In the frame
How the Random42 studio became the pharmaceutical industry’s goto producer of medical animations
The search for a treatment for CTE, a condition caused by contact sports
A picture of health
Prof Jane Anderson on the impact of art on patients and hospital staff
How does it work?
A guide to ankle arthroplasty
The periodical of the Harley Street Medical Area Issue 12 / 2023
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LEADING YOU THROUGH YOUR HEALTHCARE JOURNEY
THE WELLINGTON HOSPITAL THE PRINCESS GRACE HOSPITAL THE LISTER HOSPITAL THE PORTLAND HOSPITAL THE HARLEY STREET CLINIC LONDON BRIDGE HOSPITAL THE CHRISTIE PRIVATE CARE HCA UK AT UNIVERSITY COLLEGE HOSPITAL HCA UK AT THE WILMSLOW HOSPITAL PRIVATE CARE AT GUY’S
Prognosis is owned by The Howard de Walden Estate 23 Queen Anne Street London W1G 9DL 020 7580 3163 hdwe.co.uk
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36 Sporting chance
Dr Emer MacSweeney of Re:Cognition Health on the dangers to the brain of contact sports
04 HSMA update
Julian Best, executive property director of The Howard de Walden Estate, on supplying the buildings needed to attract the world’s leading healthcare providers
New arrivals, developments and events
10 Crystal ball
The evolution of treatments for auditory processing disorder
11 Harley Street hero
Dr Grantly Dick-Read
12 How does it work?
14 Thinking aloud
The thoughts of Paresh Patel, chief executive of OCL Vision
16 Profile of a pathogen
18 How to
20 A day in the life
Dr Phil Hopley, co-founder and managing director of Cognacity
24 Soul food
Kerrie Jones, CEO and founder of Orri, on an eating disorder service that helps people get well and stay well
26 Healthcare in the climate crisis
How healthcare organisations have been coming together to push climate change up the agenda
30 The big interview
Professor Jane Anderson of the Paintings in Hospitals charity on the profound impact of art in healthcare settings
36 Sporting chance
Dr Emer MacSweeney of Re:Cognition Health on the dangers to the brain of contact sports
42 Sight for sore eyes
Viswanathan on advances in the treatment of glaucoma and cataracts
46 Q&A Mr Erlick Pereira and Dr Moein Tavakkoli on refractory pain
50 Patient experience Michelle Hunter on how day-case surgery ended a decade of debilitating pain
54 In the frame
How the Random42 studio became the pharmaceutical industry’s go-to producer of animations
60 My Marylebone
Alexander Johnston, general manager at John Bell and Croyden
62 What’s on Cultural events near the Harley Street Medical Area
Places to get great vegetarian food in Marylebone
64 The guide
Live music in Marylebone
Four times a year I will travel with McLaren’s 120-strong F1 team and spend a week with them. I do performance coaching with the pit crew, so they can be optimally focussed when it really matters.
Dr Phil Hopley of Cognacity
Prognosis—3 54 30 42 14
Julian Best, executive property director of The Howard de Walden Estate, on supplying the buildings needed to attract the world’s leading healthcare providers
Welcome to the latest issue of Prognosis. In this issue you will hear from several operators who are new to the Harley Street Medical Area (HSMA). Their arrival is part of our continuing strategy to improve the depth and the breadth of the healthcare offer available in the HSMA.
While we already have a significant number of world-class facilities and clinicians in the area, that is no reason to be complacent. At The Howard de Walden Estate, we are continually working to bring best-in-class treatments, consultancies and facilities to the HSMA, and to address areas where we are not as well served as we would like to be. To that end we have recently welcomed Orri, Cognacity, and All Points North. Between them, they bring a real focus on the treatment of
eating disorders and mental health conditions. While there has been some mental health provision in the area, the arrival of these specialist clinics will be of real benefit to both patients and other clinicians as these new entrants collaborate with our existing heath providers to develop and deliver new and innovative treatments.
As a landlord, we are committed to creating the best environment for our clinical tenants to operate in. One of the challenges we face is creating suitable clinical premises in such a historic part of London. Differing medical specialties can have widely different requirements of their buildings, so it takes a lot of time and planning to do this well. An example is the project we are undertaking at 1-7 Harley Street, a large-scale redevelopment that
While we already have a significant number of world-class facilities and clinicians in the area, that is no reason to be complacent. We are continually working to bring best-in-class treatments, consultancies and facilities to the HSMA, and to address areas where we are not as well served as we would like to be.
27-29 Harley Street Prognosis—5
was first contemplated about seven years ago and for which we obtained planning permission about two-anda-half years ago. At the moment, the property is two buildings stitched together. The finished building will be a single unit with 26,000 square feet of dedicated consulting and medical space configured to suit a single occupier. The new building will retain the well-loved facade on both sides as well as some of the internal rooms, making this a complex demolition and construction project. It is due to be completed in about two-and-a-half years’ time and will effectively be number 1 Harley Street, so it will be an important address.
We also keep a close eye on the direction of trends in the healthcare world, so we have an idea of what the sector might need in the future and what we will need to do to deliver it. Right now, there is definitely a movement towards offering more day-case surgery and ambulatory facilities. Interventions are becoming much more effective and efficient, making increasing numbers of complex procedures possible without the patient having to have overnight stays. This changes the way that operators want their facilities set up.
As part of our continuing commitment to the HSMA we have recently completed a consulting house at 27-29 Harley Street, which is ready to take an operating consultant capable of housing several pieces of diagnostic equipment such as MRI, Linac or CT scanners. The building has been purpose built so that the end operator can install their chosen equipment very easily through the hatches at the back of the building.
Using the design process and expertise we’ve perfected over 10 or more years, we create buildings that allow the end user to seamlessly install medical equipment, which is vitally important. Our understanding of operating models and patient pathways helps a traditional property company speak in terms that clinicians understand, and our ability to pre-empt operator requirements and ‘design out’ challenges has the potential to reduce the time and cost of opening for business.
As you read through the pages of this magazine you will be hearing from some of the world leaders in their field. By continuing to provide the right environment, is it our ambition to ensure that you will be doing so for many years to come.
We also keep a close eye on the direction of trends in the healthcare world, so we have an idea of what the sector might need in the future and what we will need to do to deliver it.
27-29 Harley Street 6—Prognosis
The Howard de Walden Estate 23 Queen Anne Street London W1G 9DL 020 7580 3163 hdwe.co.uk
Re:Cognition Health, a cognitive healthcare provider, is collaborating with MYndspan, a brain and wellness analytics company, to offer patients data-led insights into their brain health. The 45-minute MYndspan service is powered by a noninvasive scanning technology called magnetoencephalography (MEG). MEG measures the electrical signals between neurons to form a detailed map of brain activity and is used alongside app-based games to test cognitive function. Within 24 hours, MYndspan sends an easyto-understand report which can help make a personalised assessment of how lifestyle factors such as sleep, exercise and diet impact on the patient’s brain.
Fortius Clinic, the UK’s largest orthopaedics and sports medicine group, has completed its acquisition of Schoen Clinic London, a dedicated orthopaedic and spinal hospital on Wigmore Street. Fortius Clinic’s other facilities include two within the Harley Street Medical Area: an outpatient, diagnostic and treatment centre on Fitzhardinge Street and a surgical centre on Bentinck Street. The former Schoen Clinic London hospital, now rebranded as Fortius Clinic London, is just minutes away from both. The acquisition creates a unique centre of excellence in central London, opening a complete end-to-end pathway from initial consultation through to treatment and recovery.
Echelon Health, the Harley Streetbased provider of bespoke preventative health assessments, has created a comprehensive health check designed specifically for women who are navigating perimenopause and menopause. The process, known as the Cullinan Assessment, was compiled by one of the UK’s leading endocrinologists, Dr Paul Jenkins. Taking around four hours to complete, it focuses on the hormonal changes that increase the risk of common deadly diseases, including lung, breast and ovarian cancers, osteoporosis and coronary heart disease.
The Howard de Walden Estate has announced the completion of three signings within its healthcare portfolio, with Cognacity, Orri and All Points North (APN) all taking space in the Harley Street Medical Area, as demand for prime healthcare space remains competitive. In response to increased demand, Cognacity, a global expert in mental health and performance, is moving to larger premises at 22 Welbeck Street after 10 years on Harley Street. Orri, a specialist treatment service for eating disorders, is taking a six-storey building at 80-81 Wimpole Street. APN, a whole-person health company, has recently opened at 12 Upper Wimpole Street.
Isokinetic, a leading clinic for injury prevention, treatment and rehabilitation, is to expand its dedicated programme specialising in the prevention and treatment of anterior cruciate ligament (ACL) and other injuries in women athletes. Dr Jesus Olmo, Isokinetic sports doctor, said: “It is essential that as women compete at elite levels we provide an infrastructure that is going to support them. We believe that prevention is key and it is crucial to assess players before they experience injury to better understand their unique movement patterns and strategise optimised ways of movement that will keep the individual healthy for longer.”
All Points North
Auditory processing disorder
Christina Kourie of Pindrop Hearing on the evolution of treatments for a complex auditory condition
State of play
Auditory processing is what our brain does with the sounds that our ears detect. Our listening skills are based on our auditory processing abilities, and auditory processing disorder (APD) occurs when part of this system malfunctions. There are a lot of different aspects to auditory processing, any one of which may be impaired. APD occurs in people with ‘normal’ hearing as well as those with hearing loss.
A detailed and thorough assessment is crucial to effectively treating APD, usually with some form of listening devices. First, we conduct a diagnostic assessment to check for any hearing impairment. Then there’s a series of tests that really challenge the person’s auditory processing system to get an accurate assessment of their
abilities. One, for example, involves playing recorded words with specific frequencies removed and seeing if the patient understands them. An innovative iPad-based assessment tool called the Acoustic Pioneer, makes it very easy for both children and adults to fully engage with a range of tests, leading to a more accurate assessment. The last thing, which is mainly for children, is the test for auditory processing skills (TAPS) which is a language-based assessment.
On the horizon
There is always ongoing research into APD. People are investigating possible correlations between certain ear-related pathologies and auditory processing issues. Or, is there a link between ADHD and auditory processing, or perhaps the link is with their diet? In terms of technology, the new tablet-based apps are producing really good results, so the fact that they will continue to make assessment more approachable and less complex is a significant forward step.
Another area is assisted listening devices – devices that help modify signals at the ear level to make processing easier in those areas the brain is struggling to cope with. These technologies include the Roger Focus system from Phonak. This FM system combines specially designed microphones and listening devices to stream highly processed auditory signals directly into the patient’s ears. Alongside noise-cancelling technology, it significantly improves the patient’s ability to process sounds. Several companies are developing systems that can beam the signals from teachers
across whole classrooms, connecting to multiple children’s hearing aids. This would hugely expand access to treatment for children with APD.
In the distance
The ultimate treatment would be some kind of implant in the brain to correct any auditory processing weakness, but we are a very long way from that. Mainly because there is so much we are still learning about the condition. There are still huge strides to be made in areas we are just beginning to explore in both assessment and treatment.
It’s incredible what tablet-based apps and assisted listening devices can do at the moment, but I think as we gain further understanding of the condition, we will build devices that are even more effective. One real difficulty with assessment is that you could see someone, especially a child, who is just not having a good day. This can mean that the results of what can be a quite intense three-and-a-half-hour-long test session may not be a true reflection of their abilities. Auditory processing is essentially a neurological condition, which may or may not be associated with a physical impairment. As our understanding grows, our approaches will keep getting better. It is a complex field in which we are continually learning new things, but that is part of what makes it such a great area to work in.
41 Harley Street London W1G 8QH 020 7487 2660
It’s incredible what tabletbased apps and assisted listening devices can do at the moment, but I think as we gain further understanding of the condition, we will build devices that are even more effective.
HARLEY STREET HERO
Dr Grantly Dick-Read
Words: James Rampton
Dr Grantly Dick-Read was a prophet without honour in his own profession.
His concept of “natural childbirth” – a phrase that he invented – is now standard practice all over the world. But when the pioneering obstetrician first introduced the idea in his revolutionary 1933 book, Natural Childbirth, he was universally derided.
The theory Dr Dick-Read gave birth to – that no medical intervention should interfere with the natural process of labour – was deemed outrageous by the British medical establishment. Doctors were so scandalised by his “heresy” that he was even thrown out of the London clinic he had founded with a group of fellow obstetricians.
Dr Dick-Read was the first to acknowledge the controversy his emphasis on natural childbirth had whipped up, admitting: “Some of my colleagues, for whose academic attainments I have great respect, argue, ‘You assume too much. This is not proved. This is not strictly scientific. We disagree with your neurology and your psychiatry is misleading, therefore you must be wrong.’”
But Dr Dick-Read, whose primary concern was always the mother’s physical and mental wellbeing, was always ready with a riposte. “My reply has been, with all humility: ‘Yes, of course.’ And then I have returned to the labour ward to be greeted by happy women with their new-born babies in their arms: ‘How right you are, doctor. It is so much easier that way.’ That is what really matters to the clinician. He should use the method that gives the best and safest result from all points of view until something better is discovered.”
When his second book, Revelation of Childbirth (later retitled Childbirth without Fear), came out in 1942, he eventually managed to win over his critics. Targeting a general readership and proffering suggestions about natural childbirth that were immediately taken up, it was an instant bestseller all over the world and is still in print today. On the back of its success, Dr Dick-Read travelled the globe delivering lectures on his cutting-edge theses about childbirth.
Born the sixth of seven children to a well-to-do miller in Beccles, Suffolk in 1890, Dick-Read began his remarkable medical career as a physician at the London Hospital in 1914. At the start of the First World War, he volunteered for the Royal Army Medical Corps. He was severely wounded at Gallipoli but recovered sufficiently to return to the frontline and work as a medic in France.
After the war, he went back to the London Hospital for a year, before gaining an MD at Cambridge University. He proceeded to work as a general practitioner at a private clinic in Woking until 1935, when he started a private practice at 25 Harley Street – outside which a plaque in his honour still hangs.
It was during the 1920s that Dr Dick-Read began to focus on obstetrics and developed his radical thoughts about the undesirability of intervention during childbirth. Never a man to mince his words, he wrote: “One of the most important factors in the production of complicated labour and therefore of maternal and infantile morbidity is the inability of obstetricians and midwives to stand by and allow the natural and uninterrupted course of labour. It may be an excess of zeal, or anxiety born of
ignorance, but it is an unquestionable fact that interference is still one of the greatest dangers with which both mother and child have to contend. Nothing is more to be abhorred. The forceps deliveries of normal babies – blue and flabby babies who will not cry, babies drugged and babies anaesthetised –these pictures so common in modern practice are deplorable blunders of both judgment and action.” Say what you really mean, doctor.
The obstetrician, who died in 1959, received criticism from some quarters for the patriarchal tone of some of his writing. For all that, there is no doubting the immense contribution he made to empowering women. Thanks to his trailblazing studies, mothers were able to take back control of their own birthing.
Dr Dick-Read’s work did not end with his ground-breaking books. In 1956, the UK Natural Childbirth Association, now called the National Childbirth Trust, was set up by Prunella Briance. It appointed Dr Dick-Read as its first president. For the past 67 years, the organisation has helped reduce the fear that so many new parents feel about childbirth. It is still the leading charity in that field.
In fact, my wife and I attended NCT meetings before the birth of our first child 28 years ago. Those gatherings very much enlightened us about the benefits of natural childbirth and put our minds at rest ahead of the often-daunting process in the delivery suite. We are still friends today with some of the other parents from that NCT group.
Dr Dick-Read, then, transformed for the better the way we and millions of other new parents have experienced birth. A true childbirth crusader.
HOW DOES IT WORK?
Mr Peter Rosenfeld, consultant orthopaedic foot and ankle surgeon at Fortius Clinic, on a complex joint replacement that has the power to transform lives
Interview: Viel Richardson
Ankle arthroplasty is the replacement of the ankle joint. My usual patient is someone with arthritic changes in the joint that are causing disabling pain. There is an excellent alternative called ankle fusion, where we fuse parts of the joint together. This makes it rigid but is very reliable in relieving pain. There are three groups of patients for whom ankle replacement is ideal: those with ankle arthritis over the age of 60; patients with arthritis in the surrounding joints of the hindfoot, as the rigidity caused by fusion puts extra stress these joints and can make them worse; and patients who may be infirm due to age or illness, as the recovery from a replacement is much easier, with very early weight bearing and little need for crutches.
Ankle arthroplasty is a more complex operation than a hip or knee replacement, as you are restricted to a small opening through which to perform the procedure. You can’t open up the joint as you can with the knee or hip joints. We also use complex jigs to ensure everything is aligned correctly throughout the operation. This makes it more complicated for the whole surgical team. There is a lot of specialised equipment involved, so we spend a lot of time planning.
The patient arrives at the operating theatre under general anaesthetic, and I usually give them an additional regional one, which keeps the whole leg numb for one to three days after the procedure.
The ankle is criss-crossed by nerves and arteries which means there is a higher potential for accidental damage than in other joint replacements. The incision and exposure are performed carefully, avoiding the superficial
peroneal nerve in the skin and the deep peroneal nerve and dorsalis pedis artery, which lie directly over the ankle joint. I usually go through the sheath of the extensor hallucis longus (EHL) tendon as this provides the safest access to the joint, avoiding this neurovascular bundle. Deeper tissues, ligaments and the fibrous capsule covering the joint are then lifted away to expose the ankle. We often find bone spurs called osteophytes on the front and sides of the joint, caused by long-term arthritis. These need to be cleared before the joint can be properly accessed. Then comes the most crucial part, where the orientation of the ankle replacement is decided using precise alignment jigs. These are carefully positioned to dictate the exact length, angulation, rotation and translation of the joint. Each ankle is different, so precision is paramount. It’s crucial to get this right, otherwise the new joint will not be straight, which can cause long-term pain and early failure. The first jig is placed on the leg and pinned to the top of the tibia by the knee, creating a foundation point. We then take a series of measurements and x-rays. Using this information, we make precision cuts to shape the end of the tibia and the top of the talus. Once everything is checked and aligned, the ankle replacement is inserted.
The main bones that make up the ankle joint are the tibia at the bottom of the shin bone and the talus at the top of the ankle joint. The tibia is pretty flat, while the talus has a dome. For this procedure we remove 8-9mm of the tibia and replace it with a flat metal piece called a tibial tray. This is made of cobalt chrome steel with a titanium-plasma-
sprayed back, which the bone grows into to help hold the prosthetic in place. With the talus, because we’re trying to connect an implant to a dome shape, the procedure is more complex. We do a lot of preparatory work on the bone, as the implant has to sit snugly onto a clean surface without any large holes, cysts or other defects. This requires multiple precision cuts to the bone to match the geometry of the implant. If there are any gaps, the bone won’t grow onto the implant and it will become loose.
Once the geometry of the cuts is correct, we drill extra cylindrical holes into the tibia and the talus to match cylindrical plugs in the implants for extra stability. Once correctly aligned, the implant is inserted and hammered into the bone – this is called impaction, and it creates an extremely tight join between the implant and bone. The ankle incision is then closed with care and the leg is protected and immobilised in a plaster cast.
After the procedure, it is vital to avoid swelling. For the first two weeks, this means keeping the leg well elevated most of the time. Swelling is a normal feature of any ankle surgery and takes months to settle. However, most patients report very little pain after the operation – the regional block and strong medications work well here. After the first two weeks, if the wounds have healed well, it’s time to move to a protective boot. At around two months, light sports can begin, and after six months full activities are possible. There will usually be some soreness as each new level of activity is attempted.
There is a risk of failure in the long term, which makes post-operative
follow-up vitally important. As with any joint replacement, the implant wears away over time, causing debris to be created and the joint to loosen – a process called aseptic loosening. As the joint wears, your body tries to get rid of the debris by secreting bone-dissolving enzymes. But as the implant debris isn’t soluble, more and more enzyme is produced, which slowly attacks and dissolves the surrounding bones, causing small holes or cysts. Initially there are no symptoms, which is why regular follow-ups are so important. All joint replacements get aseptic loosening and if it happens in a structurally important area, it’s much better that it’s addressed before something breaks. Aseptic loosening is the problem everyone is trying to solve.
On average, 90% of people do very well for 10 years or longer. I’ve been doing ankle replacements for 18 years and monitor and research all my patients – we’ve have fantastic results with really high success rates. A successful procedure can transform a person’s quality of life. The new ankle is often better than their other one. Suddenly they’re free from pain and all the physically and mentally debilitating effects that come with it. Each year I get lovely postcards from patients, with people walking the Great Wall of China or playing golf again, entirely pain free. It’s things like that that make the job so satisfying.
17 Fitzhardinge Street
London W1H 6EQ 020 3195 2442
Tibia Tibia replacement
Extensor hallucis longus A long, thin muscle starting halfway up the tibia bone in the lower leg, which runs through the ankle and ends at the big toe.
Joint capsule A fibrous layer of tissue encasing the ankle joint. The capsule contains synovial fluid which lubricates the joint, allowing it to move smoothly and painlessly. Enzyme A type of protein that helps speed up chemical reactions in the human body.
Paresh Patel, chief executive of OCL Vision
Interview: Ellie Costigan
What attracted me to the field of ophthalmology was the difference you can make to people’s lives. That’s true of all healthcare but especially ophthalmology, because you can see the change instantly.
A lot of people assume there’s no treatment available for chronic conditions such as glaucoma because, if you go back 10 to 15 years, they tended to be managed rather than treated. But awareness of the options is now growing, which is great, because we know that early intervention is best.
Given our ageing demographic, age-related conditions are increasingly common. Fortunately, the technology and therapies available to treat conditions such as age-related macular degeneration (AMD) are becoming more widely accessible.
Because our eyes are so important, people often fear getting treatment. To help manage that anxiety, we make sure we explain exactly what will happen during a procedure, calmly and clearly. The clinical team who looks after them doesn’t change, so they have continuity of care, and we can cross-refer within our facility rather than referring them outside for additional treatment.
We offer such a broad range of ophthalmological care: cataracts surgery, laser eye surgery, RLE, vitrectomies, retina issues, corneal transplants. There aren’t many privately-owned companies that can do that.
Cataracts surgery is the most common procedure. We now have a technique called refractive lens exchange (RLE), where the natural lens is replaced with a synthetic lens. You can top this up with laser eye surgery, which means that patients who would ordinarily rely on contact lenses or glasses post-surgery no longer require them, enabling them to lead an active lifestyle without hinderance.
Eye surgery has really evolved. Thirty or 40 years ago, it was all very manual; now it’s mainly laser based. We were one of the first clinics in the UK to have the Schwind excimer laser, which uses smart pulse technology to ensure the smoothest possible corneal surface. The US air force now offers it to jet pilots.
The Harley Street Medical Area is renowned worldwide. That really helps our positioning in the marketplace, especially for international patients, who know they will have access to the best consultants. Among international patients, word of mouth is important. We get a lot of embassy-referred patients – which is mainly down to positive feedback.
The most satisfying part of my job is working with the best people in the industry. Our shareholders are clinicians, which means there is a strong alignment between our commercial and clinical objectives. It’s a patient-centric organisation. That’s the joy of it.
Technology definitely plays a role at OCL Vision, but it’s the expertise of our consultants and clinical staff that sets us apart. It’s a people-related business and I believe we have one of the best teams around, providing the best possible holistic care: from making the appointment, to post-operative care.
Prognosis—15 OCL Vision 55 New Cavendish Street W1G 9TF 020 3369 2020 oclvision.com
Enterobacteria A large family of bacteria that are are able to thrive in both aerobic and anaerobic environments.
Non-motile Bacteria that don’t have the ability to move through their environment on their own. Non-sporulated Bacteria that do not produce spores. Sporulation is a strategy used by many bacteria to adapt to changes in their individual environment.
Aerobic Gram-negative bacillus Bacteria consisting of rod and coccus-shaped cells that can grow in both aerobic and low-oxygen conditions. Coccobacillus Bacteria that are shaped like short rods or ovals.
PROFILE OF A PATHOGEN
is caused by the bite of an infected flea. The plague bacillus enters at the site of the bite and travels through the lymphatic system to the nearest lymph node, where it replicates. The lymph node then becomes inflamed, tense and painful, becoming the ‘bubo’ that gives the disease its name. At advanced stages of infection, the inflamed lymph nodes can turn into foul-smelling, pus-filled open sores.
bacterium in 1894. However, it was Yersin who demonstrated that the same bacillus was present in both the rodent and human disease. Based on Yersin’s work, in 1898 biologist and physician Paul-Louis Simond identified the transmission path from rodents to humans through flea bites.
“I’d avoid that like the plague” is a phrase we will all have heard or used at some point without stopping to think how remarkable it is that we do so. There are very few things from the 1300s that we casually reference in modern life, yet such was the societal trauma that the Black Death left in its wake that we reference it to this day, and the recollection still brings a shiver to the spine.
Yersinia pestis was the bacterium responsible for the horrors of this legendary plague outbreak. It is one of three human-pathogenic Yersinia species, alongside Yersinia pseudotuberculosis and Yersinia enterocolitica, and it causes two main forms of plague: bubonic and pneumonic. Bubonic plague is the primary and most common form of the disease and
Human-to-human transmission of this form of plague is rare, though it can be transmitted by unprotected handling of infected bodily fluids. If left untreated, while extremely dangerous, 30-40% of people can recover. The disease can also spread to the lungs causing a secondary infection called pneumonic plague. This is by far the most virulent and dangerous form of the disease. The incubation period can be as short as 24 hours and it can be transmitted between humans via droplets in the breath. Untreated, pneumonic plague is invariably fatal with known cases of untreated survival being vanishingly rare. However, modern antibiotics for enterobacteria-based illnesses can effectively cure the disease if it is diagnosed and the patient treated within 24 hours of the onset of symptoms.
Yersinia pestis is a non-motile, non-sporulated, aerobic Gramnegative bacillus or coccobacillus and its identification was not without controversy. For nearly a century, the followers of two scientists – a Swiss-French bacteriologist called Alexandre Emile Jean Yersin and a Japanese bacteriologist and physician Shibasaburo Kitasato – claimed their champion was the first to isolate the
A common misconception is that bubonic and pneumonic plague are relics of a distant, disease-ridden past. But nothing could be further from the truth. Figures from the WHO show that the plague bacillus is found in animal populations on all continents except Oceania, from the jungles of central Africa to the semi-rural areas of the western United States, and there is risk of an outbreak wherever humans and diseased animals co-exist. Recent epidemics have occurred in Africa, Asia and South America, but since the 1990s most human cases have occurred in Africa, with the two most endemic countries being the Democratic Republic of Congo and Madagascar. In Madagascar, cases of bubonic plague are reported nearly every year during the epidemic season between September to April.
The history of bubonic plague serves as a reminder not to get too confident in our abilities. This is a disease capable of generating real fear – a localised outbreak in Italy in the 1940s was publicised as a virulent form of syphilis for fear of widespread panic if the truth came out. At present the disease is held at bay by effective antibiotics, but with antibiotic resistance on the rise, the possibility of this representative of the four horsemen bursting from the history books and across front pages around the world is an all-too real one.
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HOW TO MANAGE PSORIASIS
Dr Wanda Robles, consultant dermatologist at Dr Haus Dermatology
Interview: Viel Richardson
What is psoriasis?
It’s an autoimmune condition of the skin characterised by areas of inflamed, flaky skin. It can range from mild to very severe, which can be extremely distressing for the sufferer. While flare-ups can happen at any time, they are most common between the ages of 15 to 25 or 50 to 60. Psoriasis affects all ages and all races, with no group being more susceptible than any other. The condition does have a genetic component and around 30% of sufferers will have family history of psoriasis.
How will somebody know that their skin condition is psoriasis?
The classic presentation is inflamed patches of redness and dry, scaly lesions known as plaques. Some patients have small-plaque psoriasis while others have large-plaque psoriasis. In about 60% of patients this doesn’t itch, although some feel a burning sensation. The lesions can be localised or generalised, but they usually break out in areas like the elbows or knees. When it appears in places like the armpit and groin, we call it inverted psoriasis, but in reality it can affect any part of the body.
What causes it?
Psoriasis is a multifactorial disease. Patients will have a genetic predisposition to develop psoriasis, so when they meet the right environmental factors, the condition can develop. These environmental factors will vary. The best-known one is stress, but it could be the latitude where you live or are visiting, sun exposure, pollution, some medications, or one of many other possible triggers.
What treatments are available?
There are a series of steps we will go through, according to the severity of the condition. When a patient first comes through the door, we start with general advice regarding lifestyle. A significant number of people with psoriasis have other health issues such as diabetes, obesity, dyslipidemia (an imbalance of the lipids such as cholesterol) or insulin resistance. So, we advise them on losing weight, having a healthy lifestyle, reducing their alcohol intake and stopping smoking. For some people, steps such as these can be extremely effective for getting these other health issues under control.
What if those lifestyle changes don’t work?
Our first step would be to use topical preparations, which are medications applied directly to the skin. These include vitamin D analogues like calcipotriol. We can also use drugs like tacrolimus or pimecrolimus, which are topical steroid-free medications with immune-modulating and anti-inflammatory properties.
If topical medication is not working, we can advise patients to have phototherapy treatment with narrowband UVB light or with PUVA, which is a combination treatment consisting of taking the drug psoralen and then exposing the skin to long-wave ultra-violet light (UVA). The psoralen increases the effectiveness of the phototherapy. There is also the excimer laser, which can be used to remove the plaques.
Are there patients who do not respond to these treatments?
Yes there are, and in those cases we move up to what we call systemic therapies. These are usually administered at medical facilities, as they are classed as secondary care and can involve more powerful medications such as methotrexate or acitretin cyclosporine to reduce symptoms. If the patient still fails to respond, we can move on to biologic therapies. These work because the inflammatory reaction of psoriasis is produced by a type of protein called a cytokine and the biologics are targeted against specific cytokines. These medications, which include secukinumab, tildrakizumab, guselkumab and risankizumab, can be very effective.
Is psoriasis something that can be cured, or is it a case of managing the condition?
We cannot cure psoriasis but the treatments we have access to today can make a huge change for the better in patients’ lives. Also, the treatment usually doesn’t have to be constant. Most of our patients will have a holiday from their medication in the summertime because the sun can itself be quite beneficial. Only about 10% of cases are aggravated by sun exposure. With a combination of lifestyle changes and treatment, many people with the predisposition to psoriasis can keep it under control, with severe flare-ups being a rare occurrence.
Dr Haus Dermatology 75 Harley Street London W1G 8QL 020 7935 6358 drhausdermatology.com
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A DAY IN THE LIFE
Dr Phil Hopley
Co-founder and managing director of Cognacity
Before I co-founded Cognacity in 2008 I had spent my career working as a consultant psychiatrist. My work had been very varied and involved working with people and companies both in the NHS and the private sector. Through my experience, I had learnt the extent to which effective mental health treatments encompass a wide variety of often interconnected specialties. So, from the beginning we determined that Cognacity would offer access to mental health specialists from numerous fields, in a joined-up way. It felt really important to avoid being siloed – to prevent a situation where, for example, a psychiatrist might refer out to a psychologist in another clinic. We wanted to have those relationships here under one umbrella. We started small, but the company now employs
around 25 full-time staff with around 75 associates and self-employed specialists located across the UK.
A typical day in my life here begins long before I arrive at our Harley Street offices. I like to set myself up for the day with a bit of stretching to get my body warmed up, then I come in using public transport because walking from the house to the drive and then sitting in a car until you get to work is not good for you.
Once in the office, a morning clinic might involve three to four hours of seeing clients. Ideally this would be face to face, but nowadays it is not infrequently on a Zoom call. If it’s my first time with a client, the first thing would be to assess exactly what’s going on with them: their current situation but also factors such as their family history, their medical history and the way they
might interact or have interacted with alcohol, drugs or tobacco.
Having completed my assessment, I advise on what I think would best benefit them. More often than not, that’s a talking therapy with one of my colleagues. I can then make that referral. I would say that about 20% of people I see might also need to go onto medication because the severity of their anxiety or depression is such that they are going to struggle to benefit from talking therapy alone.
Another aspect of my work is seeing people who are already in the system and receiving treatment of some sort. In those cases, my task is to review how their therapy’s going; if they’re on medication, whether that’s been beneficial for them. That type of work will be the mainstay of the morning.
Interview: Gerard Gilbert
In my capacity as an expert witness, I diagnosed the gambling addiction of Ivan Toney, the Brentford and England footballer who was facing an FA hearing for breaching betting rules. The panel said that the diagnosis, and the fact that he was receiving help with his addiction, led to a lesser ban than he might otherwise have received.
there’ll be something unexpected that happens in the workplace and we will help them get through those moments.
I used to be a semi-professional rugby player and have always taken a keen interest in sports performance. We work with elite track and field athletes for British Athletics. I sometimes run those sessions at weekends or in the evening because of the need to fit around their incredibly demanding training sessions. I also work with McLaren Racing. Four times a year I will travel with McLaren’s 120-strong F1 team and spend a week with them. I do performance coaching with the pit crew, so they can be optimally focussed when it really matters. I also coach a number of leaders in the team about how their behaviour and interactions with others can be beneficial to the team as a whole.
one of their employees. We’re able to help them manage the performance elements around that.
In the afternoon I might spend some time working with colleagues in an advisory capacity. If someone has a particularly difficult case we’ll come together and brainstorm it. It’s actually a requirement; it’s called peer support, or peer review.
I also belong to WhatsApp groups where a medical conundrum will get shared anonymously, and members can check in and give advice. In our world of psychiatrists, the choice of pharmacology becomes ever-more complex, so one of our groups is a psycho-pharmacology group where issues around that are discussed.
I am a very strong advocate for taking regular breaks. I believe it’s absolutely essential. Between each consultation I’ll try my best to have a two-to-fiveminute break. I might pop down and say hello to the team, grab a glass of water, listen to a mindfulness app, or laugh at a stupid joke that someone’s sent my way. Anything to break that train of thought. But it’s not always possible for me to take a lunch break. Our corporate clients include PwC, BP and some major banks and law firms, and one of the things I do is visit their offices at lunchtime to give talks on mental health. Many workplaces have a potentially unhelpful combination of almost limitless work, but limitations on the number of hours in the day. We teach people how to interact with their work demands. We also offer crisis intervention: from time to time
I might also be called away from the office in my capacity as an expert witness. A recent high-profile example involved diagnosing the gambling addiction of Ivan Toney, the Brentford and England footballer who was facing an FA hearing for breaching betting rules. Having admitted the breaches, he was given an eight-month ban, but the panel said that the diagnosis, and the fact that he was receiving help with his addiction, had led to a lesser ban than he might otherwise have received.
As a forensic psychiatrist I spend a lot of time giving evidence in court, which is a uniquely pressured environment. As such I can advise business leaders who, for example, find themselves suddenly in the spotlight facing a House of Commons select committee or some difficult civil case that’s been brought against them by another company or
I do walking meetings whenever I can. We know that the brain evolved to do really good thinking while we’re moving. A couple of colleagues and I will literally walk round the block or across Regent’s Park for 45 minutes while discussing an issue. It’s really productive.
Before heading home to my wife and 17-year-old son (the other three kids are away at university), there is sometimes the chance for some socialising with colleagues. We have a team meeting once every couple of months – a lovely gathering with the appropriate libations.
In reality, though, the answer to the question ‘what is a typical day like’ is that I don’t really have one – and that is one of the great things about this job.
Cognacity 22 Welbeck Street London W1G 9EF
3219 3080 cognacity.co.uk
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I feel a lot safer, especially when driving, as it’s improved my peripheral vision. I don’t remember ever being able to see as well in my life. I wish I’d done it sooner.”
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Interview: Ellie Costigan
My background is in psychotherapy, and I’ve been working with people with eating disorders for 20 years now. I worked for an in-patient service for a long time and one of the things that became very apparent was the need for ongoing care after leaving hospital. People would describe getting to the end of their treatment and feeling as though they’d fallen off a cliff. They felt adrift and really struggled with that change. Orri’s day care model was developed to address that; to provide a step down from intensive in-patient treatment in a way that means people don’t have to be away from their families and homes. We also have an outpatient service, which we currently provide online and will do some in-person from September, at our new space on Wimpole Street.
Our clients are 16 and above and they
all have a diagnosed eating disorder or have concerns around an eating disorder. Anorexia, bulimia, binge eating disorder and avoidant restrictive food intake disorder (ARFID) are the primary areas we work in. People either self-refer or refer on behalf of somebody they might be worried about. We also get referrals directly from other healthcare professionals. People come to us at different stages of their recovery. Some are at the early onset of their eating disorder and we’re able to provide effective, focused, time-limited support that helps them get back on their way. Others need an intensive programme –perhaps they’ve got a very high or low BMI – and help to reset and get a balance around their eating difficulties.
Eating disorders have physical and psychological manifestations, and you
have to treat both sides. We have a small, multi-disciplinary team, with consultant psychiatrists, psychotherapists, dietitians, occupational therapists and a full nursing team. We use all different types of therapeutic intervention, from mindfulness and breathwork to talking therapies. It’s necessary to employ bespoke ways of treating people to meet the problem and the individual, so we have an individualised treatment programme. One of the key components to recovery is restructuring your relationship with food. Often if you have an eating disorder your routine gets very upset, so the symptom interruption work we do is based around reintroducing that structure. We create eating opportunities throughout the day for our day care patients and following each one, we have what we
founder of Orri, on an eating disorder service that helps people get well and stay well
call meal processing to help address anything that might have come up.
We have a fantastic kitchen team here and a big, open-plan kitchen. All the food is prepared on site and, as much as possible, the place feels like a big house. There’s lots of chatter and the radio’s often on in the kitchen. Rory, our head chef, is fantastic – all the clients chat with him. That said, it can be incredibly emotional. Often clients will come and have a look around before they commit to treatment. There’s a sign on the wall in the first sitting room that has a picture of an orri and it describes what it is: a stone enclosure where shepherds would take shelter from turbulent weathers. The sheep can be protected from those weathers if they would like to be, but they can also travel freely in and out. That’s very much the premise of Orri:
it can be your sanctuary, but you’re autonomous, you choose to come here.
We also recognise that it can be difficult for some people to make that decision, so we can support them in holding that boundary. But it’s very powerful: often people get quite tearful when they first come in, because they feel safe here. Kindness is at the core of everything we do, and that’s really important, but we do the hard work. Being kind isn’t always being nice – sometimes we have to do the tough stuff too.
Amazingly, around 70-80% of people who come to us for treatment get into recovery, which is really high for eating disorders. Dr Paul Robinson, our head of research and development, has found comparable results between our online and in-person day care, which is really interesting. People get well and they
An orri is a stone enclosure where shepherds take shelter from turbulent weathers. The sheep can be protected from those weathers if they would like to be, but they can also travel freely in and out. That’s very much the premise of Orri: it can be your sanctuary, but you’re autonomous, you choose to come here. Orri 80-81 Wimpole Street London W1G 9RE 020 3918 6340 orri-uk.com
stay well, which is really lovely. We received an email from a client recently, saying it was three years to the day since she came to Orri, with pictures of her in a dance show that she’d performed in. She said: “I didn’t think I’d ever get back up on stage, yet here I am.” People don’t always understand the impact an eating disorder can have, across all areas of your life: socially, work, education, relationships, money, physical health. To be in recovery and to be free of that is immense. It’s a huge privilege to walk alongside people while they’re on that journey.
HEALTHCARE IN THE CLIMATE CRISIS
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
Dr Diwakar Ryali Sarma, secretary elect of the RSM Surgery Section Council, and Elaine Mulcahy, director of UK Health Alliance on Climate, which counts the RSM among its members, on how healthcare organisations have been coming together to push climate change up the agenda
One of the hurdles that green surgery faces is that the outcomes are not immediate. These are three or five-year initiatives, with the changes felt over a period of time. This can feel slightly alien in a discipline used to quick outcomes.
Dr Diwakar Ryali Sarma
Green surgery is the environmentally friendly provision of surgery and surgical care. Operating theatres are the most resource-intensive part of a hospital. They generate significant amounts of electricity consumption and C0₂ emissions through their facilities and the use of instruments, equipment, gowns, sterility practices and so forth.
There has traditionally been some resistance to the idea of green surgery due to the belief that it could compromise patient safety. The primary concern has been: does the use of fewer disposable items and less plastics in packaging compromise sterility? Another is: will a ‘green’ product still be most effective product for a particular use? Will we make compromises in trying to go green? I think there is now enough evidence to show that neither of these concerns is valid.
Another hurdle green surgery faces is that the outcomes are not immediate. These are three or five-year initiatives, with the changes felt over a period of time. This can feel slightly alien in a discipline used to quick outcomes, but more people are coming on board. One important move has been the adoption
Dr Diwakar Ryali Sarma
of robust and time-tested toolkits, which allow us to measure our carbon emissions. These show people the emissions they are generating and give them confidence that making the right changes will have a measurable impact. For example, the Internal Greenhouse Gas Accounting System guidelines have been around for several years and are being adapted into the General Green Surgical Practice guidelines covering the use of electrical devices, instruments and sterile protocols.
A few months ago, the Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh and Royal College of Physicians and Surgeons of Glasgow all agreed to a series of guidelines called the Intercollegiate Green Theatre Checklist, creating a national consensus around the measures that surgical services should be adopting. It starts with simple things like powering off lights, computers, ventilation and temperature controls when the operating theatre is empty. This alone can make a significant difference.
Then there’s handwashing. We traditionally spend about five minutes washing our hands under running water for every single procedure. Using a pedal tap or a self-timer to control the water flow would slash water usage. Also, we know that doing a full handwash before the first procedure and then using alcohol rubs for subsequent ones does not compromise sterility, while also saving huge amounts of water.
Another area is the standardised surgical tray. A tray containing a whole series of instruments is opened for every single operation and while many will not be used, they will all have to be re-sterilised. By simply choosing the instruments needed beforehand, we could cut down energy wastage by 30%. Well-run surgical services will always produce a significant amount of waste but by managing our waste stream to maximise recycling of the appropriate waste we can make real progress on reducing our overall impact.
The primary barrier to the wider adoption of green surgery procedures is a lack of information. Not enough people know about and understand the principles underpinning it. This leads to a lack of guidance on how to implement it and a lack of support for green surgery initiatives. Even though I am optimistic about this protocol becoming the norm, it will not take place overnight. We have a roadmap for the next five years.
Maybe three years would be realistic for making real progress, but it will not happen in three weeks’ time.
The UK Health Alliance on Climate Change is a collective of 40 health organisations based within the UK. Our members include the Royal Society of Medicine, British Medical Association and British Dental Association, as well as other Royal Colleges, faculties, associations and societies. The Royal College of Veterinary Surgeons, the British Medical Journal and The Lancet are also members. In total we represent around a million health professionals.
We bring the organisations together on a monthly basis with the aim of identifying policies and projects where we can work together to increase the influence of our members. We also look for ways of helping each other to be more effective in our efforts to tackle climate change. Some members are quite far advanced on this journey while others are just beginning, and the idea is to spread best practice, with protocols based on lessons learned from successful policies.
A good example of our work is a document we launched called Our Commitments. We got our members together and worked on it for pretty much a full year. We looked at practical actions that organisations could take, because something we hear a lot is organisations saying they want to implement climate-friendly policies but don’t really know where to start.
Our vision is of a just, sustainable, healthy world and our work towards achieving this is based around three core activities: increasing knowledge and raising awareness about the impact climate change and biodiversity loss has on our health; empowering health professionals to be advocates for better responses to climate change and nature loss; and encouraging decision makers to strengthen policies that tackle the causes of climate change. For example, for the 2022 Health and Care Act, we pushed really hard for net zero targets to be embedded within the legislation, which they were – an example of a successful campaign at the national level.
We are also members of the Global Climate and Health Alliance, and we sit on its board of directors. Our aim is to influence decision making at international meetings leading up to and including the Conference of the Parties (COP) summits. In the lead up to COP26
and COP27 we arranged for an editorial piece to be published in over 200 health journals across the world. It was a way of getting a strong, unified health message out there while climate change was high on the agenda. Before COP26, the editorial called on the wealthier nations to do more, and before COP27 we brought together 16 editors from across Africa to explain why what happens on the continent matters to us all. For COP28 later this year, we hope to publish an editorial on the impacts of biodiversity loss and the destruction of natural environments on health, and the need to tackle the combined threat of climate change and nature loss together.
People often ask if I am optimistic –and I am. There are so many economic and societal benefits to be gained, so it doesn’t all have to be negative. Momentum is growing, but health is still not a high enough climate change priority. For example, COP28 will be the first COP summit with a dedicated Health Day. We’ve had 28 years of COP, and it’s only now we’re really putting it onto the agenda. But the important thing is that it’s there. The good news is that we know what we need to do, but we need governments to take the necessary steps much more quickly. The importance of the environmental health message is getting through to people, and democratic governments do have to listen to voters. That’s why I’m optimistic.
Royal Society of Medicine
1 Wimpole Street
London W1G 0AE 020 7290 2900
People often ask if I am optimistic – and I am. There are so many economic and societal benefits to be gained, so it doesn’t all have to be negative. Momentum is growing, but health is still not a high enough climate change priority.
THE BIG INTERVIEW
A picture of health
Professor Jane Anderson, a leading HIV/AIDS specialist and chair of the Paintings in Hospitals charity, on the profound difference that art in healthcare settings can make to the lives of patients and staff
Words: Mark Riddaway
Portraits: Christopher L Proctor
Right now, along an otherwise characterless, strip-lit NHS corridor, there’s a chance that someone –perhaps a patient recovering from a procedure, or a nurse at the end of another punishing shift – has stopped to stare at the unexpected sight of a vibrant silkscreen print hanging on the wall: Brilliant Corner III by the pioneering English abstract artist Sandra Blow. It’s possible they’ll be struck by how the hand-applied collage elements peel away from the surface. In the print’s deep, inky blues, they might sense something of a cloudless night sky or a calm sea. In the colourful corner that gives the work its name, they may see a suggestion of fluttering bunting or semaphore flags. For this moment, however brief, they might not be thinking about post-surgical pain or bone-deep exhaustion. And that, as Professor Jane Anderson makes clear, can only be a good thing.
That an abstract painting of such high value and undoubted quality might be hanging in a hospital corridor has its roots in the post-war experiences of a man called Sheridan Russell. “He was head almoner at the National Hospital for Neurology and Neurosurgery at Queen Square in London,” says Prof Anderson, the recently appointed chair of the Paintings in Hospitals charity. “His role as an almoner – something close to today’s social worker – meant that he took a wider view of what’s going on in people’s lives.” Hailing from a family deeply rooted in creative pursuits –his father was an opera conductor and director, his grandfather a composer
– Russell was attuned to the power of the arts, and what he saw at the hospital, an austere institution filled with people in desperate need of stimulation or solace, was a place utterly absent of that transformative force.
“Russell believed that putting pictures, visual arts, into spaces where patients with neurological conditions were being treated or recovering would make a huge difference,” says Prof Anderson. He began hanging artworks in the hospital’s wards and, after observing up close the positive impact they had on the patients, set out on a mission to share these benefits with other parts of the health service. In 1959, Russell founded Paintings in Hospitals. Across more than six decades, the charity has developed a significant art collection, which it lends out for use in healthcare settings. Today, that collection numbers around 3,800 pieces, spanning a wide array of movements and styles, including works by giants such as Antony Gormley, Bridget Riley, Maggi Hambling, Andy Warhol and Anish Kapoor.
Despite the organisation’s pleasingly expository name –Paintings in Hospitals – both the character and usage of the collection have broadened considerably in recent times, expanding into other forms of visual art and other health and care settings. The empirical evidence that underpins its mission has also grown in scale and sophistication. “In the past few years there’s been a deluge of work about the health impacts of visual arts. In fact, the same is true of arts in
For us, it’s not about coming up with something that matches the blue carpet, it’s about finding something that is going to have a meaning and make a difference.
general. A 2019 report from the World Health Organization gives an overview of the arts and their place in health, going from prevention to treatment, to aftercare. The report makes it clear that there is a robust evidence base across the spectrum.”
In study after study, art in healthcare settings has been shown to ease the anxiety and stress of patients and staff. It speeds recovery. It reduces the need for painkilling medication. It provides a catalyst for communication and connection. It does this through its ability to spark profound emotional responses, to trigger memories and feelings, to energise or distract. “Visual arts take people into other worlds,” says Prof Anderson. “When you’re in a very difficult place – and hospitals often are very difficult places, where difficult things are happening – you have the opportunity to be taken out of the moment.” Conversely, by creating an immediate point of focus, art can also bring people into the moment –something of great benefit to people living with dementia, for example.
Prof Anderson’s enthusiasm for the charity’s work is a product not just of the published evidence of its efficacy but of her personal experiences as a hospital doctor over several decades. In her day job, she is one of the country’s foremost experts in the treatment of HIV/AIDS, and the therapeutic importance of shaping the environment in which people receive healthcare is something of which she has been acutely aware since the earliest days of her career.
After qualifying as a doctor, one of
Royal Society of Medicine
Professor Jane Anderson is a fellow of the Royal Society of Medicine (RSM). The RSM, which was established in 1805, was originally called the Medical and Chirurgical Society of London. In 1907 it merged with 15 other specialist societies to create the RSM as we know it today. Based on Wimpole Street in Marylebone, the society’s role is to provide the highest quality education at postgraduate level and beyond to medical and healthcare professionals. It also offers a forum for discussing current medical issues in an atmosphere where innovative thinking thrives and the best ideas are disseminated. As a charity, the RSM receives no government support, thus ensuring its independence. It therefore relies primarily on membership subscriptions, support for its education programmes and philanthropy. rsm.ac.uk
her first jobs was on the HIV ward of St Mary’s Hospital in Paddington. In the 1980s, long before the development of effective antiretroviral drugs, an HIV diagnosis carried a near absence of hope, along with the weight of widespread fear and prejudice. As a result, the wards in which people with HIV were cared for had the potential to be especially daunting places. “In those early years, people were coming in and out of hospital all the time,” says Prof Anderson. “Somebody would come in because they were very sick, then they would go home for a little while, but they’d always be back. The hospital became such an important part of their lives that the atmosphere was crucially important. How do you make a place like that feel therapeutic? I learnt a great deal from people who were coming back regularly and talking about how they wanted a place to look and feel.”
In 1990, Prof Andersons was made a consultant at St Bartholomew’s Hospital in the City of London. There, one of her tasks was to set up a new HIV ward. Inspired by what she’d learnt from patients at St Mary’s, she immediately sought to make visual art part of the environment. “We commissioned a painting by an artist called Helen Napper. It was a blue leopard. As you came into the ward, it was there, about seven feet long and it was beautiful – unexpected and completely arresting. It had a real impact and people used to talk about it for quite a long time afterwards. It was something that they remembered.”
Her experiences at Barts – and later at Homerton Hospital in Hackney, a
newly built hospital that right from the start had taken the novel step of convening an art committee to ensure that the space provided stimulation and distraction – proved formative. Her role as chair of Paintings in Hospitals squares the circle. “I’ve got to a point in my career now where I’m older, and standing back from some of my clinical responsibilities. It’s the perfect moment to do more and learn more about art and health, given how important it’s been in my working life”
Earlier in Prof Anderson’s career, not everyone understood the potential power of art. “At Barts someone said to me: ‘Why on earth are we talking about pictures when we’re in the midst of such overwhelming clinical need ? You’re here fretting about the pictures. Why?’” she recalls. Over time, though, a consensus has built that investing in the environment of healthcare settings is not an expensive frippery but a therapeutic necessity. “Post-pandemic I think it’s even more understood than ever. I don’t think there’s any real resistance to how much it matters. The difficulty is that in today’s world, the pressures are so great, the financial constraints are so significant, and the healthcare economy is so complicated. In a system that’s under such pressure for resources, where does financing art fit in?”
The appeal of Paintings in Hospitals is that the charity’s vast art collection and wealth of expertise limit any financial burden on the NHS. Because the paintings are loaned out, a trust should never have
Creative Health: The arts for health and wellbeing
Inquiry report from the All-Party Parliamentary Group on Arts, Health and Wellbeing (APPG, 2017)
Evidence Summary for Policy: The role of arts in improving health & wellbeing
Dr Daisy Fancourt, Katey Warran & Henry Aughterson (UCL Department of Behavioural Science & Health, 2020)
I’m Fine Project
Dr Marion Lynch (Paintings in Hospitals, 2022)
to choose between a ventilator or a work of abstract expressionism. And by utilising the skill and knowledge of the charity’s staff and volunteers, the recipients are strongly supported in choosing, hanging and caring for the works and ensuring they’re used in such a way that maximum value is drawn from their presence. “I think of our work as a list of Cs,” says Prof Anderson. “We have a collection. It’s a collection that we curate. It is there to connect people and art. And we’re trying to get commitment from the powers that be, to make sure this goes on happening.”
Curation – in other words, choosing the right works for each setting and ensuring that meaningful interactions will occur – is one of the central pillars of Paintings in Hospitals’ work. In recent years, this has evolved into a highly collaborative process. “I think there was a time when there was quite a paternalistic attitude,” explains Prof Anderson. “A hospital would say: ‘We have a new ward. We have a blank wall, please send us some art.’ We’d pick something and send it to them. Now, instead, we would co-curate that space with them.”
Central to that process is a series of conversations between the charity’s experts and the people who best understand the setting, including staff, patients and families. “There needs to be a real clarity about what’s going to have the biggest impact for that particular group of people. Doing it this way also means that you’ve got far greater engagement before the work is even hung up on the walls. People in the
I think there was a time when there was quite a paternalistic attitude. We’d pick something and send it to the hospital. Now, instead, we would co-curate that space with them.
setting are already thinking about what it’s going to mean for them, why it’s going to be important and how they’re going to be using the art. That, to me, is crucial.”
The importance of curation stems from the need to trigger beneficial responses, not just beautify the setting. “For us, it’s not about coming up with something that matches the blue carpet, it’s about finding something that is going to have a meaning and make a difference,” says Prof Anderson. The challenge is that people’s responses to art are both completely subjective and potentially powerful. “Different people will of course react differently to the same piece of art, depending on their experiences and circumstances, and that does bring some risks. You have to overcome some of those risks at the very beginning.” She offers a real example: a painting of two empty deck chairs on a bright, sunny beach. While most observers would sense something warm, escapist and aspirational, others might find it profoundly depressing, seeing instead the emptiness of the chairs and a mood of absence and loss. With that in mind, this might be a suitable painting for an orthopaedic hospital, but not for a hospice or a cancer ward.
Attempting to minimise the risk of bad experiences is vital, and some of the art in the charity’s collection is sufficiently challenging that it rarely finds an airing, but that’s not a reason for erring on the side of blandness. There is an acceptance that not everyone has to understand or love each artwork, and that provoking
a negative reaction can sometimes be good. “Even if you find a painting not to your liking, you’re still thinking about that painting rather than thinking about your test results. It’s not necessarily just about pleasing people, it’s about distraction as well.”
The extent of the impact depends on the setting and on the measures in place to guide people in engaging with the art, in the form of information, staff training, and planned activities such as workshops and art classes. When that engagement is well managed, some environments have been shown to offer particularly strong benefits. “There’s been a lot of interest in what’s been happening in emergency departments, particularly given the way hospitals have been recently. People often say: ‘I walked down that corridor and stopped at that painting and it just took the heat out of the moment.’ Mental health facilities: absolutely no question, incredibly important. Paediatrics I think is another area where we’ve seen real connection.”
Recently, one of Paintings in Hospitals’ aims has been to take its art into an even wider variety of settings. Pilot projects have taken place in hospices, and the charity’s collection can also be found in the places in all the world possibly least suggestive of an art gallery environment: GP practices. “Again, general practice in an area that’s under quite a lot of pressure,” says Prof Anderson. “You know, these are not places that are going to be able to go out and buy artwork. If we can work
out a way to have some of our collection in those spaces, and by doing so we can allow patients and staff to have a better experience, that’s absolutely what we should be doing.” Libraries, community centres and colleges that work with neurodiverse people, people with English as a second language, or those who are socially isolated have also started to benefit.
Looking to the future, Prof Anderson is interested in art’s power not just a therapeutic aid but a preventative one. “Visual imagery has always been incredibly important in health promotion and education,” she explains. “In my world, the world of HIV, the symbol of the red ribbon is one that everybody understands, and the artistry that goes with the use of that red ribbon can change how you engage with the topic. You can go back to those early days of AIDS, think about the lilies, think about the tombstones. There’s a particularly powerful piece of art in the Science Museum by an artist called Angela Palmer, which is of the coronavirus, lit from beneath. There’s something really important about using images in a way that can also impart information. We talk a lot about the therapeutic aspect, yet we we’ve got an educational, research and academic remit that we mustn’t overlook.”
Providing distraction and stimulation in the form of a vibrant silkscreen print in an otherwise characterless, strip-lit NHS corridor is to be applauded. But using art to reduce the need for people to be in those corridors in the first place is, it seems, part of the picture too.
Paintings in Hospitals paintingsinhospitals.org.uk
Dr Emer MacSweeney, CEO of Re:Cognition Health, on the dangers to the brain of contact sports and the search for a treatment for CTE, a particularly pernicious condition
Words: Viel Richardson
Contact sports are dangerous. It’s part of their appeal. The traditionally male, but increasingly also female, participants relish the challenge of testing themselves in demanding situations. For spectators, it’s the thrill of watching their heroes going head to head in the sporting arena, with no quarter given. Many football fans will remember the famous images of England captain Terry Butcher playing on against Sweden in a World Cup qualifying match in 1989 with his head swathed in bloodsoaked bandages. We always understood from such scenes that big impacts could cause bad head injuries. Now, however, we realise that impacts to the head have short and long-term consequences, particularly to the brain, that are much more subtle and dangerous than we once believed.
“Chronic traumatic encephalopathy (CTE) is a progressive, neurodegenerative brain disease,” says Dr Emer MacSweeney, founder of Re:Cognition Health, a world leader in research into neurodegenerative conditions. “For a long time, it was assumed to be caused by concussions. However, it is now apparent that CTE is caused primarily by hundreds or thousands of minor sub-concussive head impacts, usually sustained over many years of playing contact sports. These impacts may also occur while serving in the military or as a result of long-term domestic violence.”
Dr MacSweeney emphasises the two key issues that make sub-concussions so dangerous: they are asymptomatic so go unnoticed, and the force required to cause a sub-concussive event is two to three times less than for a concussion. These factors combine to make sub-concussions around 500 times more common than concussions.
The brain has developed neuro-chemical processes to protect it from these smaller hits. However, when these
sub-concussive impacts become frequent and repetitive, this protective response sets up an uncontrollable cascade of neuro-chemical reactions in the brain that can trigger harmful, persistent neuro-inflammation, which can eventually lead to the formation of a toxic version of brain tau protein. “Tau protein in its normal state protects the healthy functioning of brain cells, especially the ones responsible for cognition and behaviour. The neuro-chemical cascade caused by the repeated sub-concussive events causes the tau protein to mis-fold during development, and in this new configuration it can no longer protect the brain cells,” Dr MacSweeney explains. “More importantly, the abnormal toxic tau protein develops the ability to replicate itself inside brain cells, which it continues to do until the cells rupture and die. Furthermore, the abnormal tau protein can jump between brain cells, enabling it to spread at an ever-increasing rate, eventually killing billions of precious brain cells. This spread of toxic tau protein occurs in a predictable fashion called Braak staging and therefore results in the development of a predictable series of CTE symptoms as the disease progresses.”
Work carried out by the director of Boston University CTE Center and Brain Bank, Dr Ann McKee, with ex-American football players has produced some telling data. It revealed a very strong correlation between the number of sub-concussive brain impacts and the development of CTE symptoms. The chance of a player developing CTE doubles with every 2.6 years they play, and more than 99% of ex-players with CTE played American football for more than five years. Also, the severity of the symptoms doubled for every 5.3 years played. Ex-players with CTE symptoms were 10 times more likely to have played for more than 14.5 years than players without symptoms.
For a long time, CTE was assumed to be caused by concussions. However, it is now apparent that it is primarily caused by hundreds or thousands of minor sub-concussive head impacts, usually sustained over many years of playing contact sports.
“The data shows that if you play for over five years, you have a significant chance of developing CTE, and if you play for over 14.5 years that risk goes up by a factor of 10.”
Head to chest, head to stomach, head to ball, even impacts that don’t involve the head at all but make it whip, causing a shearing impact to the brain cells – all of these can cause sub-concussions. A real concern is that women appear to be more susceptible to the consequences of subconcussive injury than men.
In the UK, Re:Cognition Health has studied hundreds of ex-professional contact sports players. For certain sports, the concerns may be even more significant than for American football players. For example, the professional rugby season has more games and most players are on the pitch for the whole game. This results in a much higher number of sub-concussive impacts per player each season. Records show that American footballers present with CTE symptoms most commonly in their 50s and British football players in their 60s to 70s, whereas the rugby players presenting to Re:Cognition Health with symptoms are most frequently in their 30s.
One of the key and early symptoms of CTE is the dysregulation of mood and behaviour – an inability to control the intensity of a behavioural response so it is at a level appropriate to the situation. CTE symptoms also include huge mood swings, from elation to almost suicidal, plus feelings of paranoia and unexplained anxiety. These symptoms can develop over many years, making it difficult to recognise that something is amiss.
“Individuals with CTE typically develop symptoms of disordered thinking and short-term memory loss, causing
difficulties with planning, decision making, insight and judgement. These symptoms characteristically progress to dementia, at which time the individual is no longer able to undertake activities needed for independent living. As a rule, the cognitive symptoms related to CTE will generally develop after the behavioural ones,” Dr MacSweeney explains.
When dealing with potential CTE, having a clinical differentiation from other neurodegenerative conditions is essential. This is particularly important for those presenting in their 60s and especially in their 70s, a demographic for whom Alzheimer’s disease has already reached the levels of a pandemic. To date, a pathological diagnosis of CTE has only been possible after death. This is achieved by specialist staining of brain tissue taken from someone with suspected CTE, which can show the characteristic spread of the toxic tau protein. Now, though, in collaboration with Prof Steve Williams, professor of neuro-imaging at King’s College London, and Prof Gary Green, emeritus professor of neuro-imaging at the University of York, Re:Cognition Health’s brain injury team, led by consultant neurologist and brain injury expert Dr Steve Allder, are developing a pathway towards a clinical diagnosis of CTE during life.
“Using diffusion tensor imaging (DTI) with 3T MRI scans alongside sophisticated methods of data analysis, it is possible to detect evidence of structural brain injury at a microscopic level in individuals who have symptoms characteristic of CTE,” says Dr MacSweeney. She explains that the data analysis is crucial because these individuals invariably show no evidence of structural brain injury on conventional 3T MRI brain scans alone. “We can do this
because we have gathered a huge database of scans performed on healthy brain tissue to establish the controls against which to compare the scans of people with suspected CTE.”
The brain contains a large network of nerve fibres known as ‘white matter’ that allows for the exchange of information between different areas of the brain. It is so called because the nerve fibres are covered in a protective sheath called myelin, which gives the tissue its white colour. “The abnormal tau protein, and the brain cell destruction it causes, is not detectable with conventional high-powered 3T MRI imaging, as this process takes place at an ultra-microscopic level, approximately 1,000 times smaller than can be seen with the naked eye,” Dr MacSweeney reveals. “This is why we need sophisticated algorithms to analyse the MRI information derived from white matter tracts and detect damage consistent with what we would expect to find if we stained brain tissue post-mortem for tau protein. Having an objective clinical diagnosis in life opens up enormous possibilities for a new generation of treatments.”
And progress is being made. Using megencephalography (MEG) MRI scanning, Prof Green has demonstrated results consistent with structural brain injury caused by the destruction of certain white matter tracts within the brain, which correlates with data produced by the DTI and 3T MRI analysis on people with suspected CTE.
The development of a potentially meaningful clinical tool for diagnosis of CTE during life has required many years of work to identify the clinical characteristics of the disease in large numbers of individuals. It has also needed the establishment of the huge age and sex-matched ‘normal’ reference database, with which to compare individuals with suspected CTE.
It is an interesting but difficult area of research into which Re:Cognition Health was drawn through its extensive medico-legal brain injury work. The company acts as an expert medical witness in high-profile legal test cases which are extremely demanding in terms of the accuracy and robustness of a diagnosis. Often the result of such cases is strongly predicated upon the ability of one of the parties to provide clinical evidence of structural brain injury. “It was through our work in trying to refine imaging biomarkers and other techniques to prove structural brain injury in these cases that we initiated collaboration with Prof Green and Prof Williams,” Dr MacSweeney explains.
Since 2013, Re:Cognition Health has been extremely active in delivering international clinical trials for new-generation disease-modifying drugs for Alzheimer’s disease and frontotemporal dementia (FTD). Both of these neurodegenerative diseases are caused – in large part for Alzheimer’s and more so for FTD – by the spread in the brain of abnormal toxic tau protein. The tau proteins in these diseases differ from one another but are more similar than they are different. Over the past few decades, billions of dollars have been invested in the development of medications, some still in clinical trial, to remove toxic tau protein from patients with these conditions.
Currently, the company is undertaking a pilot study to determine if a new ‘anti-tau’ medication, hydromethylthionine (HMTM), which is still in development but proving effective in removing the toxic tau protein in Alzheimer’s and FTD patients, could also be effective in removing the protein in those with CTE. Dr MacSweeney reveals: “Currently we are collaborating with TauRx Therapeutics Ltd, who are developing HMTM,
in an early access programme for a pilot study, where we give the drug to a group of ex-contact sports players clinically diagnosed with CTE.”
For people with CTE there is currently no effective treatment to prevent the relentless progression to dementia and death. “To change this outcome for a significant number of contact sports players we need to discover if removing toxic tau protein reliably reduces the rate of disease progression and stabilises – or hopefully even slightly improves – CTE symptoms. Within the next 12 months, we anticipate embarking on bigger trials for new anti-neuroinflammatory and/or anti-tau drugs to treat individuals with biomarkerproven, clinically diagnosed CTE.”
In this pursuit, the scientific and clinical communities are not starting from scratch. It is known that in Alzheimer’s the presence of an abnormal tau protein correlates more
closely with cognitive decline than any other biomarker. It is also known that the tau protein can be removed by HMTM and other medications currently in clinical trial. In November 2022, the TauRx international lucidity phase 3 clinical trial using HMTM reported significant removal of the abnormal tau protein from the brain and a 72% reduction in the rate of symptom progression in individuals with Alzheimer’s over an 18-month period. In fact, patients who are still in this trial are showing a slight lessening of symptoms.
It’s circumstantial evidence but promising even so. Looking to the future, the ability to deliver an early, reliable treatment for CTE could have enormous implications. “The ex-contact sports players on the early access programme for HMTM include some who have very mild CTE symptoms but demonstrate quite widespread damage consistent with the spread of the toxic tau protein. Slowing progression of CTE symptoms for these individuals would be life changing,” says Dr MacSweeney, with genuine enthusiasm. “Globally, we have some way to go, but here we are cautiously optimistic that CTE will follow on the heels of the historic breakthroughs with the early, accurate diagnosis and treatment of Alzheimer’s disease. This will be of real benefit to contact sports players across the world, for whom CTE is now the most feared consequence of them playing their sport.”
Re:Cognition Health 77 Wimpole Street London W1G 9RU
We are cautiously optimistic that CTE will follow on the heels of the historic breakthroughs with Alzheimer’s. This will be of real benefit to contact sports players across the world, for whom CTE is now the most feared consequence of them playing their sport.
Above: Presence of abnormal Tau protein (red-orange) in tissue with Alzheimer’s disease Opposite: a patient in an MRI scanner
SIGHT FOR SORE EYES
The pioneering ophthalmologist Professor Ananth Viswanathan of the London Eye Diagnostic Centre on how recent advances in the treatment of glaucoma and cataracts have had a life-changing impact
Words: James Rampton
Professor Ananth Viswanathan’s work is both eye-catching and life-changing.
A highly distinguished consultant ophthalmologist from the London Eye Diagnostic Centre based in The Phoenix Hospital Group’s outpatient and diagnostic centre at 25 Harley Street, he explains what is so transformative about his job. “It can be quite profound when you see the effect our work has on people. One example springs to mind. There was a gentleman who at a relatively young age had quite nasty progressive glaucoma, but luckily, it was caught early. He came along to me, but it was clear that the medicine and laser weren’t working well enough.”
And so, Prof Viswanathan continues, “I had to operate on both
his eyes. Fortunately, both operations were successful, and they halted his glaucoma. So, he can still do his high-flying job in the City with no problems. He can drive, he can do all the things he wants to do.”
But there is a sting in the tale. “When he was out of the woods, the patient said to me: ‘I need to tell you something. Glaucoma is in my family. My brother, who is two years older than me, has it. A few years ago, he went out to do some shopping in his car, and when he came back to his car, his vision had gone from day to night. He realised he couldn’t see anything, so someone had to drive him home. He was then diagnosed with end-stage glaucoma. And he’s now got a lot of problems that he’s having difficulty navigating.’”
The patient went on to tell Prof
Viswanathan: “I’m very similar to my brother, and I thought that was my future. I believed that was what was going to happen to me. I thought I was going to lose my sight, have to stop my job and not be able to drive. I thought that was it.”
That proved to be definitively not the case. “We managed to stop him suffering the same fate as his brother,” says the ophthalmologist. “To see that is very moving. It’s why you do this job.”
A pioneer in the field of glaucoma and cataracts, Prof Viswanathan outlines what his work at the Phoenix entails: “It principally involves looking after patients with glaucoma. I have very quickly to set things in context for the patients and individualise the treatment, so that they’re not just taking what they’ve read on the internet and applying that to themselves. Each person’s story is different. And it’s really important to get that right.”
Further treatment will encompass “making sure everything’s stable, and if it isn’t, getting a management plan together to make sure the vision is preserved, and if necessary, scheduling laser treatments and surgery.”
The hospital provides a top-of-therange service. “It’s got three really good components. The combination of London Eye Diagnostic Centre and the Phoenix means that for ophthalmology, we’ve got the best diagnostic equipment available, we’ve got highly trained technicians, and we’ve got a number of senior consultants who are experts in interpreting the results.
“If you don’t have all of those three things, you’re not offering a full service.
So we’re very lucky in that way. Quite a lot of places have good kit, and they can take the images. But there are often some doubts about what those images mean. You need the right experts to interpret them. When things look slightly dubious, you need to be able to tell whether that is a cause for concern or not. That’s the day-to-day work of our consultants.”
Prof Viswanathan has been greatly helped by the enormous advances that have taken place in ophthalmology in recent years. “There have been so many improvements on the technical and surgical side,” he explains. “The bread and butter of ophthalmology, cataract surgery, has changed out of all recognition since I started. When I began as a junior opthalmologist, you’d make quite a long incision of 13mm or so along the top of the eye. If the lens in the eye had become cloudy, you’d pop it out, like you were popping out a watermelon seed. Then you’d put in your lens replacement and sew the eye up.”
These days, he continues, “you’d almost never do that. It’s all keyhole surgery. The incision is so small, it almost never needs any stitches. You take the whole lens out through this tiny little incision. Then you put a folding lens replacement in so it unfolds in the eye, just to where it should. Now it’s a local anaesthetic day-case. You don’t need to stay in hospital. Rehabilitation is much quicker, and we get much better results.”
The other massive leap forward in ophthalmology has been in the application of AI. “The main improvements have been in computing
power, which means you are now much better placed to analyse large volumes of data. One of the big projects I’m part of is trying to make sure we can train AI to get the best information to help care for our patients, but do it in an ethical and legally correct way. It’s a moral imperative because AI does tell us things we didn’t know before, and it’s very good at doing certain things. AI can extract information that even expert humans can’t. For instance, AI can look at a person’s biometric data and decide what that means for their risk of eye disease. But we’ve got to be responsible about how we use it.”
Another value-added eye diagnostic programme that the Phoenix is offering is its new second-opinion service. Professor Viswanathan outlines how it functions. “I audited the first 50 new patients from primary care who were referred to me, and I discharged 46% of those on the first visit. I told the patients: ‘You’ve done all the tests. I had a look at your eyes. I can understand why your optician was concerned because looking at the test they did, they were being cautious, and that was completely appropriate. But now that we’ve done our test, and I’ve had a look, you’re all right.’
“I advise them: ‘Just go back to your optician in a couple of years and keep going as regularly as you have been. But we don’t need to keep you here in the hospital eye clinic. You can go.’ When I tell them that, the relief is palpable.”
He adds: “With this new second-opinion service, we hope we’ll be able to help the opticians who are delivering primary care, and GPs, if
When I began as a junior opthalmologist, you’d make a 13mm incision and pop the lens out like you were popping out a watermelon seed. Now, it’s all keyhole surgery.
they’re slightly unsure of something. We hope that we’ll be able to assist them in ways we couldn’t before.”
One aspect of his speciality that the professor is very eager to underscore is the importance of going for regular testing. That can help identify serious cases of glaucoma, which is known as “the silent thief of sight”.
The consultant says: “If a lot of the conditions that you develop, particularly as you get older, are spotted early, then that gives you a chance to do something about them and prevent them getting worse. That’s vital because a lot of conditions like glaucoma are irreversible.”
It is clear that prevention is better than cure. This is especially true if you have diabetes. Prof Viswanathan explains: “What’s good in the UK is that we’ve got a national diabetic retinopathy screening service. So, if you’re diagnosed with diabetes, your GP will make sure you have these photographs of the back of your eyes taken every year. That’s really important because diabetic retinopathy can be treated and really needs to be treated. If it isn’t, and it’s progressive, it can give you awful problems. It can cause a type of secondary glaucoma, which is particularly difficult to treat and very unpleasant. You want to try and head that off. If you take glaucoma as a whole, it is the commonest cause worldwide of irreversible blindness. It’s a really big problem.”
Prof Viswanathan is keen to emphasise how much he enjoys life here. “The campus really is wonderful. It’s an absolute pleasure to work here.
First of all, it’s really efficient. From the people at the desk all the way through to senior management, you get the feeling it’s a very well-oiled machine. It’s really easy to find points of contact, and we’re all working towards the same goal.”
Would it be pretentious to say that it is also very enjoyable to work at the Phoenix because you can bring patients’ hope back from the ashes? “We do that. Particularly when patients first arrive, unfortunately they’re generally quite scared. They don’t know what’s going to happen. When they come to see me, they may well have read about glaucoma on the internet, and then they’ll be terrified.”
Prof Viswanathan offers a tremendous sense of reassurance to patients who are often beside themselves with a
quite understandable, primal terror about the possibility of losing their sight. He says that when he surveyed his patients, their major fear was blindness. But he is there to calm their worries. “You can almost always say: ‘That’s not going to happen’, or you can quickly implement things to try and avert that catastrophe. That’s a big part of the job, and it’s very satisfying.”
The consultant proceeds to underline how much he enjoys working at the heart of one of the greatest centres of medical excellence on the planet. He feeds off the pool of world-class knowledge around him on Harley Street. “The concentration of expertise in the area very much acts as a magnet. We’re surrounded by very good people in our department, and also in the other practices around Harley Street. That community of experts is an absolutely superb thing to have.”
Before we part, we return to the subject of what a rewarding job Prof Viswanathan has. He closes by stressing how privileged he feels to do this work. “Seeing patients who have either got their vision back, or who know that, having been in a slightly precarious position before, they’re now pretty much in the clear – watching that weight being lifted from their shoulders is very gratifying.”
Witnessing someone whose life has been transformed by you must certainly be a very uplifting feeling. “It’s the whole focus of the work. It provides an immense sense of satisfaction. It’s hard to beat.”
25 Harley Street London W1G 9QW 020 7079 2100 phoenixhospitalgroup.com
It is very gratifying seeing patients who have either got their vision back, or who know that, having been in a slightly precarious position before are now pretty much in the clear.
Phoenix Hospital Group
Dr Moein Tavakkoli and Mr Erlick Pereira
Mr Erlick Pereira, consultant neurosurgeon at The London Clinic, and his colleague
Dr Moein Tavakkoli, consultant in anaesthesia, pain medicine and neuromodulation, on bringing relief to patients suffering from a distressing, debilitating and difficult-to-diagnose condition
Interview: Viel Richardson
Portrait: Christopher L Proctor
What is pain?
Dr Moein Tavakkoli: Pain, as defined by the International Association of the Study of Pain, is an unpleasant sensory abnormality in any part of the body, or the emotional aspect and experience associated with pain. So not just the sensations caused by illness or physical injury, such as the trauma-based pain you get when you twist your ankle or break a bone. There are occasions where the nerves responsible for transmitting pain signals to the brain can fire off pain signals for no apparent reason, causing a mis-signalling of pain. This is called neuropathic pain, where the pain transmission system is faulty and starts to generate pain signals on its own.
When does it become refractory pain?
Mr Erlick Pereira: Traditionally, it was based on time – somewhere between three to six months’ persistence. But it’s more important to look at the mechanisms by which the pain becomes chronic: the transition from an acute pain phase to a persistent chronic pain. For some reason, alternative mechanisms have activated in a person’s body that cause the pain to persist. One key aspect of the definition is that conventional medications have been tried and have not significantly relieved the pain.
That suggests that pain is a condition in its own right.
MT: Yes, we have moved away from looking at pain as simply a symptom of a condition. We’re now often looking at
pain as a primary condition. The latest data from the UK population suggests about 24% of the population will experience refractory or persistent pain at some stage in their life. And at any given time about 7% are being significantly affected by pain.
How does it start?
EP: The most common scenario is with an acute injury. The injury seemingly heals, but you’re left with significant pain in that area. A good example is post-herpetic neuralgia – shingles pain. Another example is pain that you get after a rather small operation such as a vasectomy or a hernia repair. Six months or even a year later, you still have significant discomfort sensitivity and a very unpleasant sensation in the area. We also find that patients living with cancer can often suffer this pain.
How do you approach diagnosis?
MT: You start with a detailed history and a physical examination. The physical has a very important role because there are certain patterns that can differentiate between mechanical versus neuropathic pain. Imaging can also be useful. Sometimes you use adjunct investigations such as nerve conduction studies to identify neuropathy, which is a contributing factor to developing neuropathic pain. Together with the multidisciplinary team, you then assess all the data to make your differential diagnosis. It is important to rule out all other possibilities for the pain.
EP: One of the great challenges with chronic pain is that there’s no diagnostic biomarker you can
identify. We do whatever we can to obtain objective data. Patientreported outcome questionnaires are a good example of this. We can score someone’s pain, for example, using a visual analogue scale where they will mark on a line from nought to 10 the severity of their pain. We also have more sophisticated pain questionnaires. We use body maps that allow the patient to specify where they might feel specific types of pain at particular times of day. We gather data in addition to the traditional history and examination information, then get together to discuss what we think is causing the pain.
So, how well do we understand the causes?
MT: I think the mechanisms and processes are reasonably well understood, though our clinical tools for measuring what is happening in the body outside of a laboratory remain limited. Identifying the trigger points along the pathway that activate to cause neuropathic pain is difficult. Because the nature of all pain is very multifactorial, anything could have influenced that process. Genetics is part of it, social events, medical interventions, even emotional trauma, any or all of these can trigger a cascade of events that can lead to someone suffering from persistent chronic pain.
How does your relationship work?
EP: Quite often someone contacts me thinking they have a spine problem which can be treated by a conventional spinal operation. If
It’s about developing a patient-centred treatment plan that will alleviate their pain. We start with the least invasive options with the highest level of success and the lowest risk of complications. After looking at these we may choose a surgical option.
that patient doesn’t have a squashed nerve that needs decompressing the conventional surgical way and has tried multiple pain medications, I would refer them to Dr Tavakkoli before considering significantly more invasive treatments. He would review their treatment path to date, consider the spectrum of pain medications that they’re on and consider what other interventions might be offered.
MT: In such a scenario my role is to optimise medications and lead on any kind of physical or psychological support. When they arrive, they’ve had the opportunity to discuss the options, so our conversation is focused on how to move forward. Sometimes the reverse happens. I see a patient who specifically doesn’t want surgery. We’ll go through the options but there are scenarios where their highest likelihood of success at the lowest risk is a surgical procedure. In those cases, I’ll discuss options with Mr Pereira and our multidisciplinary team to find the right treatment path.
So, it’s not just a case of choosing a standard treatment.
MT: It’s about developing a patientcentred treatment plan that will alleviate their pain. We start with the least invasive options with the highest level of success and the lowest risk of complications. This typically includes medication and/ or physical therapy. From there, we move on to minimally invasive interventions, such as injections, radiofrequency treatments, possibly neuromodulation. After looking at these we may choose a surgical option.
EP: We often see patients who have tried multiple treatments. In those circumstances it’s about teasing out previous diagnoses and treatments. For example, back or neck pain constitutes a large percentage of refractory pain. A lot of our patients come in wanting a particular operation they have heard about for spinal pain, such as a lumbar disc replacement, which is actually quite a big and complicated operation. During our assessment we might discover that while they have tried steroid injections, they haven’t tried a radiofrequency burning procedure. Or that the issue is in the joints rather than the discs. So, it’s not infrequent for us to say that the surgery they approached us for is not appropriate at their stage of treatment.
What is the radiofrequency procedure and where does it fit in the treatment path?
EP: There is a repertoire of interventions we have for refractory pain. Many of these involve targeted steroid injections, often under X-ray guidance. We can deliver a precisely calibrated electric current to deliberately damage the abnormal pain-firing nerves – a procedure called radiofrequency ablation. The idea is to damp down abnormal firing of the pain nerves of a joint. We can also pass catheters up the spine to try to break down any post-surgical adhesions if they are causing the pain. We also have implants we can introduce into the spine and brain to try to jam the abnormal pain signals. One of the main procedures we do is spinal cord stimulation, also known as neuromodulation. This involves threading a wire up someone’s spinal canal to sit over the spinal cord along the path where the neuropathic pain signals go from spine to brain. The wire is connected to an implanted pulse generator or pacemaker which sends electrical signals that jam the abnormal pain signals.
Where would you like to see more progress in the treatment of refractory pain?
MT: Improvements in early recognition and appropriate referral. People underestimate just how much suffering constant pain causes, both physically and mentally. At present, early diagnosis is difficult as it’s not something you see on an scan. It involves spending time with patients
to identify and formulate a plan. For instance, anti-neuropathic pain medication is only effective in roughly one in five people.
Also, it’s about understanding that by nature refractory pain is a persistent condition, which means you may need many episodes of treatment over several years – it is very rarely a one-off procedure that makes everything go away. But also recognising the fact that it is extremely cost effective and humane to deliver this treatment.
EP: I would come back to this lack of an objective biomarker. We need a better way to determine the severity of chronic pain and who, in the context of neurostimulation, might respond best to this therapy. We are selecting one in five patients who are not having a good result based on current subjective criteria. At the moment, some colleagues and I are looking at the autonomic nervous system, the network of nerves that control unconscious processes, in relation to pain. Certain aspects of this can be abnormal in some patients with chronic pain. So it may be that patients with specific profiles of autonomic function might also have specific profiles relating to their pain, which would make them better responders to spinal cord stimulation. The aim is to be able to determine who will benefit most, to help the most people with the resources we have. It’s still research at the moment but it holds promise.
How do you see your role as a partnership?
MT: I think the key is using our combined experience for swift, effective diagnosis and treatment. Often, the cause of the pain may not be where it presents. You may self-refer to a hip surgeon for a hip pain, but the root problem is in the spine and they may not explore that possibility. Our role as pain physicians is to identify the cause accurately and then treat accordingly. To take a step back, look at the bigger picture and gather the necessary data to ensure that the patient gets the right diagnosis and receives the most effective treatment.
The London Clinic 20 Devonshire Place London W1G 6BW 020 7935 4444 thelondonclinic.co.uk
Michelle Hunter on how day-case surgery ended a decade of debilitating pain
Interviews: James Rampton
My back has given me issues since my teenage years. I was playing netball at school when I got a spasm in my back. It was really painful, but the pain didn’t return for several years until my late teens after which it would trouble me on and off, gradually becoming more frequent.
Then one day, almost 10 years ago now, I was getting an early-morning flight for work. I bent down to tie my shoelace and was struck by the worst pain I’ve ever experienced – and I say that having delivered two children without any drugs.
I went to see a neurosurgeon and that’s when everything changed. I was severely shifted, so my pelvis was way out of place. I had minor leg weakness and altered sensation, and slight altered sensation around my ribcage as well.
I was given a scan which showed that I had lesions on my cervical spine. It also showed disc degeneration in my lumbar spine, but nobody was interested in that – it was all about the lesions.
In January 2014, I was diagnosed with multiple sclerosis. From that point on, nobody took any interest in my back – even though I was convinced from day one it was my back that was causing the pain. Over the next nine and a half years, I saw eight neurologists, four orthopaedic surgeons and a neurosurgeon. They all said: “You’ve got an MS diagnosis. That will be what it is.”
I replied: “I don’t think it is. I got the back pain first.” But that idea was very much dismissed. I felt like I was being shoehorned into a diagnosis. I really struggled to find anybody who would take me seriously. Meanwhile, my back
pain had become chronic. I have two small children, and the pain meant I couldn’t pick them up. I couldn’t run with them, play with them or do any of the normal things that parents do.
I felt very ignored until I saw Mr Mo Akmal. He was the first person who actually listened to me. He took his time. He got to know me, studied the symptoms and looked at my back in greater detail. His diagnosis was a severe disc collapse and curvature of the spine. Listening was the key – he did what none of the other surgeons took the time to do.
I’ve been seeing him for just over two years now. We tried conservative treatments to start with – steroid injections, radiofrequency ablation to kill off the pain nerves – and they really helped. But the improvement wasn’t sustained. That’s why I decided to go for
Lumbar The region of the spine more commonly known as the lower back.
Multiple sclerosis A neurodegenerative condition that can affect the brain and spinal cord, causing a wide range of potential symptoms including muscle pain.
Degenerative scoliosis A side-to-side curve in the spine which is usually the result of wear and tear on the discs and joints of the spine. It is usually found in the lumbar spine.
SPECT CT scan A type of nuclear medicine scan in which the images or pictures from two different types of scans are combined for the final result.
WHAT IS THREE-LEVEL LUMBAR FUSION?
Mr Mo Akmal, consultant orthopaedic spine surgeon at London Spine Unit
the three-level lumbar fusion surgery that Mr Akmal recommended.
I came to London from my home in Aberdeen and had day-case surgery. I couldn’t fault the clinic from start to finish. I was really well looked after. Within two hours of the surgery, they had me up and walking around. Then Mr Akmal came to see me and showed me the scan. I was amazed by what had been done. Three discs were impacted by the surgery, and cages were put in at each level. There were also titanium rods down either side, fixed with eight pedicle screws. It was a major surgery, but it didn’t feel that way in the slightest.
I went back to the hotel that day with my husband and stayed overnight. Two days after surgery I was back home, which was amazing. The recovery since then has been really good. It was around Easter and I was able to go to an Easter egg hunt with my daughter. I was able to stand for three hours while we walked around, which I couldn’t have done before the surgery. From a very early stage, I could see a huge improvement.
I do get quite emotional about it. I feel incredibly grateful to Mr Akmal because if he hadn’t listened, I don’t know what I would have done. I could see other parents enjoying things with their kids that I couldn’t do with mine, and that hurt so much. No matter what I tried, there had always been a brick wall because my back was in such a bad way and nobody would listen. So yes, I’m immensely grateful to Mr Akmal for carrying out the surgery, but mainly for listening to me and giving me hope for the future’. I want to shout it from the rooftops and tell everybody how wonderful he is!
Michelle underwent the largest operation we have ever done as a day case here at London Spine Unit. It was a multi-level lumbar fusion with screws and rods and cages. When she presented at my clinic, she had been diagnosed with multiple sclerosis for the past nine years, but I discovered that was not the root of her problem.
I always listen to patients. I want to really understand what they are describing, because I have had back pain myself. Whereas many people would dismiss them, saying: “Well, everyone’s got back pain,” I’m very much in tune with their situation.
It was clear that Michelle was very genuine in her description of her pain. So many surgeons and doctors had dismissed her, but I knew MS should not cause pain in this way. The pattern of her pain was very much consistent with people who have degenerative discs. You have to put the MS aside and filter out all the noise to home in on the actual symptoms. It’s like a jigsaw puzzle. When it all fits together, you know that you’re going to get a very successful result.
It emerged that Michelle had a significant problem. She had degenerative scoliosis, which means the discs in her spine had collapsed on one side. Because her discs were so worn, her spine needed a special scan that you don’t get in many places. It’s called a SPECT CT scan and it shows the hotspots – those painful areas where bone is rubbing on bone. It gives you a picture of where the degeneration is. In Michelle’s case it was on multiple levels.
This type of surgery is normally done at an in-patient unit, as it’s quite a major procedure. Patients are kept in hospital
for up to five days, and they have a lot of pain afterwards. But I’ve been doing spinal surgery for the best part of 30 years, and at London Spine Unit we have developed techniques which allow the anaesthetic to have a minimal impact on the patient’s body. We don’t use those heavy drugs that knock people out completely. Our patients wake up with no drowsiness, which means they’re able to stand up and start walking within half an hour of the operation.
The other key element is that we use a different technique to control muscles. For these operations, you have to retract the patient’s muscles, and the traditional method involves cutting into them. We devised a technique where you don’t cut into the muscle but instead separate the muscle layers. We use a special mixture of medication which relaxes those muscles and allows us to retract them in order to perform our operation. As a result, when the patients wake up they don’t have any pain from their muscles. The combination of these techniques is unique and allows us to achieve something which very few practices have been able to do. Michelle’s surgery was a great success. She was up and about on the day of the operation and left the clinic that afternoon. I have a real personal connection with Michelle because I’ve known her for so long. I am so pleased with the outcome of her surgery. When you fix a problem like hers the impact on people’s lives is just incredible.
London Spine Unit
19 Harley Street
London W1G 9QJ 0844 589 2020
How the Random42 studio became the pharmaceutical industry’s go-to producer of medically accurate animations
Words: Gerard Gilbert
IN THE FRAME
There aren’t many companies working within the medical field who employ movie production professionals who have worked on Batman, the X-Men blockbusters, or Disney animations like Dumbo and The Jungle Book.
But then the medical imaging studio Random42 is pretty much unique in the way it works. The company combines artists and scientists to illustrate how the human body works on cellular and sub-cellular levels, creating medically accurate animation for the pharmaceutical industry.
Established in 1992 by sculptor-turned-computer scientist Hugo Paice, Random42 got its name from Paice’s interest in both Chaos Theory (the ‘random’ part) and The Hitchhiker’s Guide to the Galaxy. For, as every fan of the Douglas Adams book and TV series knows, the number 42 is ‘the answer to everything’.
Paice sold the business in 2015 and when the current CEO, Ben Ramsbottom, joined the enterprise in 2010, Random42 was the biggest company in the world in the medical animation field. “Even so, there were just five of us and we were doing probably about eight projects a year,” he says. “We now do up to 300 plus projects in a year with over 200 different companies and employ 140 people.”
Formerly based in London’s Soho, the creative hub of Britain’s film industry, the company moved to spacious new premises in Marylebone two years ago. The workforce is split between scientists and animators – with a greater preponderance of the latter. “Our clients want to be in contact with someone who understands the complexity of their science,” says medical director Elly Spreckley. “That’s the reason that our project management team have a science background and PhDs so they can really get into the detail. The animators don’t have a medical scientific background
but they’ve come from those big production houses in the film industry as well as people who’ve come straight out of university having done their video animation degree.”
The science and production teams have a symbiotic relationship because ultimately, she says, they are making scientific animations and you can’t have one without the other. “And artists really need to understand the story that they’re telling so the communication between those two departments is super important.”
Asked to explain the process of making the films, Spreckley (who did her PhD at Imperial College London in neuroendocrinology) explains how they go through four main stages: the script, the storyboard, animation and then high definition (HD). “We’re working really closely with the client the whole way so they can also see that we’re using valid and accurate structures and published data to create something that really tells their story,” she says. “Every statement we make in the script is accurately referenced. A lot of our clients request that they’re put through a medical-legal review (MLR) which essentially checks that every statement is accurate. It’s quite a rigorous process.”
For research purposes the company uses online resources like Protein Data Bank. “That allows us to find the accurate structures of proteins and molecules and our scientists put this together into a bit of a collage and explain to our artists exactly what we’re trying to show from start to finish and make sure it’s a cohesive story flow.”
One of the most exciting and rewarding projects in recent years has been creating the videos for the Covid hub on AstraZeneca’s website. “It was all this brand-new science and making sure we were telling their story correctly was
We’re creating short, digestible content compared to long, boring PowerPoint presentations that would take someone half an hour to go through. Instead, we give them a two-to-four-minute animation.
Images: stills taken from a selection of Random42 films, created for a range of different clients
obviously of utmost importance because the general public didn’t really have an understanding,” says Spreckley. “The opportunity to work on projects like that is super rewarding because we know at the end of the day it’s going to help the general public’s understanding of something quite confusing and scary.”
And the Covid pandemic proved a boost for the company’s bottom line. “Pharma was incredibly busy during the pandemic, so we had a lot of business come our way,” says CEO Ramsbottom, who has a PhD in cell biology and oncology and originally joined Random42 as a scriptwriter. “And obviously with lockdowns they couldn’t go on the road to meet people so they wanted us to create animated video content to explain what they were doing. Before the pandemic pharma companies employed thousands of reps and super reps to go out into the field to sell their drugs. Now in the pandemic that didn’t happen at all, they were all at home; maybe making the odd call, but that was about it.
“On average, in the US reps have less than three minutes with a doctor when they meet them. They do six meetings a day, three minutes each, and that’s their working day. That sort of model doesn’t make sense anymore – so if you can reach people through digital resources online, they can do two or three minutes watching themselves, the job’s done and you save yourself an absolute fortune.
“Our target audience is doctors. It’s for pharma companies to explain a specific disease and how it can be treated. We’re creating short, digestible bits of content compared to long, boring PowerPoint presentations that would take someone half an hour to go through. Instead, we give them a two-tofour-minute animation or virtual reality experience that they can easily understand.”
Virtual reality, and the level of immersion that the headset experience can bring, is another growth area. “If you’ve got a conference booth where you’re trying to attract lots of healthcare professionals, having something like a headset where they’re focused on that one thing and
not chatting to someone else, that has to be better,” says Spreckley. “The videos are very immersive, especially where you can travel through the body on this journey – in the same way that they’re used in architecture and interior design. It allows you to be really there in the moment and appreciate it more.”
Random42 has also worked on Netflix documentaries that are on current release, including The Game Changers, a 2018 documentary about athletes who have a plant-based diet, and Fantastic Fungi, which is about how different types of mushrooms effect biological processes. “We did some clips for them about what neuroregeneration can do with Alzheimer’s,” says Spreckley. “We love to get involved in that sort of thing, and it’s great for the team to see their names on Netflix.”
Having recently been bought by the US-based The Lockwood Group, expansion is clearly on the cards for Random42. “The core business is growing 20-30% annually so we could be lazy and stick with that,” says Ramsbottom. “But it’s the broader education thing that appeals to me. It might be for internal use of pharma companies but it could also be for universities and schools creating content through a subscription model. Hopefully in the next couple of years we can start making inroads into that space.
“We’ve worked with the all the top 25 pharma companies globally, all the way down to small biotechs. Companies like Moderna have been great for us, along with many others in that sort of space. We’re pretty unique, I suppose. There are other companies but it’s all fragmented from sort of two-man bands up to about 30 people tops. There’s nothing on our scale.”
114-116 Marylebone Lane London W1U 2HH 020 7734 6001 random42.com
THE HARLEY STREET BUSINESS IMPROVEMENT DISTRICT
The Harley Street BID has been established to promote the area and represent the exciting mix of businesses here. In November 2021 the business community were invited to vote in the ballot to develop a business improvement district and there was an overwhelming “yes” for a BID to be established from the businesses. The BID term runs 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.
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.
If you would like more information on the newly developed business improvement district please do not hesitate to contact Nicki Palmer. Email: email@example.com Telephone: 07944 386903
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Marylebone, in fact almost anywhere. It’s just so intimate, so cosy, and the food’s impeccable. It’s not what everyone first thinks of, but the wine selection is excellent as well. The Golden Eagle pub is a great place to meet friends and people watch on a summer’s evening. Tommi’s is a great burger joint, Bonne Bouche is great for patisserie, sandwiches or a quick lunch, and you can drop into the new WatchHouse for a coffee and a bite with its New York vibe. But you can also go to Chiltern Firehouse or The Ivy Café for something fancier. Then you have places like La Fromagerie, which sells fantastic cheeses, and The Ginger Pig, which is an amazing butchers. It’s hard to think of anywhere else with such a wide variety of wonderful places to buy food.
Mine is quite a diverse role. I’m the general manager of John Bell and Croyden. I’m also the head of marketing, PR and brand. I look after the day-today running of the company, as well as the selection of products and brands we have in store. I’m also responsible for the look and feel of the pharmacy itself, I look after business development in terms of the hospitals and other brands we work with, and I’m involved in setting the strategic direction of the business. We try to create a very personal experience for people coming to John Bell and Croyden. There’s a small team of two buyers, a marketing team of three, a couple of strategic managers and me. Between this little group we test, feel and curate every item, service and product we sell. We have our own superintendent pharmacist, and she guides us on new incentives and initiatives in the pharmacy.
The shops in Marylebone are phenomenal. Koi Bird, which completely rebrands itself every single quarter, is just amazing. There is a nice big branch of The White Company, which everyone needs in their life. You’ve got Cire Trudon, which is a beautiful candle shop, and Daunt Books, which is for me the best bookshop in London. My partner Allan and I recently adopted a child and I’m now noticing all these cute children’s clothes in Bonpoint. I just love David Mellor kitchenware. You even have a traditional hardware shop, Penton’s, where you can grab a huge variety of everyday things that you might need in a hurry but are usually surprisingly hard to find. The area already has a great reputation for shopping and it’s getting better and better. We’ve got lots of independent stores popping up here and there. It’s the diversity that makes it so interesting.
Wigmore Hall is a very special place for me. I played the cello when I was at school, and they often have solo cellists playing. Then you have the Hellenic Centre, which has been there for years and always has quite interesting events taking place. I think that The Wallace Collection is typically Marylebone. It’s tucked away and everything’s a bit low key, but then you scratch the surface and there is lots of amazing stuff going on. One of my favourite memories comes from the opera teacher on Marylebone Lane. I was standing outside the Golden Eagle pub having a pint on a summer’s evening listening to the students singing. They were advanced students and were wonderful. It’s like nowhere else in London.
Fischer’s is my absolute favourite place to eat in
I like the fact that it is literally like a village, that when walk I around I see friends I’ve made here. In 2019 James and I cycled to Paris with a group of people, organised by The Howard de Walden Estate in support of the West London Mission. That was one of the best experiences of my life. It was three days with people from the community. I think we raised about £50,000 and it solidified that sense of community between people who live or work in the area. There is a real sense that we look after each other here. Everybody who knows Marylebone loves Marylebone, and I genuinely think it’s the friendliest part of London. So many other areas try really hard to be cool or trendy. Marylebone isn’t; it just tries to be itself. And that’s what makes it a cool place to be.
JOHN BELL AND CROYDEN
50-54 Wigmore Street
London W1U 2AU 020 7935 5555
Alexander Johnston, general manager at John Bell and Croyden
Left: David Mellor Opposite: Fischer’s
CHIARA AMBROSIO: MONOCHORDS
Until 28th July
The Hellenic Centre
16-18 Paddington Street London W1U 5AS helleniccentre.org
Chiara Ambrosio presents a suite of linocuts inspired by Yannis Ritsos’s Monochords, a collection of 336 one-line poems composed by the Greek poet in August 1979 following one of his many political exiles on the island of Samos. Each line is a poignant and essential observation of an instant in time, at once ephemeral and resonant. The resulting collection of poems reads as a personal archive of time past, present and future, offering, in the poet’s own words, keys to his own poetic sensibility.
THE BARBER OF SEVILLE
6th August, 6.30pm
The Nannies Lawn Regent’s Park London NW1 4NU operabrava.com
Opera Brava, a touring opera company that specialises in outdoor performances, brings Rossini’s comic masterpiece to Regent’s Park. Using bribery, deception and disguise Figaro, the titular barber, needs all his wits as he sets out to assist his good friend Count Almaviva as the Count tries to woo the beautiful Rosina away from her lecherous guardian, Dr Bartolo. Frivolity and timeless melodies abound in this hugely popular opera which has been brought back by popular demand.
SIR STEPHEN HOUGH
7th September, 7.30pm
36 Wigmore Street London W1U 2BP wigmore-hall.org.uk
Much-loved musician and composer Sir Stephen Hough provides a suitably stellar opening to the new Wigmore Hall season after the summer break. His characteristically varied programme will begin with music by Federico Mompou, a Catalan composer he has championed, continue with pieces by Debussy, Skryabin and Liszt, and include a performance of Partita, one of Sir Stephen’s own works for piano.
REGENT’S PARK MUSIC FESTIVAL
17th June – 17th September
Regent’s Park London NW1 4NR regentsparkmusic festival.org.uk
Throughout the summer, the Regent’s Park Band Stand will be hosting a series of free outdoor concerts every Sunday afternoon (12-5pm). This year’s programme also includes a regular Saturday afternoon performance at the Broadwalk (2-4pm). The highly diverse line-up features 45 different groups, including brass bands, concert bands, jazz bands, opera, and choirs, large and small.
The Barber of Seville
Sir Stephen Hough
PORTRAITS OF DOGS: FROM GAINSBOROUGH TO HOCKNEY
Until 15th October
The Wallace Collection
Manchester Square London W1U 3BN wallacecollection.org
Dog portraiture developed contemporaneously with its human counterpart flourished, particularly in Britain, from the 17th century onwards. Perhaps more than any other nationality, the British have commissioned and collected artworks of their dogs. This exhibition explores our devotion to four-legged friends across the centuries. Bringing together over 50 works of art, including paintings, sculptures, drawings and even taxidermy, this exhibition highlights the unique bond between humans and their canine companions across many centuries, showing dogs in all their different shapes and sizes.
Five places for great vegetarian food in Marylebone
WULF & LAMB
66 Chiltern Street
London W1U 4EJ
Wulf & Lamb is a restaurant whose menu is entirely plant-based. Its aim is to satisfy vegans’ craving for comfort food by creating plant-based versions of familiar classics. Each dish is stacked with flavours and surprising ingredients, drawing inspiration from around the world. Best known for an indulgent vegan mac’n’cheese, the menu includes dishes like American pancakes with maple syrup, strawberries and vanilla whipped vegan cream, and Wulf soup featuring lion’s mane mushroom. Open all day, this is definitely a place to drop in for breakfast, lunch or dinner.
22-24 Seymour Place
London W1H 7NL
Opened by Michael and Adrian Daniel, brothers with an Indo-Iraqi heritage, this restaurant aims to recreate the diverse flavours and culinary experiences they had enjoyed as children, eating food with Arabic, Indian and Jewish influences. Dishes like beetroot and mascarpone mousse, pressed multi-seed crumble, and aubergine schnitzel layered with applewood smoked cheddar, basil pesto, roasted red peppers and plum tomatoes, have made it a firm local favourite. It was even named the ‘jewel in the crown’ of vegetarian restaurants in London by Conde Nast Traveller. That’s some accolade.
15-17 Blandford Street
London W1U 3DG trishnalondon.com
Established in Marylebone since the days when Barack Obama was a little-known
senator in Illinois, this Michelin-starred Indian restaurant is a favourite with locals on a plant-based diet. While not wholly plantbased, there is an extensive range of vegetarian dishes on the menu, with vegan and gluten-free options available for many of them. They even offer a fully vegan tasting menu for those special nights out, with dishes like tawa subz salad (candy beetroot, asparagus, cashew nut, lotus root crisp, pea shoot) or jackfruit and pea chettinad (coconut oil, garlic, mustard seeds), making sure no-one misses out on the occasion.
20 Seymour Street
London W1H 7HX daisygreenfood.com
A little part of Australia in London, Daisy Green is one of a collective of cafes, restaurants and garden eateries which aim to bring some of the relaxed Aussie coffee culture to London. The menu is mainly vegetarian, with dishes like sweetcorn fritters or vegan alternatives like their healthy-start breakfast. This relaxed and welcoming cafe even offers the occasional bit of animal protein for the bacon-lovers out there.
19-21 Blandford Street London W1U 3DJ jikonilondon.com
The fact that founder Ravinder Bhogal’s latest cookbook is called Comfort and Joy: Irresistible pleasures from a vegetarian kitchen, should tell you all you need to know about this restaurant. Dishes like butternut squash pakoras, moilee, lemon rice and green bean & cashew nut thoran offer a vibrant celebration of immigrant cultures, with vegetarian cuisine playing a central role. A must-visit restaurant for lovers of land-based cooking.
sonatas, Flaming Alligators with a selection of New Orleans tunes and heartbreaking ballads, and an always popular-evening with Rick Wakeman.
28°-50° BY NIGHT
76 Jason Court
London W1U 2SJ 020 3307 6006 2850bynight.co.uk
orchestral, jazz and even musical theatre are among the genres on offer. A visit to the website is sure to reveal something tempting on offer.
ST MARYLEBONE’S PARISH CHURCH
London NW1 5LT 020 7935 7315
36 Wigmore Street
London W1U 2BP 020 7935 2141 wigmore-hall.org.uk
Situated in the heart of Marylebone, Wigmore Hall is one of the world’s great concert halls. It is globally acknowledged for its work with chamber and instrumental music, early music and song. Founded in 1901, Wigmore Hall offers music-making of outstanding quality and hosts a wide range of events in the community. The repertoire on offer extends from the Renaissance, incorporating both worldfamous music and littleknown gems, and includes contemporary jazz and new commissions in a variety of genres from today’s most exciting composers. This summer sees performances from Mao Fujita on piano, playing the final instalment of his traversal of Mozart’s
Founded in 1901, Wigmore Hall offers music-making of outstanding quality and hosts a wide range of events in the community.
Having established the 28°-50° restaurant as a firm favourite with locals and visitors alike, the team responsible have branched out into live music with 28°-50° by Night. Located in an atmospheric basement venue just a few metres away, it delivers the same food, wine and service, but with the addition of live jazz every night. Guests can expect dixieland, trad jazz, blues, swing and stomp from some of London’s best-known Jazz musicians. Boasting live jazz and blues until 2am and late-night dining until 1am, it’s the ideal spot to toast the weekend or enjoy a mid-week escape.
ROYAL ACADEMY OF MUSIC
London NW1 5HT 020 7873 7373 ram.ac.uk
The oldest conservatoire in Britain, and the second oldest in the world, is currently celebrating two centuries of teaching and creating music. With alumni ranging from Sir Simon Rattle and Dame Felicity Lott to Sir Elton John, the Academy believes in nurturing a wide variety of musical talents. As part of its programme, the institution hosts a comprehensive calendar of events featuring global superstars, ex-students and those still undergoing their studies. A mix of free and paid for events ensures access to music is available to everyone who has time to swing by. Opera, recitals,
The parish of St Marylebone enjoys a vibrant musical life. The parish church has two organs, a Blüthner Grand piano, a Yamaha upright practice piano in the choir vestry, a 10-voice professional adult choir, and a youth choir. Under the musical direction of Bertie Baigent, music director of Waterperry Opera Festival and assistant conductor with the City of Birmingham Symphony Orchestra, St Marylebone’s performers present a wide variety of liturgical and secular music, organ recitals and choral performances, many of which are free to attend.
229 Great Portland Street
London W1W 5PN 229.london
229 is a multi-purpose entertainments venue which plays host to gigs, club nights and weekend festivals. This is definitely one for the night owls and clubbers. Managed under the umbrella of the International Students House charity, all profits go to support the charity’s mission. The charity believes that every young person should have the opportunity to succeed whatever their background. Together with university partners and supporters, it provides scholarship opportunities, a home and a social programme to enable students to succeed. So if you want to rave for a good cause take a trip to the 229 website.
28°-50° by Night
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The centre of medical excellence in the heart of London harleystreetmedicalarea.com