospect of further interventions – they are even more important. The best thing is to have a healthy diet, take daily exercise and not smoke.

If a valve does start leaking and is affecting the pumping chamber underneath, we replace it with a tissue valve.

There is a real focus on the patient’s quality of life after the procedure; the more effective these systems are, the better that will be.

Do the repairs last a lifetime?

Not at the moment, unfortunately. Patients can enjoy a very long and rich life, but many of them will need further attention after 20 years or so. The great thing is that the technology now exists to enable us to give them a new valve with a minimally invasive procedure, entering through the groin. This means we don’t always have to go in through the chest, which is a significant operation for the patient to go through. A patient may have to have three interventions between the ages of 35 and 75, but if they look after themselves, there is no barrier to them having a long and full life.

You mention looking after themselves. Do these patients need to amend their lifestyles?

I think there are some universal principles that we can all adhere to, but with these patients – who have this background of structural heart disease and major surgery, with the prospect of further interventions – they are even more important. The best thing is to have a healthy diet, take daily exercise and not smoke. With my colleagues, I look after about 12,000 adults with congenital heart disease. During our consultations I spend as much time talking to them about cooking and exercise as I do about the specifics of congenital heart disease, possibly more, because it does make a difference. If you want me to be a bit political, there’s a problem in this country that too many people don’t cook.

Is there anything else patients should do?

Actually, I think we in the profession also have to change.

We need to be better at educating the patients, helping them to understand their condition and map out what can be a very positive life trajectory. We also need to find ways of giving them a lot more clinical information, without overloading them. Because this is such a specialised and complex condition, even to people in cardiology,

I think it is unrealistic to expect the general profession to comprehend all the aspects relating to each individual patient. As a result, I have no doubt that the best route to the most effective care for these patients is to place them at the centre of their own clinical information. They understand better than most people the condition’s trajectory, they know about lifestyle choices, they know what to do and what to look for in case of an emergency in the middle of the Highlands. It sounds like a lot, but everything they need can be accessed via their mobile. It’s just a case of us finding the right ways to deliver it to them.

If you had a silver bullet, what area would you want to see real progress in?

It’s what I’ve just been saying: turning the current healthcare model on its head, putting the patient at the centre of it, utilising technology in a much more sophisticated way. I’d like to see more patient engagement and empowerment, with an understanding that this is a two-way thing. I’d like the patients to assume some agency in how the monitoring and treatment of their condition interacts with their daily life.

To get this right, the way in which we manage the communication will be key. My team is in the very early days of developing an application aimed at working this way. It could mean that low-risk patients don’t need to regularly make trips to see their consultant. We should be able to follow them remotely, with an application linked to wearable health technology. We’re now working with Intel to see how, even in this low-risk group, we can use specialised artificial intelligence algorithms to detect any outliers who may develop problems we wouldn’t expect. I would like to see a model that is very different from the traditional model, which has created a culture of dependency, involving continual visits to hospitals. Of course, this approach is aspirational and needs to be supported by rigorous data, but I truly believe it is possible to achieve.

RB&HH Specialist Care Outpatients and Diagnostics 77 Wimpole Street, London W1G 9RU 020 3553 9648 rbhh-specialistcare.co.uk

Prognosis—51

52—Prognosis

Patient experience Susan Bridgman on how revision knee replacement restored her mobility and freed her from severe pain Interview: Viel Richardson

In 2014, I suffered a severe injury to my right knee when I fell down a flight of stairs while helping a relative.

At the local hospital, I was told that the damage was severe. Their conclusion was that I would require a complete knee replacement.

As a result, on the day I went down to the operating theatre I was expecting a full knee replacement, but during the operation the surgeon apparently decided that a partial knee replacement would be the better option, so this was the procedure he performed. He clearly thought this was for the best, but as time passed it turned out to have been a poor decision.

While it never felt 100%, I did start going for longer walks and thinking that the knee felt okay, but that soon changed. I started getting niggling pains in the knee. At first, I thought that it might be part of the healing process, something that would clear up as the implant settled in, so I just continued living with the niggles.

But things deteriorated so much I ended up back in hospital, where I was told I would need another operation.

The surgeon apologised and told me I would now require a full knee

replacement. Three weeks later, I was back in the operating theatre undergoing a full knee replacement. It was my second major operation in less than three months.

Things were definitely better for about six months after the second operation was completed. Again, I can’t say that my life was back to normal – it was a big improvement, but there was always a bit of discomfort on most days. There were some days without pain, and I was walking further than before, but I don’t think I had that confidence in the knee to say: “Yes, I’m back; this time the operation was a success.”

Within a year, I was experiencing the same sharp stabs of pain I’d had before the second operation. I tried to ignore them but over the next few years they started happening more frequently and getting worse. To be honest, I tried really hard to put up with the pain, because I was so reluctant to go under the knife again.

I would have been devastated if another surgery had failed, If I’d had to go through the pain of recovery for a third time. I soldiered on until I ended up back on crutches.

Eventually, in early 2020, my family persuaded me to go back my GP. This time, I was referred to a different hospital, where I started undergoing numerous tests and scans on my knee.

But then COVID hit and everything was put on hold. By this time, I couldn’t walk unaided and spent lockdown, using crutches. The pain was so bad that I was reduced to climbing the stairs on all fours.

The first time I heard of Schoen Clinic London was when I got a call to say they’d like to offer me a slot for my operation at the clinic in the Harley Street Medical Area. I asked if they could wait a day before confirming the procedure. I was very scarred from my previous experiences and need a bit of time. I spoke to my sons, and they said it was a no-brainer. I called back and agreed to the third operation.

When I met Mr Rhidian MorganJones, he immediately seemed very approachable and informative. I knew a bit about him already, because we had checked him out online when the clinic had told me who the surgeon was going to be. He had great credentials and I remember thinking to myself, w crikey, I’m a very lucky lady. He Prognosis—53

WHAT IS REVISION KNEE REPLACEMENT? Mr Rhidian Morgan-Jones, consultant orthopaedic surgeon at Schoen Clinic London

explained to me very clearly exactly what the issue might be and how he planned to fix it.

All the staff at the clinic were wonderful, and this time the operation went as well as could be hoped. For the first time I have real confidence in the outcome. The rehab physio has been hard, but I felt very supported by the clinic and by my family. After each of the other operations, I had tried to do the same, but the pain was just too horrendous.

When I went to the clinic to meet Mr Morgan-Jones for my final consultation six months later, he couldn’t believe the improvement in my condition. I didn’t wobble when I walked, my gait was back to what it should be. It’s given me a new lease of life. I feel like I can do anything now.

Patella tendon The tendon that attaches the bottom of the kneecap (patella) to the top of the shinbone (tibia).

Flexion The major action through which the knee bends when raising the heel.

Knee revision The replacement of prosthetic implants for a person who previously had a total knee replacement.

Prosthetic malrotation A surgical error that can lead to the knee not moving smoothly along one of its planes of motion.

This can lead to significant pain for the patient.

54—Prognosis

The procedure I performed on Susan is called a revision knee replacement.

I suppose technically it was actually a ‘re-revision’, because this was the third procedure and we were there to correct an error from the previous revision operation. That error was causing a malrotation in part of the knee, and my aim was to correct that malrotation and rebalance the knee.

When I first examined Susan, the knee joint was stiff with limited movement and what movement she did have was very painful. The issue was that the kneecap wasn’t running smoothly. The original operation had led to some ligament damage, causing what we call an insufficiency, which is when a part of the body is unable to perform its normal function.

The aim of the second operation had been to produce an internal stabilising mechanism called a rotational hinge.

The problem was that although it made the knee stable, it also made the knee stiff. The knee is a highly complex three-dimensional joint, and while the implant was placed with two of the planes of operation spot on, the third rotational plane was slightly out of alignment. That was the cause of Susan’s symptoms.

The structure of the knee’s hinge mechanism is internally constrained, and that was part of the issue here. It would have looked fine on a post-operative x-ray. But on closer examination it became clear that the rotational profile of the joint just wasn’t quite right. It was only a matter of a few degrees, but it was enough to cause significant symptoms for Susan.

Without a surgical pre-operative investigation, it’s only when you get in and see the layout of the knee that you know exactly what the situation is. I was hoping it would just be a matter of releasing a little bit of tissue and some tissue scarring. But once I could see everything, it became clear that a malrotation was the real issue. That meant I had to remove the implant, reshape the bone and reposition the implant with a slightly different rotational plane so that as the knee bent and straightened everything worked in alignment.

This was quite an extensive operation. I had to lift the kneecap and the patella tendon off the bone to expose the whole thing. I had to recap the bone and recreate a three-dimensional joint that worked in straight extension, bent flexion and rotation. All that might sound a bit dramatic, but part of my job as a surgeon is to know what I think will happen, but to have all the right equipment available to proceed with the operation if I find something I wasn’t expecting.

Susan has done very well since the procedure. That’s partly because the knee is now sitting correctly, but also because she is a very motivated lady.

Once I got rid of the pain, she’s done all her rehab, however hard it might be.

She is off her crutches, off painkillers and is even driving again. We’re very pleased about that.

Schoen Clinic 66 Wigmore Street London W1U 2SB 020 3929 0801 schoen-clinic.co.uk

Revision knee replacement

Femoral component (metal alloy)

Femur (Thigh)

New joint bearing Tibial component (metal alloy)

Tibia (Shin)

Prognosis—55

How a holistic rehabilitation and treatment programme designed to bridge the gap between doctors and fitness specialists is giving patients like Paul Mylrea, who felt some of the more extreme physical effects of COVID-19, a chance to fight back

STRONGER TOGETHER Words: Julia Price

56 – Prognosis

w Prognosis – 57

The concept of social distancing is now embedded in our psyche, but over in the Harley Street Medical Area, two centres of expertise located just a few hundred metres apart have been showing why, at a time when safety is often measured in distance (and isolation prescribed as a remedy), working closely together is still important.

In the world of professional sport, open communication channels between trainers and medical professionals are a vital part of an athlete’s rehabilitation journey in the aftermath of injury.

It is a multidisciplinary approach that champions synergy – where physical therapy interventions are supplemented by medical expertise; physical recovery upheld by psychological readiness. Holism is the name of the game.

During the COVID-19 pandemic, Isokinetic, a sports medicine and rehabilitation clinic on Harley Street, has been working with AMP Athletic, a personal training gym located a short walk away, to offer patients like Paul Mylrea a model of rehabilitation and treatment usually reserved for elitesport. The tailored programme has been designed to bridge what can often be a wide gap between the doctors, physiotherapists and fitness specialists involved in a patient’s recovery process.

The dual approach was developed to ensure exercise is controlled and monitored by medical professionals in a safe way, mirroring the professional sport environment.

Mike Davison, who heads up Isokinetic’s Harley Street clinic, says: “For patients, our integrated approach 58—Prognosis

goes deeper than physiotherapy, with the objective of restoring optimal performance – and then maintaining it. It combines the latest technology and neuro-motor exercises to prevent the reoccurrence of injury, supported by clinical evaluation. Key to this is enlisting the support of specialist facilities to deliver to patients a complete care package tailored to their needs and to support their ongoing progression.”

This collaborative programme, which offers an evidence-based approach to rehabilitation, has been central to Paul’s impressive recovery. In April 2020, seriously ill with COVID-19, he was left hospitalised and fighting the more severe, physical effects of the illness. While in intensive care and receiving treatment, Paul suffered two massive strokes within a couple of days of each other – both caused by the coronavirus infection. Although typically considered a lung infection, COVID-19 has been found to cause blood clots that can deprive vital areas of the brain of blood supply and lead to severe stroke, including in patients as young as 30. The symptoms can leave patients with weakness or paralysis, lack of sensation, facial droop and speech impairment.

The condition left Paul unable to get out of bed when he awoke in hospital.

The second stroke he suffered was so big, in fact, that doctors thought it likely he would not survive, or would be left hugely disabled. With the pandemic seriously affecting stroke treatment and care, Paul was also unable to rely on standard rehabilitation therapy. “When I was in hospital I could only walk with a

I have known Paul personally for a little while and his story just connected with me, not only because of his survival but also because of his willingness to live life, pursue activity and fight back

walker and two people walking with me – that was in April,” he recounts. “The NHS is great, but unfortunately they cannot always bring you back to the level of fitness you had before or help you enjoy every element of life.”

The 64-year-old, who is director of communications at Cambridge University, is now able-bodied. His physical recovery has been remarkable, which Paul credits to the holistic support he received from AMP Athletic and Isokinetic. Following his debilitating encounter with COVID, he underwent a tailored rehabilitation programme devised by Isokinetic to help with his strength and coordination and reduce the immobility-related complications of stroke. This was followed by ongoing maintenance and performance at AMP Athletic focused

on therapeutic exercises, muscle strengthening and movement.

“Working with the trainers at AMP has been fantastic,” says Paul. “The trainers have noticed things that I wasn’t aware of and have helped me fix them.

One example of this is the stroke affected my right-hand side – I am naturally right-handed, and I thought things were going well, but in reality I had lost muscle mass and strength. These are the kind of things that if you don’t fix will affect you later on in life.”

When it comes to stroke, the main physical problem facing survivors is weakness in their limbs, according to the Stroke Association, and this can be improved with a combination of strengthening, stretching and endurance exercises. Meanwhile, studies indicate that prolonged immobility among patients can result in significant functional decline. Key to combatting this is a multidisciplinary approach combining medical expertise with exercise and physiotherapy.

Rehabilitation success relies on creating a less disjointed experience for patients. Matt Curley, head coach at AMP Athletic, says: “With experience of working with sport injury clinics over the years, we understand there is a gap between physiotherapy and returning back to exercise. We pride ourselves on bridging that gap. It is important to get patients out of the clinical environment and get them back into a gym for their mental health. Ultimately the relationship between us and the medical professionals at Isokinetic has been really good for our clients, as in Paul’s case. We have open lines of

communication where in the past I think people would have been intimidated to work with medical professionals.

In professional sport the channels of relationship and communication have always been open and that is what we have replicated.”

It isn’t just Paul’s physical condition that has seen a marked improvement.

“Medical evidence shows that keeping yourself fit doesn’t just have an impact on your body but also your mind and mental health,” says Paul. “I feel great now – not likely to do any marathons, but so much closer to my old self. It’s fantastic that AMP and Isokinetic work together in this way, as quite often there is a gap between the medical and the health side. It’s been great to benefit from an integrated approach with both organisations working together to get the best outcome for me.”

Doctors have attributed Paul’s extraordinary recovery to his previous very high level of fitness. While lockdown has no doubt had an impact on our daily routines in recent months, the benefits of exercise, both physically and mentally, are well-documented.

In fact, research shows that exercise can reduce the risk of major illnesses such as heart disease, stroke, type 2 diabetes and cancer by up to 50% and lower the risk of early death by up to 30%. All of these are conditions that can increase susceptibility to the worst rigours of COVID-19.

“I have known Paul personally for a little while and his story just connected with me, not only because of his survival but also because of his willingness to live life, pursue activity and fight back,” says Mike. “In essence, to use exercise

to combat stress, be an inspiration to other people around you and to think proactively about your future. Exercise is a form of anti-ageing, but what you’re trying to do is live healthily for as long as possible.”

If there’s one thing we’ve learnt this past year it’s that the global pandemic can only be ended by a unified approach.

And it is this collaborative spirit that Isokinetic and AMP Athletic are trying to embody. Located one street apart, the two facilities are combining their expertise in medicine and rehabilitation to help patients who have been physically affected by COVID-19.

Mike concludes: “Isokinetic is part of the Harley Street Medical Area, an area that we like to think as being the world’s largest hospital. The area has world-class specialists but it’s important to ensure we have bridges of connectivity and communication, and also understand when we are not best placed for the patient experience. I’ve known AMP for two years and we have a great ongoing relationship. I think it’s an example of two groups within HSMA in health and wellbeing working together to give Paul and other patients like him the opportunity to live their lives as well as they can.”

Isokinetic 11 Harley Street London W1G 9PF 020 7486 5733 isokinetic.com AMP Athletic 14a Beaumont Mews London W1G 6EQ 020 7486 9127 amp.fit

Prognosis—59

MY MARYLEBONE

access makes it so much more than just a gallery and more of a genuine cultural hub.

Eat The restaurants are one of the real joys of working in Marylebone. There are so many of such a high quality and they are so varied. You just pop around the corner.

Myrna would come up to join me at lunchtime when I had some time off and it was only a short walk to any number of great places to eat. Places I regularly frequent are Fischer’s, Fishworks which serves really wonderful seafood, and The Ivy Cafe, but there are so many others I could mention. The nice thing is that new places come along to keep things interesting.

You can eat British, Italian, Middle Eastern and Japanese all a short walk from where I practice – it is remarkable really and a real tribute to the management of the area.

Dr Adrian Whiteson, GP and co-founder of Teenage Cancer Trust

The Ivy Cafe

Work I have spent my career as a GP in private practice and have always been based in Marylebone. I started in Upper Wimpole Street, going on to Harley Street, then Wimpole Street, and now the corner of New Cavendish Street and Welbeck Street.

I’ve been around the Marylebone block! My first room was in the practice run

by Dr Peter Curley. He was the radiologist to the royal family and had a spare room on offer. This was the early 1960s and I had turned up with my hair slightly longer than was normal, wearing a light suit and a style of shoe we called brothel creepers. I was assured I could have the room but also politely told to get my hair cut a little shorter.

It was also ‘suggested’ that I wear a dark suit with a white shirt, a dark sensible tie and get some decent shoes. It was a different world then.

In the late sixties, I joined British Boxing Board of 60—Prognosis

Control as a medical adviser and went on to become their chief medical officer. After that I became the chairman of the Medical Committee of the World Boxing Council.

Then in the late eighties, together with my wife Myrna, I co-founded Teenage Cancer Trust, all while running my GP practice in Marylebone.

Shop This is a tricky one because I’m allergic to food shopping.

I will not go anywhere that involves shopping for food.

When Myrna wants to go, I would rather sit in the car and wait for her to come back. She once pointed out that I was happy to go to an art gallery and spent time enjoying and appreciating the wonderful paintings and sculptures.

She suggested that I adopt the same approach with the window displays in the area.

Marylebone has wonderful shops that display their

products beautifully, so I’ve taken up a bit of window shopping. It really opened my eyes to the variety of lovely things available here.

You can get everything from beautiful furniture to stationery without leaving the area.

Culture I’ve always loved Wigmore Hall. I have always liked going to their concerts in the evenings and weekends. I’m a real lover of all kinds of music, except punk, and Wigmore Hall has always produced a wide range of musical styles. I have seen many wonderful performances just by popping into the box office to see if they have any spare seats. Then, of course, there’s the Wallace Collection. It’s such a major part of Marylebone’s cultural landscape. Something really lovely is that local organisations can hold receptions there. This extra

Community When I arrived in the sixties, it was an amazing time.

There were no meters, so you could park where you liked. If you wanted to find consultants to talk to, really senior people, icons of the medical and surgical professions, you just went to the right pubs, and they were all there on Friday evenings.

I used to love coming in on the weekends. You would see the consultants out with their wives or their families, chatting away. It was a village atmosphere, and that continues to this day. I’m in the surgery by 7am and on my way in the guys sweeping the streets or cleaning the windows will call over: “Hi, how are you? Have a good day. ”The welcome you get here from everyone is just so warm.

They are happy, proud to be a part of Marylebone. I don’t see very many people scowling. Everybody’s going about their day with a smile.

Wigmore Hall

Prognosis—61

WHAT’S ON EXHIBITION

THEATRE

MUSIC

FOOD

LULAMA WOLF: NDIZALWE NGE NGUBO EMHLOPHE (I WAS BORN WRAPPED IN A WHITE BLANKET) Until 4 March SoShiro 23 Welbeck Street, W1G 8DZ soshiro.co

THE TEMPEST 9 – 19 March The Cockpit Gateforth Street, NW8 8EH thecockpit.co.uk

BACH IN LEIPZIG 20 March Royal Academy of Music Marylebone Road, NW1 5HT ram.ac.uk

MARYLEBONE FOOD FESTIVAL 26 April – 1 May marylebonefoodfestival.com

The The Bridge Theatre Training Company’s new time shifting production of The Tempest mixes the Elizabethan world with the 1950s painter’s studio that is Prospero’s desert island. Betrayed by family and peers and racing against time to complete a masterwork, Prospero must choose between revenge and justice, violent retribution, and forgiveness.

Beat poet Allen Ginsberg meets outrageous vaudeville comic Max Miller, Leonardo da Vinci and abstract expressionist artists Jackson Pollock and Lee Krasner in this extraordinary new version of Shakespeare’s hymn to the imagination.

The third Bach in Leipzig concert of 2022 features an opulent cantata for Epiphany surrounded by two intense, questioning works written for occasions later in the year. The use of recorders, horns and oboes da caccia in Sie werden aus Saba alle kommen colourfully illustrates the magnificence of the Magi’s arrival at the crib. Ich glaube, lieber Herr is a work of subtle drama, musing on the complex interplay between doubt and faith. The expressive Mein Herze schwimmt im Blut, one of Bach’s most popular solo cantatas, sings of the pain and torment of sin and seeks forgiveness through reconciliation with God.

This exhibition of new works by the South African visual artist Lulama Wolf features the fruits of residency in Antibes, France, for the Undiscovered Canvas residency programme for emerging African artists.

Lulama’s approach is rooted in her heritage, and her work captures some of the simplicity and deep spiritual power of the pre-colonial African experience, but her interrogation of history, geography and spirituality feels highly contemporary.

Lulama Wolf

62—Prognosis

The Tempest

The amazing Marylebone Food Festival marks its highly welcome return after an enforced two-year hiatus. Visit the website for updates on the dozens of culinary events taking place across the neighbourhood throughout the festival, which is organised and funded by The Howard de Walden Estate and The Portman Estate.

Highlights include a gala dinner hosted

by Jay Rayner, with each course cooked by a different chef from the area’s best restaurants.

PAUL ROTHE AND SONS 35 Marylebone Lane London W1U 2NN

Tatsuo Miyajima’s profoundly spiritual art explores Buddhist philosophy through technological installations.

EXHIBITION TATSUO MIYAJIMA: ART IN YOU 10 February – 9 April Lisson Gallery 67 Lisson Street, NW1 5DA lissongallery.com Japanese installation artist and sculptor Tatsuo Miyajima, whose profoundly spiritual art explores Buddhist philosophy through technological installations, unveils three new bodies of work – Keep Changing (Mondrian), Painting of Change and Unstable Time – all of which use digits, in the form of LED lights, oils or gold leaf, to explore ideas of life, reincarnation, chance and flux.

Tatsuo Miyajima

Places for a bowl of soup in Marylebone

It’s been 50 years since Paul Rothe took over from his father, Robert—and 119 years since his grandfather Paul opened this German-ish deli.

To step inside and survey the 1950s-style tables and gleaming jars of handmade jam and chutney is to feel all is right with the world – at least for the time you’re there. Paul is still serving, alongside his son Stephen, and their soups are as reassuring as they are retro.

There’s a vegetable and a meat option, which change daily – pea and mint, celery and stilton, lamb broth, chunky vegetable – and while plain bread is available, the traditional Rothe practice of ordering a sandwich to dip in your soup is advised.

LE PAIN QUOTIDIEN 72-75 Marylebone High Street London W1U 5JW lepainquotidien.com Growing up in Belgium, Alain Coumont spent every Wednesday afternoon at his grandmother’s house, where she treated him to a small bowl of hot chocolate. The memory of cupping his cold hands around it, soaking up its warmth, followed him to the tables of the bakery he founded almost 30 years ago in Brussels – and thence to his opening in Marylebone, where hot drinks and soups continue to be served in wide, round bowls. The soup is organic, seasonal – think icy gazpacho in summer, butternut squash topped with rosemary in winter – and served alongside Le Pain Quotidien’s eponymous daily bread.

GAIL’S 4-6 Seymour Place London W1H 7NA gailsbread.co.uk There are not one, not two, but five richly flavoursome

soups to choose from at Gail’s, each created with the help of a nutritionist to provide maximum nutritional boost for your buck. Choose from hot paprika beef goulash; soothing, protein-rich Moroccan lamb harira; fragrantly spiced sweet potato and coconut; lentil broth bright with lemon and sweet with pumpkin; or chicken and vegetable. And get dunking with the fresh, local, handcrafted sourdough Gail’s serves alongside.

FISCHER’S 50 Marylebone High Street London W1U 5HN fischers.co.uk Those looking for the ultimate soup for sore bodies (chicken) can rest easy.

Fischer’s chicken soup with spätzle is the platonic ideal of Jewish penicillin: silky, buttery, laced with noodles and studded with just the right amount of chicken broth-infused veg. Enjoyed in the decadent comfort of this wood-panelled, marble-floored homage to the grand cafés of 19th century Vienna, this – and maybe a small, restorative glass of Austrian riesling – is the culinary equivalent of a Lemsip all-in-one capsule.

LA BRASSERIA 42 Marylebone High Street London W1U 5HD labrasseria.com Tomatoes, pasta, parmesan, beans. When it comes to comfort food in a bowl, it’s hard to beat minestrone – especially when that minestrone is made to a Milanese family recipe and served in the soothing surrounds of teal blue walls and velvet chairs. Order Nonna Rosa’s focaccia alongside—another family favourite—and soak up the bustling, buoyant atmosphere and Italian hospitality. The experience of a holiday, but in your lunch break.

Prognosis—63

in pink Scottish granite, the imposing Hamilton memorial in Portman Square was one of its installations – and among the finest, the grandeur of its design rendering it as much a work of public art as a functional piece of infrastructure.

Donated by Lady Hamilton in memory of her late husband, this Grade II listed memorial was recently restored to full working capacity by The Portman Estate.

Hamilton memorial drinking fountain

THE GUIDE

A tour of Marylebone’s most notable memorial sculptures

JOHN F KENNEDY MEMORIAL After the assassination of John F Kennedy in 1963, an appeal in the Sunday Telegraph led to more than 50,000 readers making individual donations of up to £1 to create a memorial.

The bust, commissioned from Cubist sculptor Jacques Lipchitz, was unveiled on 15th May 1965 by the late president’s brothers, Robert and Edward Kennedy, outside the new International Students House on Marylebone Road. In 2017, the sculpture was attacked by vandals, who caused significant damage to the plinth. It was returned to public display on a new plinth and in a new location – inside the lobby of International Students House, but viewable through the windows.

THE TRITON FOUNTAIN This ornamental fountain, a bronze sculpture of the Greek god Triton, which stands in 64 – Prognosis

An appeal in the Sunday Telegraph led to more than 50,000 readers making individual donations of up to £1 to create a memorial to JFK.

the middle of a pool in Queen Mary’s Gardens, Regent’s Park, was erected in memory of Sigismund Goetze. Goetze, now largely forgotten, was once a renowned artist—his 1904 painting Despised and Rejected of Men, was an “artistic sensation” at the Royal Academy, and the vast patriotic murals he created for the Foreign Office are a sight to behold—but it was as a donor of public art, including the park’s ornate Jubilee Gates, that he is best remembered.

In 1936, he commissioned the sculptor William McMillan to design the Triton Fountain, but the outbreak of war meant it was not finished until 1950, when it was installed by Goetze’s wife Constance.

HAMILTON MEMORIAL DRINKING FOUNTAIN The Metropolitan Drinking Fountain and Cattle Trough Association was set up to improve access to clean drinking water in public places. Rendered

THE RAOUL WALLENBERG MONUMENT Raoul Wallenberg was a Swedish diplomat who helped save the lives of more than 100,000 Jews in Nazi-occupied Hungary toward the end of World War II. The Great Cumberland Place monument, which depicts Wallenberg against a 10-foot bronze wall, made up of 100,000 Schultz Passes – a pseudo-legal document that made Hungarian Jews honorary Swedish citizens, thus exempting them from wearing the yellow star and, in many instances, being sent to concentration camps – and draped in the Swedish flag, is the work of Scottish sculptor Philip Jackson. It was unveiled by the Queen in 1997 in a moving ceremony attended

by Holocaust survivors.

WILLIAM PITT BYRNE MEMORIAL FOUNTAIN This elaborate drinking fountain in Bryanston Square was erected in 1862 in memory of the journalist and newspaper proprietor William Pitt Byrne, who inherited responsibility for The Morning Post newspaper from his father. Designed by his wife, the novelist Julia Clara Pitt Byrne, it includes a plaque with a wordy and rather breathless testament to Pitt Byrne’s qualities as a man (“noble disinterestedness … forgiving temper … unobtrusive piety”) that sits somewhere between touching and embarrassingly over-egged.

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