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Winter 2014 • Issue 15

BOWEL SCOPE SCREENING reducing the incidence of colorectal cancer

TRIPS AND FALLS: ANKLE INSTABILITY steady ground offered in advanced treatment


advances and developments of neuroendocrine tumour care

The Wellington Hospital South Building

The Wellington Hospital North Building

Platinum Medical Centre

The Wellington Diagnostics and Outpatients Centre

WELCOME A very Happy New Year to all, This year marks some landmark celebrations here at The Wellington Hospital, notably our 40th anniversary since first opening our doors. It is hard to believe that the hospital opened with just 98 rooms and three operating theatres and has grown vastly not only in capacity, but in staff numbers and technology too. However, one thing remains the same; the drive to provide the best in private healthcare. In this, our winter issue, Mr Jonathan Wilson, Mr Lee Dvorkin and Dr Ana Wilson discuss the advanced treatment of bowel scope screening, including the challenges of implementing such an impressive technology (page 12-13). We are proud of the state-of-the-art systems and services we offer here at The Wellington and on page 11, Specialist Hand Therapist Melita Ryan highlights the advanced technology being used in the London Hand and Wrist Unit, including ‘on the move’ applications available at the end of your fingertips! Also in this issue, Professor Martyn Caplin discusses developments in the diagnosis and treatment of Neuroendocrine Tumours and how The Wellington Hospital will be growing to accommodate the call for more specialist facilities in this area. For those interested in this innovative treatment, there will be more featured in coming issues. Best Wishes,

Keith D Hague CEO

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Editor: Hannah Rogers Production & Distribution: Runwild Media Group


12 CONTENTS 04 | PNI Unit: an introduction Mr Anthony MacQuillan presents the Peripheral Nerve Injury Unit

06 | Developments within gynaecology Mr Angus McIndoe

07 | Off piste: contemporary management of ski injuries to the knee Mr Howard Ware

08 | Neuroendocrine tumours: advances and developments Professor Martyn Caplin discusses the developments within NETs

10 | Modern management of temporomandibular joint disorders

Mr Luke Cascarini


11| TherAPPy: hand and wrist Melita Ryan

12 | Bowel scope screening: modern care of colorectal cancer Mr Jonathan Wilson, Mr Lee Dvorkin and Dr Ana Wilson present the screening service, Bowel Scope

14 | New treatment options for uterine fibroids Professor Ellis Downes

15 | Advanced treatment for a common problem: ankle instability


Mr Simon Moyes

16 | GP news Updates from the primary care sector

18 | Latest news and new consultants

08 3


PNI Unit: Consultant

an introduction

FOCUS The Peripheral Nerve Injury Unit at The Wellington Hospital offers expertise in the field of nerve injury, nerve tumours and limb reconstruction that is unparalleled in Europe.

Mr Michael Fox MBBS, BSc (Hons), FRCS (Orth)

Consultant Orthopaedic Surgeon

Dr Marco Sinisi MD Consultant Neurosurgeon

The peripheral nerve consultant team is drawn from the disciplines of neurosurgery, plastic and orthopaedic surgery. This comprises each of the key ingredients required to treat nerve injury or tumour reconstruction. The unit at The Wellington reflects the expertise offered by the same team in

Diagram of free functional muscle transfer for biceps reconstruction, using the gracilis muscle.

the world famous Peripheral Nerve Injury Unit at the Royal National Orthopaedic Hospital (RNOH). All treatments can now be offered privately at The Wellington Hospital. In addition to vast clinical experience, the unit has an excellent research background. The scope of conditions and injuries treated vary from nerve compressions (such as carpal tunnel, cubital tunnel and thoracic outlet syndrome) through to traumatic injuries of all peripheral nerves, immediate treatment and late reconstructions. Nationally recognised by fellow surgeons for the treatment of nerve lesions following bone fractures and fixation, the unit also deals with the management of complex nerve-related pain. One of the only places in the world to offer nerve root reimplantation into the spinal cord after major brachial plexus injury, it is also one of the only centres to have a functional muscle transfer program. Alongside this, the unit offers resection and reconstruction of benign and malignant nerve tumours.

The unit comprises of: Mr Michael Fox Dr Marco Sinisi Mr Anthony MacQuillan

Mr Anthony MacQuillan MBBS, MRCS(G), MD, FRCS(Plast)

Plastic and Reconstruction Surgeon

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Diagram of an ulnar nerve fascicle to biceps and median nerve fascicle to brachialis transfer. This is used following brachial plexus injury to the upper trunk or C5 and C6 nerve roots.

To find out more information about Mr Michael Fox, Dr Marco Sinisi and Mr Anthony MacQuillan, please visit website/contributors.php


Case REPORTS Case Report: Nerve root re-implantation BR, a 26 year old man, sustained a complete avulsion of all five roots of the brachial plexus following a motorcycle accident. He attended the PNI Unit two weeks following the injury and was operated on within three days. Three nerve roots were re-implanted directly into the spinal cord. Following a further week in hospital, patient BR was discharged. A physiotherapy and exercise program began and at review 18 months after the procedure, BR had regained 90째 of shoulder abduction and 120째 of elbow flexion with full elbow extension.

Case Report: Biceps reconstruction (free functional muscle transfer) CG, a 32 year old man, presented to the PNI Unit three years following a motorcycle accident abroad. He had been operated on previously but had failed to regain elbow flexion. A muscle was transplanted from his leg to his arm and fresh nerves from his shoulder were used to re-innervate the transferred muscle. Physiotherapy commenced six weeks after the operation and the transferred muscle began to move nine months after the operation. Range of motion and muscle strength continued to improve over the next 18 months and, by three years following the procedure, CG had regained full elbow flexion and was able to lift weights using the injured arm.

Case Report: Radial nerve repair post-humeral fracture TS, a 46 year old woman, sustained a fall whilst skiing, fracturing her right humerus. The fracture was treated abroad with open reduction and internal fixation using a plate and screws. Following the procedure, TS noticed a total wrist drop with an inability to extend the digits on the injured side. She presented to the PNI Unit six weeks following the operation, where she was examined and neurophysiology tests undertaken. These demonstrated a lesion of the radial nerve at the level of the fracture and after an exploration of the nerve it was found to be adherent to the fracture site with dense scar tissue surrounding it. The nerve was released (neurolysed) along the entire length of the lesion and then intra-operative nerve conduction testing was performed, demonstrating improved nerve function. At two weeks following the intervention, TS was reviewed in clinic where all hand and wrist functions were found to have recovered. 5


PM: What cases are carried out robotically and what are the benefits of this to patients? • Simple hysterectomy • Radical hysterectomy • Myomectomy • Sacro-colpopexy for vaginal prolapse • Colposuspension

Developments within gynaecology Consultant Gynaecologist, Mr Angus McIndoe describes his career and advances within his specialist areas, including the state-of-the-art da Vinci Si robot

PM: Can you explain your role as a Consultant Gynaecologist here at TWH? I am a full time private Gynaecologist at The Wellington Hospital, where I see and treat patients with a wide variety of gynaecological conditions. I try to put patients at ease and make their experience as reassuring as possible. My specialty areas are surgical conditions including gynaecological oncology, uterine fibroids, ovarian masses, colposcopy, vaginal prolapse, and abnormal vaginal bleeding. I also function as advisor to the Chief Executive and Medical Director on gynaecological matters and have supervised a number of my colleagues through difficult clinical circumstances. PM: Can you tell us a little bit about your education/work history? Early in my career I decided to focus on the surgical aspects of gynaecology. I worked for a total of three years in general surgery, and gained my FRCS qualification. I have also completed subspecialty training in gynaecological oncology. My academic training included a PhD from London University in immunology of cancer of the cervix and HPV.


I am keen to undertake surgery as a minimally invasive procedure (where appropriate), and now use the da Vinci Si robot for many procedures. Enquiry Helpline: 020


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I was appointed as Consultant in Gynaecological Oncology at the Hammersmith Hospital, which I undertook for 18 years. During this time I was responsible for subspecialty training of many young doctors and also trained many in colposcopy. In addition to this, I was Chief of Service for Gynaecology, Lead Consultant for Gynaecological Oncology and Lead for Colposcopy at the Hammersmith Hospital for over ten years. PM: Can you explain the patient pathway both in the UK and overseas? Accurate diagnosis is the key to the best treatment. I have built up a diagnostic team that can give the correct diagnosis rapidly and this is the basis for formulating the treatment plan. If patients require surgery, this can be organised usually within two working days.

Following robotic surgery, patients make a truly remarkable recovery with many able to return to normal activities within one to two weeks. Complication rates and pain following surgery are significantly reduced and early mobilisation is encouraged making the recovery following surgery rapid. PM: What are the latest developments within gynaecology? Recent studies have suggested that a more radical approach to surgery for ovarian cancer may lead to significant benefit in terms of survival. The surgery is technically more demanding but the complication rate and length of stay are not adversely affected, if the surgery is performed well.


For international patients, imaging can be reviewed prior to their arrival in the UK to expedite their management once they arrive. PM: Which specialist treatments do you offer? I am keen to undertake surgery as a minimally invasive procedure (where appropriate), and now use the da Vinci Si robot for many procedures. The single site robotic approach is a new technique which is conducted through a single incision to the umbilicus, which is invisible when healed. Currently, I am the only gynaecologist in the UK offering this treatment option. The most common operation performed using this technique is a hysterectomy, although other procedures can benefit from this revolutionary approach.

For international patients, imaging can be reviewed prior to their arrival in the UK to expedite their management once they arrive.

Many studies are pointing to a fallopian tube origin of ovarian cancer as precursors of this disease have been found in this area and not in the ovaries. It appears likely that the disease originates in this area and by the time it is diagnosed, it has spread to the ovaries and other structures within the abdomen. More studies are needed but our understanding of this field is developing rapidly. HPV vaccination has been shown to reduce the incidence of precancerous abnormalities in the cervix but recent studies also suggest that it reduces the risk of recurrence after treatment for this disease. Effect of caesarean section scar on future labours has been well studied recently. Depending upon the size of the defect after LSCS, performance in future labours can be predicted to some extent. Further work is needed to determine how to ensure that the uterus heals without defect so that future pregnancies are not adversely affected. To find out more information about Mr Angus McIndoe, please visit his website http://www. or www.practicemattersmag.


Off piste: contemporary management of ski injuries to the knee Prevention and treatment for knee injuries on the slopes by Consultant Orthopaedic Surgeon, Mr Howard Ware Approximately half of all injuries sustained by skiers are to the knee, caused by strain placed on the legs by manoeuvres. Most injuries settle with simple therapy such as icing the knee, rest and topical or oral analgesia but, occasionally, the damage to the joint can be significant and surgery may be required.

Injury to the MCL

In most cases the injury is not severe. The pain can persist for several weeks and physiotherapy may enhance the recovery. If it does not settle then an injection of steroid into the tender area (ideally using ultrasound to accurately insert the needle) resolves the problem. Where there is an isolated but significant injury to the MCL, the joint must be rested in a knee brace for several weeks.


A simple valgus manoeuvre can stretch the medial collateral ligament (MCL) causing pain and swelling on the medial side of the knee. There is usually point tenderness on the medial femoral epicondyle and it is painful when testing the collateral ligament.

An MRI of the knee is invaluable in cases where there is significant pain, effusion or instability. If there is no clear fracture on the X-ray then an MRI is essential and will inevitably cement a diagnosis, resulting in an effective treatment plan.

Occasionally, the examination of the knee demonstrates that the medial joint line opens up significantly when tested, indicating a serious tear in the MCL. If it appears very unstable, the joint has dislocated or swollen dramatically. This is often an associated injury to the anterior cruciate ligament (ACL).

A simple twist can also tear the meniscus in the joint, with the medial meniscus more likely to be injured than the lateral, particularly with age. In younger adults, the menisci are more malleable. However, as we age, the water content in our tissues decreases. As a result of this, they become stiffer and less able to resist a twisting injury with the same degree of force. If the medial meniscus is torn, pain and tenderness is experienced on the medial side of the knee, often this indicates a tear in the posterior part of the medial meniscus. Typically, the patient will complain that it hurts to twist and kneel, and it may lock or give way.


If the injury is to the ACL, an MRI will establish the diagnosis as, in the early stages, it may be difficult to assess the joint due to swelling and pain.

Medical meniscus injuries

If the MRI shows that the meniscus is displaced, then an arthroscopy will be required. However, if the meniscus is not displaced and the symptoms settle, then this may be treated conservatively (particularly in older patients).

An MRI of the knee is invaluable in cases where there is significant pain, effusion or instability. Injury to the ACL

If the injury is to the ACL, an MRI will establish the diagnosis as, in the early stages, it may be difficult to assess the joint due to swelling and pain. The injury is usually towards the end of a skiing holiday and will require further evaluation and often ligament reconstructive surgery. If the MRI shows an ACL rupture, bone bruising on the lateral condyles, but no other injury, then the treatment is ice, analgesia as required and physiotherapy. If there is a displaced meniscal tear, then an arthroscopy is required. If there is an isolated ACL injury and the knee remains stiff (especially with loss of full extension after three or four weeks), then the patient needs an arthroscopy to remove the ACL remnant, followed by physiotherapy to restore movement. If the joint recovers with a good range of movement after a few weeks, then an ACL reconstruction can be considered, if appropriate for that patient. To find out more information about Mr Howard Ware, please visit www.practicemattersmag. 7


Neuroendocrine tumours: advances and developments

Professor Martyn Caplin, Consultant Gastroenterologist at The Wellington Hospital, Chairman of the European Neuroendocrine Tumour Society and former chair of the National Cancer Research Institute Neuroendocrine Tumour Committee, discusses advances and new developments within NETs PM: What exactly is a neuroendocrine tumour (NET)? PC: Neuroendocrine tumours (NETs) originate from cells that have the ability to make hormones and can be found anywhere in the body. A NET develops when these cells grow abnormally with the most common sites including the intestine, pancreas, stomach and lungs. PM: What are the symptoms? PC: Many have no symptoms or non-specific symptoms such as abdominal pain. 10 per cent of patients can present with symptoms such as flushing and diarrhoea, which is part of carcinoid syndrome, or recurrent peptic ulcers and diarrhoea as part of Zollinger Ellison syndrome. Some present with sweaty and vague episodes as part of hypoglycaemia and insulinomas symptoms. The problem can be the rather non-specific symptoms, for example flushing in women is often thought just to be due to menopausal type symptoms. Diagnosis is often delayed, as symptoms may sometimes be misdiagnosed, particularly in patients who


We have a team at The Wellington able to carry out a whole range of treatments. Enquiry Helpline: 020


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experience abdominal pain and diarrhoea and are diagnosed with IBS. The average time to diagnosis can be three to seven years from the time of onset of symptoms, meaning that often patients have advanced disease that has spread to other organs such as the liver, bones and lymph nodes at diagnosis of a NET. PM: How common are NETs? PC: New cases in the UK are thought to be relatively rare (incidence 6:100,000) but as the tumours are often slow growing, the prevalence in terms of people living with a NET are reported as high as 30:100,000. This means that there are about more than 10,000 people in the UK with NETs in any year. This rate makes them more common then gastric cancer, myeloma and non- Hodgkins Lymphoma. Over 100 patients alone were seen at The Wellington last year for NET related issues. PM: What tests are available for diagnosis? PC: In addition to usual blood tests, the most important is plasma chromogranin A and fasting gut hormones. The 24 hour urine 5HIAA is performed for patients who are thought to have carcinoid syndrome. Standard imaging protocols are used including contrast CT and MRI scans and patients often require special nuclear medicine imaging such as the Octreotide scan or (new to The Wellington)

the Gallium-68 Octreotate PET Scan, which lights up tumour ‘hot spots’ and is the most sensitive imaging modality. PM: What is the background to diagnosis and treatment? PC: There is a large research programme based at The Royal Free Hospital, which is the largest centre in the UK and the first to be awarded a European Centre of Excellence for NETs. The Wellington Hospital is linked to this European Centre of Excellence as a partner hospital, ensuring we have the right standards and that patients are seen by a multi-disciplinary team. All of that expertise is going to be transferred across here and nurses will have a range of specialist training including radiation.




New cases in the UK are thought to be relatively rare, meaning that there are about 10,000 people in the UK with NETs in any year. PM: What about the treatments that will be made available? PC: At The Wellington we will be able to carry out a whole range of treatments. The first line treatment for patients with symptoms or syndrome are the somatostatin analogues, and these intramuscular octreotide LAR or deep subcutaneous injection lanreotide Autogel usually given every 28 days. Somatostatin analogues have more recently been shown to have anti-tumour effects. We have GI surgeons and hepatobillary/pancreatic surgeons who can resect the primary tumour and also operate on the liver metastasis. We have thoracic surgeons who have specific experience with lung NETs. A percentage of patients with carcinoid syndrome can get carcinoid heart disease, as the hormone levels affect the valves and make them fibrotic. To support this, we are able to perform carcinoid heart valvular surgery here and have cardiologists who specialise in this area. PM: What are the options for patients who are inoperable? PC: Besides the anti-hormonal treatment, we occasionally use chemotherapy, mainly for the higher-grade pancreatic, gastric and lung NETs that are advanced and inoperable. With a small minority, we use interferon which stimulates the immune system to fight the tumour cells. There are new, specifically molecular targeted agents (Sunitinib and Everolimus), which block the enzymes that cause the tumours to grow. Then we have radiological procedures such as embolisation (cutting off the blood supply to liver tumours), radiofrequency ablation (burning away tumours in the liver) and we will be able to offer SIRT radioactive beads into the liver.


Additionally, based on the Octreotide scan or Ga-68 Octreotate PET, we can change the imaging isotope for a stronger radioactive beta emitting particle and inject the ‘magic bullet’ targeted therapies, which then bind to the tumour cells and can kill them – using Lutetium-177 or Yttrium-90 Octreotide. PM: Can you tell us a bit about advances in treatments and the planned new NETs unit? PC: All patients are discussed in our multidisciplinary meetings as to the best treatment protocol. We have access to the most recent, cutting edge opportunities. For example, recently we published papers on circulating NET cells in the blood stream, which has prognostic implications. We will be able to tell if tumours are growing and isolate tumour cells in the blood stream. We have a whole programme looking at the genomics and isolating DNA from circulating tumour cells. The aim is to have a liquid biopsy where we can repeatedly look for any changes in the genetic profile of the tumour, following different treatments. The basis of the Unit is that we have this European Centre of Excellence status and we are transferring those world class quality standards and reputation to the private sector. It will be unique with nothing else in the independent sector to match it. It will adhere to the Centre of Excellence guidelines so that we know that we are always treating patients optimally. As these cases are relatively rare, we will also be supplying information to the primary care and international referrers. We will also have hotlines so people can get hold of the team easily. These are important aspects and undoubtedly a key feature to the success of the new unit. To find out more information about Professor Martyn Caplin, please visit www.practicemattersmag.

Professor Martyn Caplin BSc, (HONS), DM, FRCP

Consultant Gastroenterologist Professor Martyn Caplin has a special interest in general gastroenterology, upper and lower GI endoscopy, peptic ulcer disease, IBS, coeliac disease and abnormal liver function. He has an international reputation in the field of intestinal cancers including neuroendocrine (carcinoid) tumours. He has just been elected chairman of the European Neuroendocrine Tumour Society and is the immediate past chairman of the National Cancer Research Institute Neuroendocrine Tumour Committee as well as immediate past chairman of the UK & Ireland Neuroendocrine Tumour Society. He has a large research programme investigating the effect of intestinal hormones on the gut, new therapies for neuroendocrine tumours and HPB tumours. Between 2007-2012 he was the NHS clinical lead for the National Library for Health under the auspices of NICE for evidence based practice in Gastroenterology and Liver Diseases. Professor Caplin is also a consultant gastroenterologist at The Royal Free Hospital in North London and Professor at University College London Medical School. 9


Modern management of

temporomandibular joint disorders Consultant Oral and Maxillofacial Head and Neck Surgeon Mr Luke Cascarini discusses the benefits of advanced treatments for TMJ The Temporomandibular Joint (TMJ) is a synovial joint between the mandibular condyle and the cranium. It is separated into an upper and a lower space by a disc of fibrocartilage. The joints are connected by the mandible and one side cannot move without affecting the other. The TMJ is susceptible to the same conditions as any other small joint and the modern management options are not unlike other types of orthopaedic management.

Causes of TMJ Prolonged Repetitive Strain Injury (RSI) can lead to internal damage to the joint with osteo-arthritic changes including synovitis and degeneration. The disc is often irreducibly deranged, degenerate and the joint, dysfunctional. Sadly, in advanced cases, the impact on quality of life can be huge with poor function and constant pain.


Although RSI are common, this is secondary to parafunctional habits such as jaw clenching and tooth grinding (often related to stress). Pain is often worse in the morning and usually presents as ear

A significant number of patients present with internal derangement and pain as first signs of hypermobility syndrome.

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ache pain. There may be some clicking of the joint and (in severe cases) there may be locking. Many patients are initially referred to an ear, nose and throat (ENT) specialist for assessment.

Common symptoms and signs of TMJ disorders • Clicking of the joint • Ear ache-type pain • Tension-type lateral headaches • Restricted movement (indicates internal derangement, disc displacement) • Swollen and tender muscles of mastication • Tender TMJ capsule • Evidence of tooth wear A significant number of patients present with internal derangement and pain as first signs of hypermobility syndrome. This is often due to the type of cartilage in the TMJ, (which is fibrocartilage rather than the hyaline cartilage in most other joints), and also due to laxity of supporting ligaments. Those with hypermobility normally do less well with invasive surgery, benefitting from more conservative methods in their overall management.

Management options If the parafunctional habit is short lasting, then the condition can often be managed by rest, ice, non-steroidal anti-inflammatory drugs (NSAIDs) and a basic dental splint. However, where these early stage methods of management fail, further, more intense treatment or even surgery may need to be considered.

TMJ arthroscopy A camera is used to investigate problematic areas and, if necessary, treatments such as removing scar tissue or suturing the discs can be performed at this time. Modern disposable TMJ arthroscopes are a mere 1.2 mm in diameter and complications are rare and usually minor. The benefits of TMJ arthroscopy, lysis and lavage, have proved to be a highly effective tool for a multitude of problems including synovitis, internal derangement and open joint surgery.

Total TMJ replacement surgery This type of surgery is used not for pain relief but to restore function, making it a last resort for TMJ patients. The prosthetics are custom-made with a metal ramus and condyle articulating with an ultra dense polyurethane fossa. Total TMJ replacement surgery has now reached a stage where good longterm results have been demonstrated using either of the two systems available.

Current treatments after conservative management • Advanced dental splint to remove occlusal interferences • Botox for muscle spasm • Therapeutic and diagnostic arthroscopy • Joint wash-out and intra-articular anaesthetic and steroids • Open joint procedures to restore anatomy (if failed arthroscopy) • Total joint replacement (in selected cases) in accordance with NICE guidelines To find out more information about Mr Luke Cascarini, please visit www.practicemattersmag.


TherAPPy: hand and wrist

Specialist Hand Therapist Melita Ryan presents the advances in technology being used in the world of hand and upper limb therapy In a world that is increasingly focused on technology, many patients want to know about the latest and most advanced methods to help them recover from hand and wrist injuries. Hand and upper limb therapy has certainly progressed over the past few years, particularly with the introduction of smartphone apps and easily accessible methods. As a result, our therapists are utilising more modern, patient accessible techniques in their treatment sessions. Here are some recent advances that we are using at The London Hand and Wrist Unit and some great apps you can recommend to patients:

Kinesiotape Yes, every athlete at the Olympics was decked out in kinesiotape but what does it actually do? Kinesiotape was developed in Japan by Kinesio Kase as an alternative method of sports strapping which, up until that point, had been rigid and restricted movement. The tape itself is designed to imitate the role of the skin over the underlying muscle structures. It is great for soft tissue sport injuries of the hand and upper limb as it has been demonstrated to reduce the bruising and swelling associated with localised inflammation. Kinesiotape supports underperforming structures when it is applied over a particular tendon or ligament, increasing the body’s awareness of the structure and assisting it to perform.

Apps–Therapy at the touch of a button Orientate Through research, we are learning more and more about the role of the brain in rehabilitating hand and upper limb injuries. Increasingly, studies are demonstrating that improving laterality enhances movement and control. This can reduce pain symptoms in patients with painful conditions. Orientate can be set to work on hand and/or foot laterality.

Powerballs These are not for the light hearted and must be used under the instruction of a therapist as they can be damaging for some hand injuries. We feel that the powerball is a great device to develop strength and stability. There is increasing evidence to suggest that assistance with regaining wrist movement and strength post-injury and the restoration of proprioception (the awareness of the position of the wrist in space) is important. The powerball creates a feeling of resistance as you rotate the ball, developing your body’s joint awareness.


In a world that is increasingly focused on technology, many patients want to know about the latest and most advanced methods to help them recover from hand and wrist injuries.

There are other laterality apps provided by the NOI Group which are more in-depth. A therapist will be able to advise patients on which is best suited for specific conditions.

Hand Decide The best way to understand a hand injury is to be able to picture what is happening to the injured structure. Hand decide is a free app that gives the patient a 3D image of the hand, the underlying structures and how the structures work together to create movement.

Rehab Minder A patient will never forget their exercises again! Rehab Minder is great for the busy patient. The therapist can set up the timing and exercises to remind them when an exercise is due, complete with guided demonstration.

To find out more information about Melita Ryan, please visit www.practicemattersmag. 11


Bowel Scope Screening: modern care of colorectal cancer

Dr Ana Wilson, Mr Lee Dvorkin and Mr Jonathan Wilson are members of The Wellington Hospital GI Unit treating patients with a variety of gastrointestinal diseases. Here they present ‘Bowel Scope’, a new screening initiative to help reduce deaths from colon cancer

Colorectal cancer (CRC) affects approximately 1 in 18 people in the UK, making it the third most common cancer. In addition to this, statistics show that CRC causes more than 16,000 deaths every year, making it the second leading cause of cancer related mortality. The vast majority of CRCs develop from polyps, which can be removed through a polypectomy. This treatment has been shown to reduce the incidence of CRC by 75-90 per cent.

What are the current screening methods in the UK? The NHS Bowel Cancer Screening Programme is fully rolled out across England for people aged 60 to 75. Those eligible for screening receive a faecal occult blood test (FOBT) for completion at home, which analyses the patients’ faeces for the presence of blood. The completed kit is then posted back to one of the five screening ‘hubs’ in England, which each have between 5 and 17 screening centres attached to them. Patients with a positive FOBT are invited for a colonoscopy, which is performed by nationally accredited colonoscopists. The aim of colonoscopy is to detect cancers but also to reduce the incidence of colorectal cancer through polypectomy. The test is repeated every two years and the evidence suggests that it reduces the CRC fatality risk by 16 per cent.

What is ‘Bowel Scope’ Screening (BSS)? A large randomised controlled trial (Atkin et al, 2010*) has shown that a one-off flexible sigmoidoscopy at the age of 55 reduces the incidence of CRC by 33 per cent and mortality by 43 per cent. It is estimated that this BSS would prevent about 3,000 cancers every year. The Department of Health has committed to investing £60 million to incorporate flexible sigmoidoscopy into the current screening programme, and aims to make BSS

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available to all 55 year olds in England by 2016. Since March 2013, patients in six endoscopic excellence pilot geographical areas have been invited for BSS around the time of their 55th birthday. The pilots are run in 6 centres of endoscopic excellence: • South of Tyne (Queen Elizabeth & South Tyneside) • West Kent & Medway

‘‘ • Norwich

• St Marks (London) • Wolverhampton • Surrey (Guildford)

The NHS Bowel Cancer Screening Programme is fully rolled out across the England for people aged 60 to 75.


What does BSS involve? The hub invites those who are eligible eight weeks in advance of the appointment date. Once the appointment is confirmed, enemas are posted to patients and should be self-administered an hour before leaving home for their procedure. During the examination itself, patients are offered ‘Entonox’, but not sedation, and the bowel is examined only as far as comfort allows. Polyps smaller than 10mm in size are removed during the examination. The majority of patients will have a normal test and be discharged with reassurance. Almost five per cent of patients will be referred for colonoscopy because of the type or number of polyps found. One in 300 patients will present with colorectal cancer at this stage.


FOCUS Dr Ana Wilson BA MD MRCP Consultant Gastroenterologist

Dr Wilson specialises in all aspects of general gastroenetrology, including abdominal pain, change in bowel habit, rectal bleeding, inflammatory bowel disease, irritable bowel syndrome and food intolerance. She also has a specialist interest in complex therapeutic endoscopy and colorectal cancer surveillance in colitis.

What are the challenges to the implementation of BSS? Bowel Scope translates into approximately 80 additional flexible sigmoidoscopies and four colonoscopies per week for the regional BSS unit. This large increase in demand clearly requires innovative ways of working, including weekend and evening lists, especially as the majority of invited population will be in full-time employment. All currently accredited screening colonoscopists are automatically accredited for BSS, but there will be a need to further increase the pool of endoscopists to cope with the extra demand. Nurse endoscopists, specialist registrars and allied health care professionals will be allowed to accredit for BSS providing they meet the required key performance indicators (a minimum of 300 flexible sigmoidoscopies or colonoscopies including quality parameters) and have passed the formal assessment. They will also be expected to undertake a minimum of 400 flexible sigmoidoscopies per year. Currently, the UK falls behind our European neighbours in colorectal cancer survival rates. As these figures show, although there are significant challenges ahead in regards to the successful implementation of BSS, any further reduction in the incidence of colorectal cancer is greatly needed.



It is estimated that this ‘Bowel Scope Screening’ would prevent about 3,000 cancers every year. To find out more information about Dr Ana Wilson, Mr Lee Dvorkin and Mr Jonathan Wilson, please visit website/contributors.php

Dr Ana Wilson BA MD MRCP is a Consultant Gastroenterologist and accredited specialist screening endoscopist at St Mark’s Hospital, London, where she is involved in the implementation of ‘Bowel Scope’ screening.

Mr Lee Dvorkin MD FRCS Consultant Colorectal Surgeon

Mr Lee Dvorkin MD FRCS is a Consultant Colorectal Surgeon at The North Middlesex University Hospital where he is Clinical Lead for the Department of Surgery. His interests are laparoscopic colorectal cancer surgery, inflammatory bowel disease and proctology (advanced fistula surgery and neuromodulation for incontinence). Mr Dvorkin has an MD in ‘pelvic floor dysfunction’ and completed a fellowship at St Marks Hospital. Mr Dvorkin is a Senior Lecturer at University College Hospital and Associate Professor of Surgery at SGU.

Mr Jonathan Wilson PhD FRCS Consultant Laparoscopic Colorectal and General Surgeon

Mr Jonathan Wilson PhD FRCS is a Consultant Laparoscopic Colorectal and General Surgeon at the Whittington Hospital, London, where he is the clinical lead for colorectal cancer. His interests are laparoscopic surgery for colorectal cancer and inflammatory bowel disease, advanced colonoscopy and proctology (contemporary haemorrhoidectomy “haemorrhoidal artery ligation”). Mr Wilson also offers minimally invasive surgery for abdominal/groin hernias and gallbladder pathology. Mr Wilson has a PhD in Colorectal Cancer and has completed a Colorectal Fellowship at St Mark’s Hospital, London. 13


New management options for

uterine fibroids Consultant Gynaecologist Professor Ellis Downes discusses the surgical and medical treatment available Uterine fibroids are very common and can effect an estimated 15-20 per cent of women. For the majority of women with fibroids they are asymptomatic, but for some they can cause menstrual symptoms (menorrhagia, inter-menstrual or post-coital bleeding), infertility or pressure symptoms (bloating, urinary frequency and incontinence). Fibroids may be suspected clinically, as patients will usually present with a hard enlarged uterus. This diagnosis is then confirmed on ultrasound examination, which can accurately measure the fibroids’ size and location. Occasionally, an MRI may be needed to see if there is any evidence of the rare sarcomatous fibroid change.

Surgery options

Medical treatment Fibroids are oestrogen sensitive and often shrink after the menopause. LH-RH agonist drugs such as Zoladex have been used for many years to shrink fibroids, and are very effective at doing this. However, many women have significant menopausal side-effects and are not able to tolerate LH-RH agonists, even with back therapy (oestrogen patches or livial, for example).


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Hysterectomy used to be the traditional treatment option for women with fibroids who had completed their families, but it is now just one of several treatment options. The numbers of women having hysterectomies in the UK is falling, year on year. Despite published evidence of the safety and benefits of laparoscopic and vaginal approaches, the most common mode of performing a hysterectomy in the UK is still via the open abdominal route. This is in stark contrast with our colleagues in Europe and the US where an open abdominal approach is relatively unusual. However, with large fibroids, it may achieve better results for the patient if an abdominal approach is taken.


Over the last year, the medical management of fibroids has changed significantly with the arrival of the drug Ulipristal acetate, marketed as Esmya. This is a new class of drug, known as a SPRM (synthetic progesterone receptor modulator), which stops the fibroid tissue from proliferating whilst inducing cell death (apoptosis). A major multi-centre study (PEARL 1) randomised women with fibroids to conventional

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Zoladex or Esmya. Both groups of patients had an approximate 50 per cent reduction in fibroid size within three months. But the Esmya group had a lower side-effect profile and a much slower rate of fibroid regrowth (after stopping treatment) compared to patients given Zoladex. I have been using Esmya on over 30 patients and have been delighted with the results.

Fibroids may be suspected clinically, as patients will usually present with a hard enlarged uterus.

If patients have sub-mucous fibroids (in the uterine cavity), and are keen to preserve their fertility and avoid major surgery, then a hysteroscopic myomectomy procedure may be an ideal solution. Using an operating hysteroscope, the fibroid is resected, leaving the rest of the cavity and endometrium intact. The success of hysteroscopic myomectomy in patients with recurrent miscarriage is lacking in good quality supporting data. As a result, most gynaecologists only offer it to recurrent, extensively investigated miscarriage patients that have no other potentially treatable causes.

The numbers of women having hysterectomies in the UK is falling, year on year. Laparoscopic myomectomy is now well established and may be of benefit for carefully selected patients with symptoms of sub-fertility or pressure symptoms. Multiple fibroids can now be removed laparoscopically avoiding a laparotomy incision. Bleeding can be a problem during surgery, and it’s important to obliterate the “dead space” carefully after the fibroid is removed to maximise the strength of the myometrium, reducing the risk of problems in any subsequent pregnancies. In addition to this, other procedures which have been shown to be good treatment options to treat fibroids include fibroid embolization and MRI-focused ultrasound. To find out more information about Professor Ellis Downes, please visit www.practicemattersmag.


Advanced treatment for a common problem:

ankle instability


With ankle injuries affecting thousands of people each day, Consultant Orthopaedic Surgeon Mr Simon Moyes discusses the options available to patients

An ankle injury is something that many people experience in their lifetime, with around one in 15,000 people injuring their ankle every day. Although this number of cases represents huge numbers worldwide, most injuries to the ankle can be treated conservatively. One of the most common complaints seen by orthopaedic surgeons are lateral ligament injuries to the ankle joint, which can be treated using a number of methods.

Diagnosis of lateral ligament injury The diagnosis of lateral ligament instability is straight forward and comprises of history, clinical findings and imaging. The lateral ligaments are normally tender and the ankle joint is unstable, this being exhibited by an exaggerated anterior draw test which involves trans-locating the foot and ankle anteriorly within the mortise. The amount of anterior play within the ankle joint is compared to the contralateral side and recorded. This represents damage and stretching to the anterior talar fibula element of the lateral ligament complex. Excess inversion implies damage to the calcaneo fibula element of the lateral ligament complex. This is determined by a combination of clinical assessment and radiographic stress tests through the application of set forces. Arthroscopically the patient will present with ballooning of the anterolateral capsule which feels and looks thinner than normal. Frequently there is also scarring in the lateral gutter of the ankle joint and syndesmosis. There may be associated loose bodies in the lateral gutter and in about 5 per cent of cases damage to the talar dome.

A cast, such as an Aircast boot, should be worn for approximately three weeks and followed by a physiotherapy program.

Non invasive treatment A complete rupture of the lateral ligament complex would normally be treated with a clinical assessment and imaging followed by a short period of cast immobilisation. A cast such as a VACOped walker would normally be worn for approximately three weeks and followed by a physiotherapy programme. It is expected that by following these steps some 95 per cent of patients should be fully recovered at six to twelve weeks.

Surgical options Surgery for ankle instability was discovered as early as 1949 with a tendon transfer using peroneus brevis. However, it was Brostrum in the 1990s that showed that a direct repair of the lateral ligaments was possible, even years after an acute injury. Hamilton later reported 95 per cent good or excellent results with a modified Brostrum repair. With lateral ligament tears it is the anterior talar fibula ligament (ATFL) that fails first, with calcaneo fibula ligament ruptures rarely presenting. The modified Brostrum reconstruction needs to reproduce the ATFL in its anatomical position and length and is usually successful. There are a small percentage of patients who fail to settle with conservative management and this small sub group, probably 5 per cent or less will be offered either an arthroscopic or open Brostrum repair. This is followed by three weeks in a VACOped walker and a standard physiotherapy programme, with success rates for this surgery being 95 per cent good or excellent results.

Recovery Although this is a common injury and many suffer it, the outcome with initial conservative management is excellent with a highly successful recovery rate. Even the minority of patients that require a lateral ligament reconstruction will also find the prognosis extremely favourable.

VACOped walker

To find out more information about this go to or 15

GP NEWS Round-up In the busy world of General Practice, we look at trending stories, interesting updates from the primary care sector and upcoming GP events here at The Wellington Hospital.

Shingles vaccine for over 70s now available at The Wellington Our private GPs can now offer shingles vaccinations at our facilities at The Wellington Hospital. Recent supply issues meant that the national programme to vaccinate older people against shingles was put on hold until stocks were replenished. The UK-wide programme is used to vaccinate people aged 70 and over and began in September 2013. Since its launch, the Zostavax vaccine has encountered problems in delays with the manufacturing process caused by longer testing periods than originally anticipated.

WDOC GP seminars 2014 The New Year begins with the first of our GP events for the calendar year. Coming up in early 2014 are: Consultant ENT Surgeon Mr Elliot Benjamin & 27th February Consultant Neurologist Dr Paul Bentley – Otology in General Practice & Audiology - Developments in Service and Technology 20th March

Consultant Urologist Mr Guy Webster – An Update on Urology

24th April Consultant Orthopaedic Surgeon Mr Haroon Mann – An Update on the Foot & Ankle All GP seminars are held on the 3rd Floor of The Wellington Diagnostic and Outpatient Centre (WDOC) at Golders Green. The events are hosted by Cardiologist & Medical Director to the centre, Dr David Lipkin. If you are a GP and wish to attend any of our seminars, please RSVP to your invitation by contacting GP Liaison Officer Ricardo Pereira –

Looking to use The Wellington Hospital for a consultant meeting? If you are a GP interested in using our boardroom facilities for meetings with consultants, please contact the dedicated GP Liaison Officer for your area. All details, including direct mobile number and email address, can be found on the back cover of this issue of Practice Matters.

Enquiry Helpline: 020


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Stocks are now being limited until supply and demand are level. If your patients are interested in receiving the shingles vaccination or would like to speak to one of our private GPs to find out more, please contact the enquiry helpline on: 020 7483 5145




For You

My colleagues and I have consistently found working alongside The Wellington Hospital to be a straightforward and pleasant experience Dr Anna Romito (RCGP) is a GP in west London and also works as a tutor of Imperial College medical students. Here, Dr Romito discusses the bi-monthly meetings held at The Wellington Hospital and the benefits she and other GPs have gained. PM: Can you introduce yourself and tell us about your professional background?

PM: What role have the consultants at The Wellington Hospital provided?

AR: I am currently working as a salaried GP, having completed my postgraduate studies in 2012 at University College Hospital. During my training, I undertook additional academic studies and practiced overseas. This further developed and concreted my interests in global health, cultural ethics, medical education and family planning. I completed an MA in Clinical Education in 2011 and currently enjoy being a tutor for Imperial College medical students. I am also part of the RCGP Junior International Committee, which helps to support young GPs’ interests in global health issues, and the RCGP Ethics Committee.

AR: The consultants have provided us with a wealth of information which has always been delivered in a highly engaging, personable and entertaining manner. The sessions simply would not have had the same gravitas or appeal without their substantial contribution. That the talks are CPD accredited renders them of additional value to GPs formal learning and helps promote the sessions to new GP members.

PM: When did you first start working with the GP Liaison team at The Wellington? AR: I first met The Wellington GP Liaison team as a GP registrar in 2011 during a talk at my training practice. I was very impressed with the calibre of the talks delivered and the smooth organisation that facilitated them. In early 2013, we coordinated our first meeting to a new cohort of recently qualified GPs. PM: What was the original idea behind these bi-monthly meetings? AR: The idea was to facilitate teaching that was richly meaningful to First5 GPs. Through my own teaching experience, discussion with GP peers and that learnt during my masters, it was felt that small group learning would promote a more focused discussion. This not only deepens theoretical understanding and learning of what is practically implementable, but also improves understanding of the primary-secondary care interface in managing patients.

PM: How have you found working alongside The Wellington Hospital so far? AR: My colleagues and I have consistently found working alongside The Wellington Hospital to be a straightforward and pleasant experience and I have received excellent feedback from my patients regarding their care. PM: If you were not a GP, what would you to be doing? AR: I would most likely commit further time to developing and delivering educational resources and activities in medicine. I would particularly seek to enhance medical ethics teaching and global health education, both of which are becoming increasingly relevant in modern medical practice. It would be enormously satisfying for me to know that I have contributed to improving standards in medical training and practice.

If you would like to find out more about the bi-monthly meetings, please contact GP Liaison officer, Supriya Taggar.

PM: How do GPs benefit from these bi-monthly meetings? AR: We are incredibly lucky to benefit from highly informative talks that are focused towards primary care and the learning needs of the group. This has proven invaluable to enhancing clinical knowledge and confidence. I have also enjoyed helping to establish a regular, safe environment for GPs where we can discuss complex issues whilst promoting and maintaining professional networks of local First5 GPs. 17

NEWS from

2014 will see The Wellington Hospital celebrate 40 years of service within the private healthcare sector. In conjunction with this, we are further celebrating our advancements and milestones marking 15 years of Acute Neurological Rehabilitation services, which continue to evolve this year.

THE RUBY ANNIVERSARY OF THE WELLINGTON HOSPITAL 2014 brings with it a celebration of 40 years of The Wellington Hospital at St John’s Wood. Over this time, the hospital has gone from strength to strength, gaining worldwide recognition as HCA’s largest private hospital in London. Originally commissioned by the British and Commonwealth Shipping Group, when The Wellington Hospital South opened it had just 98 rooms and three operating theatres. Dr Arthur Levin, The Wellington Hospital’s founder and first medical director, had a vision of a first-class hospital, incorporating the best medical and nursing care alongside the accommodation and service normally associated with a luxury hotel. With the success of the first hospital behind it, 1982 saw the opening of the hospital’s twin – the North Tower built on Circus Road. This was followed in 2007 with the opening of the satellite centre in Golders Green – the Wellington Diagnostics and Outpatients Centre. And most recently, the hospital’s day case and outpatient centre, Platinum Medical Centre, opened, making it the largest independent facility of its kind in the country. Even with an international reputation for excellence, one thing has always remained – a commitment to provide the very best, first-class healthcare for our patients.

CELEBRATING 15 YEARS OF ACUTE NEUROLOGICAL REHABILITATION SERVICES In our autumn issue of Practice Matters, we provided a leaflet celebrating the crystal anniversary of The Wellington Hospital’s Acute Neurological Rehabilitation services. Within the brochure we highlighted the services, patient journey, multidisciplinary team and advanced technology which continues to make the unit a world renowned expert facility. 2014 brings with it the opening of the new Acute Neurological Admissions Unit, located on the fifth floor of the hospital’s South building facility. Designed to offer preliminary assessment to patients and the creation of personalised rehabilitation programmes, this development will bring the unit to our largest capacity of 60 beds, of which 46 are CARF accredited. Look out in our future editions for the further information and announcements we have planned for our Acute Neurological Rehabilitation services at The Wellington Hospital.

To mark our Crystal anniversary, 2014 welcomes the opening of the new Acute Neurological Rehabilitation Admissions Unit, designed to offer preliminary assessment for patients commencing personalised rehabilitation programmes. This will bring the unit to our largest capacity of 60 beds; 46 of which are CARF accredited.

Building a combined programme of excellence The Acute Neurological Rehabilitation Unit at The Wellington Hospital is an established, state-of-the-art facility which has gained an international reputation for excellence. The unit launched in 1999 with seven beds available for spinal and brain related conditions. Over the years, our integrated team of specialists have seen a large increase in the numbers of UK and international patients using our specialised facilities. We are currently in our third year of CARF accreditation, an accolade to The Wellington Hospital from the Commission on Accreditation of Rehabilitation Facilities. This standard is awarded for efficiency and exceptional service across all our

Acute Neurological Rehabilitation services and proof that we deliver not only a decade and a half’s worth of expertise but continue to provide a recognised high level of care to patients. Over the next few pages, we offer an insight into the team, services and innovative technologies in place at the hospital. Look out for our new Acute Neurological Rehabilitation Unit dedicated section in Practice Matters, offering an insight into the individual elements of our integrated services.

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NEW CONSULTANTS General/Vascular/Bariatric


Mr Radu Mihai, John Radcliffe Hospital

Mr Ziali Sivardeen, Homerton University Hospital

Mr Jeremy Samuel Crane, Hammersmith Hospital

Mr Ahmad Malik, Buckinghamshire Healthcare NHS Trust

Mr Shaw Somers, Queen Alexandra Hospital


Dr Stephen Karp, North Middlesex Hospital

Mr Aziz Momin, St George’s Hospital Mr Justin Nowell, St George’s Healthcare NHS Trust

Enquiry Helpline: 020



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07/01/2014 14:24


Q &A Erica Moretti has worked at HCA for 8 years and has recently been appointed to a new role of Rotational Physiotherapist, starting on orthopaedics. Here, Erica discusses how she moved from being a qualified lute maker to securing a first class honours degree and climbing the physiotherapy career ladder. PM: How did you start your working career? EM: I was always interested in working with my hands and mind. At home in Italy and inspired by my father who repaired antiques, I qualified as a stringed instrument maker specialising in acoustic guitars. I then moved to England in an effort to promote my own instrument making business. PM: Have you always wanted to work in healthcare? EM: I have always been empathetic with an impulse to help anyone, where possible. Consequently, although I was skilled in my field, I felt drawn to working with people in a way that could really benefit them. Anatomy had always fascinated me and I felt that becoming a masseuse would fulfil my want to help people. I gained the professional qualifications and really enjoyed easing people’s tension and pains. I wanted to progress in this field and decided that training to become a physiotherapy assistant was the perfect path for me. PM: Can you tell us about your previous role as a therapy assistant? EM: On my first day at The Wellington, I was very excited and nervous but I was made to feel welcome and greeted with smiles from everyone. Through working with such a highly skilled team, I felt inspired to further my studies and become a fully qualified physiotherapist. I loved the patient interaction and got such satisfaction from observing their progress. I liked to try to ease their discomfort with a smile or joke and seeing this work was fantastic. The senior staff were an inspiration to me, guiding me in a way that increased both my enthusiasm and my confidence. Working in the assistant team was a great learning opportunity and has made me a more skilled, competent and confident person. PM: What prompted your move to rotational physiotherapist and what did your studying involve? EM: As a newly qualified physiotherapist, I feel it is essential to rotate through as many areas as possible. I find every area fascinating and I am very keen to learn as much as possible. The idea of leaving The Wellington to continue my career

Radiology Dr Robert Pearce, Chelsea & Westminster Hospital Dr Zahir Amin, UCLH Dr Kate Hawtin, UCLH

Microbiologist Dr Michael Kelsey, Whittington Hospital

path left me feeling heartbroken. So, when an opportunity to continue developing my skills here presented itself, I was overjoyed. I felt that continuing my development at The Wellington, surrounded by such a wonderful team was a natural path and great opportunity. PM: What did you do to celebrate your first degree honours? EM: My course was exciting, interesting and very demanding. For the duration of my course I was also working as an assistant at The Wellington to supplement my studies, which made my schedule very busy. I felt a great sense of achievement when I gained a first class degree and I celebrated with my family and friends at my favourite Italian restaurant. As I sat there surrounded by love, I felt an enormous sense of relief and achievement. PM: What will your new role involve? EM: I will be responsible for the assessment of the patients and the creation of their treatment plan. I will also be responsible for attending MDT meetings, monitoring patient progress, organising discharges and much more. In this role I will rotate through orthopaedic, cardiothoracic, general surgery, neurosurgery and neuro-rehabilitation. Being able to work in these varied disciplines is my dream job and I cannot wait to start! PM: What do you like about working for HCA? EM: The key thing I have enjoyed about working for HCA, is the support and encouragement they provide in facilitating the professional development of their staff. If you work hard and apply yourself, it is recognised. It is inspirational that best practise is encouraged, nurtured and implemented. This strongly motivates me to do my very best, as I see everyone around me doing the same. Another wonderful thing about HCA is working with such an incredible staff. They are dedicated, highly qualified, compassionate, professional and patient. The team is an inspiration to me and has helped me in my achievements. I know I have made friends for life! PM: Where do you see yourself in the future? EM: I see myself continuing to work and progress as a physiotherapist at HCA. I hope to be a good therapist and to be able to repay the time, energy and kindness everyone has put into my development. PM: What do you like to do in your spare time? EM: I am a keen fan of music with an eclectic taste from medieval to classical and punk rock. I love dancing and have been involved in several charity dance marathons. I also love nature and animals and am a supporter of animal welfare and charities. I’ve found myself being called a ‘cat lady’ as I often have a stray (or two) stay with me whilst I find them a home. I have a passion for antiques and vintage clothes leading to a rather full wardrobe ready to explode every time I attempt to open or close it! 19 For more information about the GP Liaison service, or to make a referral, please contact the GP Liaison Officer for your area: Supriya Taggar Central London 07826 551 318

Ricky McKinson North & East London 07889 317 769

Ricardo Pereira North West London 07889 318 336

Veronica Brown Beds, Herts, Bucks & Middx 07889 317 774

Practice Matters - Winter 2014  
Practice Matters - Winter 2014