Autumn/Winter 2015 â€˘ Issue 22
strength to strength Intensive Care Expansion
The Wellington Knee Unit
25 years of caring for the most complex joint
craniofacial reconstruction A Holistic Multidisciplinary Approach
The Wellington Hospital South Building
The Wellington Hospital North Building
Platinum Medical Centre
The Wellington Diagnostics and Outpatients Centre
Welcome As you’ll see from the cover, this issue celebrates 25 years of The Wellington Knee Unit. Not ones for looking back, the unit take a look at the future of knee surgery across the whole speciality, with some interesting insights. As we embark on the next phase of our expansion programme, the future of the hospital is looking bright too. We’re very pleased to announce that The Wellington will be opening two new outpatient centres: in Chiswick and Elstree, in early 2017. We will keep you updated as the project moves forward, so do keep checking our website, our blog, or ask your GP liaison officer for an update. We’ve also been busy expanding our services for patients - as you’ll hear about in our ‘60 seconds with…’ interview with Patient Experience Manager, Gerry Sloan. Gerry talks about how this new role is getting the ‘thumbs up’ from our patients, and how we are listening and learning from them to improve every patient’s experience here at the hospital.
In this issue: With the wonders of the Rugby World Cup not far from our memories, our Foot and Ankle Unit take a look at the injuries that can be sustained in the big game; Dr Stuart Bloom discusses the latest developments in bowel cancer screening; Mr Angus McIndoe talks about robotic surgery for gynaecological conditions; while Mr Sudhanshu Chitale discusses the management of peyronie’s disease. We also introduce you to the London Craniofacial Unit; discover a quicker cure for cataracts and reflect on why RSI can be a dangerous term. If you’re not already following us on Twitter or Facebook, make a visit to our social media pages for the very latest news from around the hospital. Best Wishes,
Neil Buckley CEO
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Editor: Jaclyn Lott Production & Distribution: Runwild Media Group
Contents 04 | RSI – a misused and dangerous term Mr Ian Winspur
05 | Recent developments in UK bowel cancer screening
Dr Stuart Bloom
06 | Rugby: prevention better than cure The Wellington Foot & Ankle Unit
08 | The London Craniofacial Unit: A coordinated approach to patient care
11 | Celebrating 25 years The Wellington Knee Unit
14 | Gynaecological conditions and advanced robotic surgery Mr Angus McIndoe
15 | Bent penis needs fixing: Peyronie’s disease Mr Sudhanshu Chitale
16 | The Wellington’s intensive care unit - a growing success 18 | The slimmer effects of weight loss surgery Mr Sanjay Purkayastha
19 | Cataracts: a quicker cure Professor Charles Claoué
20 | GP News 21 | 2016 Events Schedule
22 | News from The Wellington 23 | 60 Seconds with...
www.practicemattersmag.co.uk PRACTICE MATTERs autumn/WINTER 2015 • 3
hand & wrist
RSI - a misused
and dangerous term Mr Ian Winspur
Repetitive Strain Injury (RSI) was a new term coined in 1983 by Dr. Stone, an Australian physician, to describe a group of his patients. These patients were all female and performing menial low paid repetitive work who complained of arm pain, without any physical signs and which “fit no known organic cause neither dystrophic, atrophic nor neuropathic.” It was seized upon by the unions and the newspapers and it was accepted by the courts although the scientific background was highly questionable. Large compensation claims were won and it became a cause célèbre and soon involved work related arm pain in Britain where large awards were also made. The term RSI became a cult term for any painful condition of the arm associated with work – CTS, tendonitis, tennis elbow, thumb CMC arthritis, to name but a few – implying a causal relationship with work and the potential for compensation. The bubble burst in Australia and Britain when it was demonstrated that RSI occurred in unusual clusters within similar groups of women performing the same tasks. At a telephone exchange in Perth, there was no incidence of RSI whereas in Melbourne the incidence was near 100%. It was also realised that the statistics which had been used in the USA to relate repetition to injury were flawed, large population surveys in Sweden demonstrated that CTS – typically related to repetition - was
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less prevalent in computer operators than in the general population and that conditions typically associated with repetition are less common (in my experience) among professional musicians than the general public. Repetition in general does not cause injury. The courts ceased awarding on RSI claims.
The statistics which had been used in the USA to relate repetition to injury were flawed But the term lives on and is still being used by many physicians as a “diagnosis” in patients with arm pain occurring in the workplace often pending investigation but without a clear diagnosis. By using the term RSI and, worse still, writing it in the patient’s notes, one is making a firm statement by implication of a causal relationship of their condition. Whatever the final diagnosis turns out to be, this sets up a chain of events with a patient expecting compensation, a leery employer, the onset of expensive litigation in today’s current climate and the hapless employee usually losing their job. If a patient is suffering from arm or hand pain, which is worse at work (remembering that most
of the known described painful conditions are worse with activity or work) but for which no clear explanation or diagnosis is apparent, the term” non-specific” is very useful with no implied connotations regarding causation. The term RSI is not a diagnosis; it is an inaccurate and inflammatory term and should only be used with extreme caution. To find out more about Mr Ian Winspur please visit www.londonhandandwristunit.co.uk
Recent developments in uk bowel cancer screening Dr Stuart Bloom
Bowel cancer is diagnosed in 30,000 people every year and kills 16,000 people per year. These sobering statistics, coupled with widely reported inadequacies in UK survival from bowel cancer compared to similar countries, emphasise the need for a national screening programme for bowel cancer – especially because it is relatively easy to diagnose premalignant lesions or adenomatous polyps, remove them via a colonoscopy, and greatly reduce the chance of progression to carcinoma.
assess the local population for the presence of blood in stools. • FOB positive participants are then brought into screening centres for a nurse-led assessment and further treatment as appropriate. Around one in ten people with a positive FOB will go on to be diagnosed with a cancer. • Screening centres in London have been operational since 2007; each centre performs around 4,000 colonoscopies and diagnoses around 30 early stage cancers per year.
There is a high level of awareness of the need for screening in high risk individuals – those with a strong family history of bowel cancer or conditions conferring increased risk, such as inflammatory bowel disease. But what about the general population who can be classified as ‘average’ risk?
• It is designed to run alongside and complement current FOBt screening. • It is based on a UK study which was shown to reduce incidence of bowel cancer by 33% and mortality by up to 43% in the areas where bowel scope has been performed (Atkin 2010, Lancet 375:1624-33). • About 95% people who have bowel scope screening once at age 55-64 receive a normal result.
The current bowel cancer screening programme for the general population was introduced in 2007. • The eligible population for screening is those aged 60-74 registered with a GP. Invites are issued every two years. • Screening centres in London work collaboratively with the London Hub, based at St Mark’s Hospital, which manages the invitation process. This includes the processing of faecal occult blood or “FOB” tests, which
More recently a separate screening programme has been designed and is in the process of being rolled out across the country by 2016. This is entitled “Bowel scope” and is a one-time flexible sigmoidoscopy offered to all 55 years olds.
Screening with flexible sigmoidoscopy was found to reduce the incidence of colorectal cancer over
11 years’ follow-up from 5 in 300 to 3 in 300 in a UK randomised controlled trial; in other words, 2 cases of colorectal cancer are prevented for every 300 people screened. People with high risk polyps are invited for subsequent colonoscopy. Flexible sigmoidoscopy screening reduces colorectal cancer mortality. It reduces colorectal cancer deaths over 11 years’ follow up from 2 in 300 to 1 in 300; in other words, one colorectal cancer death is prevented for every 300 people screened. 5% will be invited for a follow up colonoscopy because high risk polyps are found. These are defined as polyps that are large (> 1 cm diameter) have villous histology, show severe dysplasia, and/ or are multiple (3 or more). At colonoscopy, further polyps may be removed. Generally people are invited for surveillance colonoscopy in one year or three years’ time depending on the number and size of the polyps. If numerous or large polyps are found at bowel scope screening or colonoscopy, they may be referred directly for surgery If someone is not suitable for colonoscopy, they will usually be offered CT colonography which is 95% sensitive at detecting polyps over 1cm. To find out more about Dr Stuart Bloom please visit www.drstuartbloom.co.uk
www.practicemattersmag.co.uk PRACTICE MATTERs AUTUMN/WINTER 2015 • 5
rugby: prevention better than cure The Wellington Foot & Ankle Unit
As the dust settles on another fantastic Rugby World Cup, Practice Matters speaks to the four orthopaedic surgeons at The Wellington Foot & Ankle Unit on rugby’s ever-growing popularity, common injuries and ways to prevent them. The 8th Rugby World Cup claimed to be the third largest sporting event in the world, behind the FIFA World Cup and the Olympics. With 2 million registered players in England alone the popularity of the sport is ever-growing and
Careful planning by experienced clinicians, physiotherapists and coaches has lead to a marked reduction in re-injury rates it’s easy to see why. With every cycle another generation become inspired to emulate the
achievements of their favourite players, who demonstrate the ethos of the game, namely team spirit, strong competition, fair play, discipline and respect. Rugby is a game played by people of all shapes and sizes, but as with all contact sports players are susceptible to injuries during training and game time, and of these injuries, a significant number occur in the foot and ankle. Mr Mark Herron believes that “the old adage, ‘prevention is better than cure’ holds for foot and ankle injuries in rugby. The increasing emphasis on building core strength and balance as part of the rugby players' training, alongside strength and fitness conditioning reduces game related injuries." “Although there is an emphasis on early return to sport and rehabilitation, it is vitally important to allow adequate time to recover from injury – and returning too early can be counter-productive in our experience," says Mr Simon Moyes. “Careful planning by experienced clinicians, physiotherapists and coaches has lead to a marked reduction in re-injury rates.”
The Foot & Ankle Unit have created a video to show their patients the journey they will take and the care they will receive throughout their treatment by the unit. To view the video visit www.thewellingtonfootandankleunit.co.uk
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Mr Andy Goldberg believes players and coaches have become more aware of injuries that could develop and will tend to seek advice earlier, and that is partly due to the widespread media
Common Rugby Injuries • Ankle Sprains • Cartilage Injuries • Calf Muscle Tears • Achilles Tendon Rupture • Achilles Tendinopathy • Metatarsal Fractures • Turf Toe
About The Wellington Foot & Ankle Unit
Mr Mark Herron Mr Nick Cullen Mr Simon Moyes Mr Andy Goldberg
coverage that rugby enjoys. “Public and professional awareness has helped the way we manage problems at an earlier stage, which not only reduces the time that players are out of the game but also helps players avoid surgery that might have been necessary if the injury was neglected." Mr Nick Cullen tells us about new techniques that exist for treating common injuries such as the Internal Brace to reinforce ankle ligament repairs, allowing for reduced splintage after surgery, less muscle wasting and earlier return to the physiotherapy gym. “I have also found that using rehabilitation tools such as reduced gravity running machines, and pool based therapy, allows for quicker return to ‘protected’ sports and shorter time to safe return to play.”
The Foot & Ankle Unit at The Wellington Hospital combines the experience of a highly skilled team of orthopaedic surgeons, with the latest state-of-the-art technology, to offer first class healthcare to patients with all manner of foot and ankle problems. The unit has earned an international reputation for excellence with the team specialising in all the latest methods, from minimally invasive surgery through to the most advanced reconstruction techniques.
Although there is an emphasis on early return to sport and rehabilitation, it is vitally important to allow adequate time to recover from injury The unit offers a same-day diagnosis service as well as a full multidisciplinary team that will take care of you from first appointment through any necessary treatment to rehabilitation back to the field and to your workplace. To make an appointment please call +44(0)20 7483 5148 www.thewellingtonfootandankleunit.co.uk
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Craniofacial Service for Adults patient care The London Craniofacial Unit Reconstructive surgery has always been a leading specialist area at The Wellington Hospital. However craniofacial conditions and injuries, not only affect appearances they can also have an effect on functional abilities. The face and skull are important for the ability to eat, speak, see, smell and hear and also to protect important structures such as the brain. Due to their complex nature, the London Craniofacial Unit (LCU) has joined The Wellington Hospital to provide a patient centred, multidisciplinary approach for adults with craniofacial and maxillofacial conditions and injuries. Many units provide surgical
The adult craniofacial service is based at The Wellington Hospital and is principally directed at reconstruction after trauma. Surgery for adults with congenital and acquired craniofacial conditions is also undertaken. Many of the patients seen have complex problems requiring extensive planning and multi-specialty input.
A Holistic Multidisciplinary Approach At LCU we have formed a team of highly skilled reconstructive surgeons who are supported by specialists with expertise in
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International Patients As well as UK based craniofacial patients, The Wellington Hospital sees many international cases. Often patients will come with very complex conditions and may present with a history of previous surgical reconstructions or need reconstructive surgery after the primary condition has been treated. International patients frequently have complex conditions and that require individualised investigation and treatment planning. The LCU team is experienced in providing complex care to patients from overseas and can provide the most up-todate and holistic investigation and treatment quickly and efficiently.
LCU is experienced in treating patients from all parts of the world reconstructive services in isolation, the LCU believes that ideal treatment cannot be provided without the input of specialists with expertise in function and rehabilitation. The London Craniofacial Unit was founded by Mr Owase Jeelani and Mr David Dunaway in 2012. Using their consulting rooms in Harley Street as a central location, they have established a craniofacial service for children at the Portland Hospital.
technologies. This holistic approach provides the best opportunity for effective restoration of form and function.
vision, hearing, speech, feeding, psychological well-being and rehabilitation. We are actively involved in research into craniofacial reconstruction, and with our industry partners, provide the most up-to-date computer image guided reconstructive techniques and implant
We have good links with surgeons and doctors in many parts of the world and can therefore coordinate further rehabilitation and treatment in patientsâ€™ home countries if this is required. LCU is experienced in treating patients from all parts of the world and is able to provide interpreters and advocates for most languages and cultures. To find out more about the London Craniofacial Unit, please visit www.lcuuk.com
Consultant Focus Mr David Dunaway MBChB, BDS, FDSRCS, FRCS(Plast) Consultant Craniofacial, Plastic & Reconstructive Surgeon David Dunaway leads the worldfamous craniofacial team at Great Ormond Street Hospital for children. He has worked closely with HCA over the last 15 years building the adult and paediatric craniofacial service. His special interests are in the treatment of congenital craniofacial conditions and facial reconstruction after trauma.
Mr Yassir Abou-Rayyah MSc(CU), MSc(UCL), PhD(cu), FRCS (Glasg), FRCS(ED), FRCOphth Consultant Oculoplastic Surgeon Yassir Abou-Rayyah has a special interest in the management of conditions affecting the orbit and eyelids. He is one of the few oculoplastic surgeons with special expertise in managing paediatric problems. He leads the paediatric oculoplastic surgery service at Great Ormond Street Hospital for children and Moorfields Eye Hospital and is a key member of the LCU craniofacial team.
Dr Malcolm Schaller Specialist in Oral Reconstruction & Rehabilitation
Malcolm Schaller is a specialist in both oral surgery and prosthodontics. He has a special interest in oral implants and complex oral reconstruction. He has worked closely with
the LCU team for many years participating in the reconstruction of drawers and teeth and the rehabilitation of oral function. Together with direct care from the consultants, the patient’s case is managed within a specialist multi-disciplinary team of ENT specialists, Ophthalmologists, Geneticists, Orthodontists and other specialists such as Paediatricians. The team members meet at least once a week to discuss the individual cases as necessary.
Mr Tim Lloyd MBBS, BDS, FRCS(OMFS), FDS, RCS(Eng) Consultant Oral & Maxillofacial Surgeon
Tim Lloyd has led the multidisciplinary adult/ adolescent craniofacial service at University College
Hospital London for the past 12 years. He specialises in the treatment of facial deformity, maxillofacial trauma, temporomandibular joint disorders and orthognathic surgery. He has a special interest in treating complex bony deformities and injuries, reconstruction of the temporomandibular joint and the management of congenital facial problems.
Mr Owase Jeelani MBA, MPhil(Med, Law), FRCS Consultant Neurosurgeon Mr Owase Jeelani is a leading neurosurgeon at Great Ormond Street Hospital for children. His special interests are in the treatment of congenital craniofacial conditions, reconstruction after trauma and the treatment of paediatric brain tumours.
Niamh Curley Practice Manager The practice manager Niamh Curley has been with LCU since its inception in 2012 and is available to help coordinate and organise all elements of the patients’ care from the first appointment through to their final treatment.
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Mr Colin Elton
MBBS, Ms, FRCS (Gen Surg)
Consultant General Surgeon We spoke to Colin Elton, Consultant Colorectal Surgeon and Chair of the new Wellington GI cancer MDT, about the importance of collaborative decision making and the bright future of GI cancer treatment at The Wellington.
PM: Why was The Wellington GI MDT first set up? CE: There is a standard of care within the NHS for all hospitals to be linked to cancer MDTs, but there are few private cancer MDTs, particularly in GI cancer. Most patients will be discussed at their consultant’s local NHS MDT, but these MDTs have become much busier, not always providing enough time for private patients to be discussed. The introduction of The Wellington GI cancer MDT has provided a forum for clinicians to discuss all their private patients.
PM: Who makes up the regular members of the GI Cancer MDT? CE: We have: Radiologist, Dr Marc Pelling; Professor Chris Foster, Head Pathologist at HCA Labs; Oncologists: Professor Justin Stebbing, Dr Andrew Gaya and Dr Jonathan Krell, GI surgeons: Mr Colin Elton (Chair), Mr Daren Francis, Mr Olagunju Ogunbiyi, Mr Romi Navaratnam and Mr Jonathon Wilson. We also have gastroenterologists, and each meeting is also attended by The Wellington’s Medical Director, Mr Geoffrey Glazer. The team will soon be expanded to include a colorectal clinical nurse specialist, and we also have an MDT coordinator, Nicola Turner, who runs our patient database and helps to organise the meetings and send out patient outcomes.
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Introducing our GI Cancer MDT Tell us about that first MDT meeting…
How does this MDT benefit patients?
At first, we toyed with the idea of eMDTs (online discussions) but decided that we needed all clinicians present in a room, having active discussions about each patient to reach a conclusion (just like the NHS). This had to be the best way.
Patients are benefitting from having a wide spectrum of experts, from all the particular fields, in one room. These experts bring together their knowledge of the latest treatments from the UK and around the world, along with their strong knowledge base from previous patients. We have had excellent discussions about current patients which have led to very good decision making. It would be interesting to audit all these patients after12 months to see the exact success of our MDT outcomes.
‘Over 25 people attended the first two meetings - there were people standing at the back because there wasn’t enough seating – that’s how successful it’s been’ After three months of further discussions and decisions, we held the first meeting on 22 April this year. Over 25 people attended the first two meetings - there were people standing at the back because there wasn’t enough seating – that’s how successful it’s been. This high attendance shows that there is obviously a big interest and a need for these patients to be discussed. The monthly MDTs run on Wednesday mornings (although, if they continue in popularity the meetings may be made fortnightly) between 7am – 8am. At every MDT there have been six new patients discussed. All are prospective patients who have colorectal cancer and require decisions to be made regarding their treatment.
‘It is also very important that both GPs and patients should be reassured that private patients at The Wellington are receiving the very best of care, with expert discussions at our new GI MDT.’
It is also very important that both GPs and patients should be reassured that private patients at The Wellington are receiving the very best of care, with expert discussions at our new GI MDT.
What is the future for GI cancer treatments at The Wellington? More complex bowel cancers are now being treated in the private sector, especially at The Wellington, which has high-quality intensive care units for patients after surgery, great support from interventional radiologists and excellent oncology support (which has grown hugely over the past two years and will continue to grow and become more complex). It used to be that one consultant would make the decision on a patient’s treatment – that’s now changed – for the better. MDT is one of the shining examples of good quality within the NHS; we’ve recognised that, taken it on board and have adopted it to make sure private practice is leading the way in treating cancer patients, here at The Wellington. Mr Colin Elton holds regular general surgical clinics at both The Wellington Hospital’s outpatient locations: Every Tuesday morning at the Platinum Medical Centre, St Johns Wood Every Thursday morning at The Wellington Diagnostics and Outpatients Centre, Golders Green
celebrating 25 years: wellington’s knee unit The Wellington Hospital
The Wellington Hospital’s internationally renowned knee unit has come a long way since it first opened its doors 25 years ago. The unit was the idea of four pioneering orthopaedic surgeons – Paul Aichroth, Clare Marx, George Dowd and David Hunt – who decided in 1990 that it made sense to pool resources and treat all their private knee patients under one roof. This was soon extended to offering regular on-site clinics as well as training opportunities for other relevant staff. Consultant orthopaedic surgeon and current director Mr Howard Ware joined the unit 22 years ago and has seen it expand massively in that time. The unit now boasts nine surgeons covering a range of different disorders from children’s abnormalities to knee ligament and cartilage injuries and arthritis of the knee.
But the collegiate ethos that underpinned its beginnings remains. “It’s nice to be able to discuss any problems you may have with a colleague in the same building,” says Howard. “And we are always focused on the needs of the patient, doing the right thing for that person in their particular circumstances.”
Knee ligament injuries – Mr Richard Carrington “The anterior cruciate ligament (ACL) is the most commonly injured ligament. Rupture of the ACL commonly occurs in contact sports and also in skiing. Often a large twisting force has been applied to the knee before the ligament ruptures, and a snap or pop is heard at the time of rupture. The knee then becomes painful and swollen. Since the anterior cruciate ligament controls knee stability, after the knee pain has settled, which may take a number of weeks, the knee remains unstable. MRI scans are performed to confirm the diagnosis and to see if other damage to the knee joint has occurred. Treatment initially consists of rehabilitation of the joint with the aid of physiotherapy to reduce knee swelling and strengthen the
muscles. But patients who suffer with recurrent instability will require ACL reconstruction. Most medial and lateral ligament injuries, as well as isolated posterior cruciate ligament ruptures, are treated non-operatively with a brace for six weeks. Rupture of more than one ligament requires reconstructive surgery.” The number of patients coming through the doors during that time has risen significantly while the ad hoc facilities that sufficed at the start have given way to a purpose-built unit with the latest equipment and technology in the south wing of the hospital. “The last 25 years has also seen a transformation in the understanding and treatment of knee injuries”, says Howard. “The volume of total knee replacements has increased significantly. We are also discharging patients faster than we did and the rehabilitation is faster.”
Knee arthritis – Mr David Sweetnam, “Knee replacement surgery is an increasingly common operation with most patients undergoing the procedure being over
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We are very lucky. We work in a specialty where for the vast majority of our patients we can restore their function and eliminate their pain 65. It is nevertheless a major undertaking. We always give the patient every opportunity to discuss all aspects of their care before making this important decision. For most people, knee replacements last over 20 years, especially if the knee is not put under too much strain. The two main types of knee replacement are full; where both sides of the knee joint are replaced, or partial replacement, where only one side of the joint is replaced. The science involved in knee replacements is improving all the time, leading to more successful patient outcomes. The key to successful knee replacement surgery is not only choosing the right patient, but also making sure that the operation is undertaken in the right environment to minimise the chance of complications, such as infection, and that postoperative care is as good as it possibly can be.” Outcomes are also improving. “Long-term results are now excellent and much better than 20 years ago,” says Howard. “Our techniques are better, the instruments are better, implants are better.”
Another important innovation has been MRI scanning which can in some cases avert the need for an operation altogether. “It’s changed our practice. In the past if you came in with a painful knee and the X-rays showed a problem we’d probably have operated. But now MRI can deliver a different diagnosis that doesn’t necessarily lead to surgery.”
Cartilage injuries – Mr Chinmay Gupte “Cartilage injuries in the knee are becoming more common as activity among both young and old has increased. At the Knee Unit we aim to tailor treatment options that best suit the individual patient based on symptoms, patient preference and prognosis. There are a number of different treatment options, including physiotherapy, cartilage trimming or cartilage repair but the common goal is excellent short and long-term recovery.”
Kneecap instability – Mr Jonathan Miles “With kneecap instability the patella subluxes or dislocates, usually to the lateral side. This can be a result of trauma but is more commonly due to congenital abnormalities in the patellofemoral joint. It is most prevalent in females between 10 and 30 years old because
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at that age they have an increased risk of the ‘miserable malalignment syndrome’ of femoral anteversion, genu valgum and external tibial torsion. Other risk factors include hypermobility, patella alta and trochlear dysplasia. MRI scanning can help diagnosis. Treatment usually begins with physiotherapy but more severe cases can require surgery. This can be a tibial tubercle osteotomy to move the patella tendon medially or a medial patellofemoral ligament reconstruction.” This has been mirrored by changes in people’s lifestyles. “I think more people are active than 25 years ago,” says Howard, “and more are active for longer. People are still playing football and many other sports late into their lives and are not prepared to give up on that. In fact sometimes we have to give them a reality check!”
Of course more activity also means more wear and tear on the knee joints – the number of knee operations on men aged between 45 and 55, for instance, has shot up in the last decade. There has also been a significant rise in arthritis of the knee among older people. Meanwhile the speed of treatment and rehabilitation continues to accelerate. The unit offers same-day appointments and treatment within one to two weeks if required. For a joint replacement, the patient will probably be taking their first steps within hours of the surgery and should be out of hospital in days and back to work within weeks.
Knee injuries in children and adolescents - Mr David Hunt ”When treating children we always attach great importance to focusing on their needs and communicating fully with them. MRI has transformed the management of conditions such as osteochondritis dissecans where the indications for operating are complex. MRI monitoring shows whether healing is taking place and often makes operating unnecessary. Meniscal repair is rewarding in children because they heal more readily. This is particularly relevant to the discoid meniscus where the dilemma of repair versus excision is most acute. As more children participate in sport, we are seeing more cases of damage to the anterior cruciate ligament. Surgical reconstruction
in children is now established as a safe and reasonable option.” Knee problems can be congenital, occupational or sports-related but their impact cannot be under-estimated. The knee is the hardest working joint in the human body and when it breaks down for whatever reason it can be debilitating – as well as extremely painful. Offering someone ligament surgery or joint replacement can eliminate the pain they have been in and restore their entire quality of life in a matter of weeks. “They’re no longer a burden on themselves or their family,” says Howard. “And they can walk and run again.”
Knee injury prevention – Mr Rahul Patel “Although knee injury diagnosis and management continues to advance steadily, prevention is always the preferred solution. Because knee injuries are so common, research on prevention strategies and programmes is fairly advanced. This has already led to reductions in the incidence and severity of knee injury in some groups such as female soccer players. Continued surveillance and robust data collection will undoubtedly improve our understanding from aetiology to outcome. When combined with constantly advancing knowledge of lower limb kinematics and biomechanics, it is clear there will be more and more scope for prevention. This should help to reduce the burden on health systems but, even more importantly, it will reduce short- and long-term knee injury-related morbidity for all age groups.”
Demand is expected to continue to grow and with that in mind the unit is itself going through a number of changes. In the shortterm its suite of rooms are being extensively refurbished. Longer-term there are plans to move to more capacious, state-of-the-art accommodation elsewhere in the hospital. Howard predicts that over the next 25 years drug therapies rather than surgery may increasingly be employed to treat arthritis of the knee and prevention programmes will become more prominent. However, surgical interventions will still play a major role. The prospect of injecting stem cells to replace worn or damaged knee parts remains a long way off. But some elements will always be constant. The opportunity to transform lives is one of the most rewarding aspects of his and his colleagues’ work, he says. “We are very lucky. We work in a specialty where for the vast majority of our patients we can restore their function and eliminate their pain. It’s always a pleasure to have someone coming back with a smile on their face to say thank you for what we’ve done.”
‘Composed by Mr Howard Ware, Director of The Wellington Knee Unit
To find out more about about The Wellington Knee Unit please www.thewellingtonkneeunit.com/
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gynaecological conditions and advanced robotic surgery Mr Angus McIndoe
Robotic surgery is a relatively new technological approach which is increasingly being used for gynaecological procedures that previously required much more invasive techniques. These include hysterectomies, myomectomies, repairing vaginal prolapse and tubal surgery to reverse sterilisation.
About the robot Named the da Vinci robot, this FDA-approved machine is made up of a magnified 3D highdefinition viewer and tiny wristed instruments that bend and rotate far greater than the human wrist. The robotic arms move in such a way that no pressure is placed on the port or channel going into the abdomen. It’s the site of these ports that is a major cause of pain for patients undergoing keyhole surgery.
The 3D view with depth perception is a vast improvement when compared to conventional laparoscopic camera views Enhancing surgeon precision and comfort Robot-assisted surgery allows the surgeon to perform operations with much greater accuracy and precision. Through this minimally invasive technique, the surgeon is able to make tiny
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incisions with greater control than in an open surgery. Hand movements made by the surgeon are scaled by the robot to be incredibly precise, and the robotic computer is able to detect and remove any fine hand tremor. The 3D view with depth perception is a vast improvement when compared to conventional laparoscopic camera views. The surgeon has the ability to directly control a stable visual field with increased magnification, which contributes to high degree of surgical precision. The technology also ensures that the surgeon is able to sit in a comfortable position throughout the procedure. His or her hands are in a natural position in the line of vision making it feel like the instruments inside the body are the surgeon’s hands. The movements of the surgeon’s hands are mimicked by the robot, returning surgery to a very intuitive procedure. This allows the surgeon to perform at his or her best at all times without needing to compromise. In contrast, laparoscopy can be very awkward with instruments moving in a counterintuitive manner.
Improving patient comfort and recovery Most studies comparing robotic surgery with open surgery and conventional keyhole surgery show that patients that have had robotic-assisted surgery are able to leave hospital more quickly and require less pain relief. And because patients
require less pain relief and are able to move around more freely from immediately after surgery, they tend to be ready for discharge sooner and can resume normal day-to-day activities more quickly. Patients can also expect reduced blood loss and minimal scarring. Without doubt, within the next 10 years more and more procedures will be done using the current and yet to be developed robotic platforms. These will enhance the ability of surgeons to do more complicated procedures with less damage to the surrounding tissues, leading to improved recovery. To find out more about Mr Angus McIndoe please visit www.mcindoecentre.com
bent penis needs fixing: peyronie’s disease - Part One Mr Sudhanshu Chitale
Awkward angulation of an erect penis is not to be considered an uncommon problem any more, as more and more men come out of the woodwork, desperate to communicate or share their concerns with their clinicians. So it’s time clinicians dealt with it openly and bravely just as they did with erectile dysfunction (ED) over the last two decades. Peyronie’s disease (PD) is the commonest cause of bent penis and although known to medicine more than 250 years ago, its causative mechanism still remains ill understood and as a consequence the treatment efforts have been directed towards the effect rather than the cause.
What is PD? By definition, it is an acquired penile abnormality characterised by fibrosis of tunica albuginea (TA) and may be accompanied by pain, deformity, erectile dysfunction and/or distress. It is a collagen disorder and could be associated in some cases with co-existent Dupuytren’s contracture. Other associated risk factors with unclear contribution to the pathophysiology are diabetes, hypertension and dyslipidemia.
How common is PD? Prevalence of PD varies widely from 0.5-20% in the literature and if that is true, it’s a significant patient burden on any health care system. However, this could be the tip of the iceberg, as most men tend to shy away from approaching their doctor due purely to embarrassment. It would therefore
be imperative that the clinician probes into this problem when men present with ED and/or lower urinary tract symptoms (LUTS), as the two co-exist.
Understanding the impact of PD: PD is known to have physical and psychological impact; with a high incidence of clinical depression in men with PD; up to half of them admit to an adverse impact on their relationships, never mind the negative effect on their macho self-image and quality of sex life. So they tend to suffer silently and so do their partners.
>90%. Penile deformity is progressive in 30-50% of men and stabilises in 47-67% with a hard / calcifies plaque. The resultant curvature may make penetrative sexual intercourse difficult or painful to patient and/or his partner causing further physical/psychological distress and difficulties with relationship. ED may set in due to pain/deformity/distress. Part Two on managing PD will be published in the next issue of Practice Matters.
Natural history of PD: Men with PD initially go through an Active or Acute phase characterised by dynamic and changing symptoms in particular penile pain and deformity on erection leading to increasing distress. Erections may or may not be compromised. Subsequently, the disease enters its Stable or Chronic phase, with the symptoms unchanged for 3-6 months with pain subsiding but deformity/curvature and induration/plaque remaining static. However, in 3-15% of men the disease process is known to resolve spontaneously over 6-12 months, particularly in younger men.
Presentation of PD: Men commonly present in their mid-fifties with recent onset penile deformity without any precipitating event to account for it. Pain present in the initial stage resolves with time in
To find out more about Mr Sudhanshu Chitale please visit www.privateurologylondon.co.uk
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The Wellington’s intensive care unit - a growing success The Wellington Hospital
An intensive care unit is at the heart of a modern acute hospital. Patients with a wide range of medical conditions, from pneumonia to a heart attack or stroke, will often spend part of their hospital stay in intensive care. We talk to Dr Adrian Steele, Dr Jim Buckley and Andrew Roche about The Wellington’s two units and why we are expanding…
The unit is served by four intensive care consultants as well as resident doctors, specialist nurses and a large support team Unusually for the independent sector, both intensive care units at The Wellington Hospital are able to care for the full range of medical emergencies and can support patients with the most serious forms of multi-organ failure. With 24 dedicated beds and more than a 100 specialist staff, The Wellington Hospital’s intensive care units offer our patients some of the finest facilities in the UK independent sector.
The ITU Team A clinical service manager and two modern matrons manage and supervise the highly
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It is recognised for having low hospital-acquired infection rates, higher than average survival rates and one of the cleanest and safest environments in the healthcare sector skilled nursing team, while four renowned intensive care consultants (who are linked to major London teaching hospitals) oversee the units and lead wards rounds, 365 days a year. This is in addition to two dedicated and highlytrained intensive care resident doctors who are available, on-site, 24/7. The units also have an outreach team who work with staff on our hospital wards to identify patients who may be at risk of rapid deterioration. Intensive care requires a team approach, so heavy emphasis is placed on employing a team with a wide-ranging skill set. A recent recruitment drive has allowed us to build on our strong foundation and inject further diversity into the team. For example, Dr Jim Buckley, who joined the unit this year, is not only an intensive care consultant but a specialist in infectious diseases and sepsis – a near unique combination of skills. Working with the unpredictability of critical conditions means that relying on the whole team is paramount to providing great care. Weekly multidisciplinary team meetings, which
open up case discussion and monitor patient progress, are a big part of this. Despite being new to the unit, Dr Buckley has already experienced this cohesiveness when caring and treating critically ill patients at The
skilled nurses and the availability of the unit’s specialist consultants. “We also don’t suffer from the resource constraints seen in some NHS hospitals. This means we can admit patients without delay, as soon as the need arises, and we never have to discharge patients earlier than we would like”.
Wellington: “I can always rely on my colleagues for advice and to work together closely as a team. To save a patient’s life and give them a second chance, by working together, what could be more rewarding than that?”
First Class Service Ensuring that patients, and their referring clinicians, have easy access to our service is important too. Dr Steele, Lead Consultant Intensivist, says that he is particularly proud of the unit’s open access. “We have never turned a patient away because a bed isn’t available.” Andrew Roche, Clinical Services Manager, who was appointed to lead the units earlier this year, believes that this is because of the unit’s
Having a loved-one in intensive can be one of the most stressful experiences for families, even more so if you are travelling from afar and are in an unfamiliar country. As well as a large number of London-based patients The Wellington intensive care units have developed a wide international referral base. Patients in a critical condition are regularly transferred by air ambulance from the Middle East and Africa. Citizens of the United States and Australia who are taken ill in Eastern Europe are often flown first to The Wellington Hospital. During these difficult times, excellent communication is key to supporting families; and we aim to achieve this with flexible visiting times and regular family meetings. For our international patients, we are also assisted by a team of multi-lingual interpreters who are available not only on weekdays but also
evenings and weekends, too. As Andrew says: “Supporting the families is just as important as supporting our patients.”
Expansion The Wellington recently began a Xmonth project to expand its intensive care service to 35 beds, which will include a new 6-bedded high dependency unit and 15 state-of-the-art isolation rooms. Dr Adrian Steele, who has worked at The Wellington Hospital for more than 15 years, expresses understandable pride at the intensive care facility’s transformation over that time: “It is fair to say that a generation ago intensive care in the independent sector was quite limited in the range of conditions it could support. Now, after a huge investment in staff, equipment and facilities, The Wellington Hospital Intensive Care Unit is able to treat and support patients with the most complicated conditions to the highest international standards.” For more information and to keep updated on the unit’s expansion programme, visit The Wellington Hospital website: www.thewellingtonhospital.com or follow the hospital’s blog.
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the slimmer effects of
weight loss (bariatric) surgery Mr Sanjay Purkayastha
Obesity and type 2 diabetes are in the national headlines almost every week. The burden to the individual, health service and society are clear. Although in the long term, prevention is the cure, currently many individuals are already struggling with the fallout from these two common and linked conditions. Obesity is also closely associated with infertility, obstructive sleep apnoea, high blood pressure, heart disease, joint and back pain and even liver disease. These combined with type 2 diabetes results in medical complications that significantly reduce quality of life and life expectancy. So much so that recently, NICE (National Institute for Care Excellence) reduced the BMI (body mass index) criteria for bariatric surgery for obesity with type 2 diabetes to a BMI of 30 and above (from BMI
The potential for bariatric surgery to improve the health of the nation and reduce the burden of obesity and type 2 diabetes in the UK and internationally is huge 35 and above). There is now evidence to suggest that bariatric type surgery will benefit type 2
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diabetes patients who are not morbidly obese. In fact, studies have shown resolution of diabetes in patients with a BMI of 20-25 in certain countries. My patients will tell you that although this kind of surgery is life changing for the better and often described as miraculous, it is not an easy choice or an easy option. For the surgery to work well it requires a multidisciplinary approach and careful lifelong compliance to the changes brought on by surgery and, once able to exercise more, that this should be continued along with the balanced diets, vitamin supplementation for life and avoidance of smoking, excess alcohol and fatty, sugar rich and carbohydrate foods. The approach to bariatric surgery has been well entwined with patient safety issues in major centres in the UK. The National Bariatric Surgery Registry (NBSR) to which all my patient and surgical outcomes data is entered prospectively allows monitoring of outlying surgeons and units. Indeed bariatric surgeons are only the second subspecialty in surgery to have a publically accessible database for surgeonsâ€™ results. Bariatric surgery is about making people healthier with a better quality of life, a longer lease of life and even to help some to conceive and start families. Our outcomes have been demonstrated to be safer than having a gallbladder operation in many hospitals due to most surgeons working in dedicated bariatric units. To get the best of this
sort of surgery, patients usually see a bariatric surgeon, dietician, anaesthetist, psychologist and a diabetologist prior to surgery and the patient journey, surgery and over all pathway is should be tailored for each individual patient. The potential for bariatric surgery to improve the health of the nation and reduce the burden of obesity and type 2 diabetes in the UK and internationally is huge. It can improve the following: sleep, lifestyle, insulin need, metabolism, mobility, energy levels and reproductive potential (SLIMMER effects). Safe surgery and even safer aftercare and follow up are the key to the best long term results, but this life changing surgical approach is available to everyone who chooses to access it. To find out more about Mr Sanjay Purkayastha please visit www.londongeneralsurgeryclinic.co.uk
a quicker cure Professor Charles Claoué
Cataract is opacification of the crystalline lens of the eye causing visual failure, and cataract surgery is the most common procedure in developed countries. Although the surgical technique has changed significantly over the past 20 years, the mode of delivery has not been examined, and most patients have two visits before surgery, one cataract surgery, one or two post-operative visits, second eye surgery and at least one more visit: so that’s seven trips to hospital in total! Cataract is normally a bilateral disease – hence the “CataractS” plural in the title. It is common for both eyes to be equally effected, or for one eye to be worse than the other. However, in most patients bilateral surgery is needed and there is excellent peer-reviewed evidence for additional benefit from second eye surgery. Many patients find the delivery of cataract care drawn-out, confusing and cumbersome. They often ask why both eyes cannot have surgery on the same day; if given free choice 80% of patients would choose this. What are the advantages? If pre-operative assessment and biometry (measurements for the intraocular lens) occur at the first visit, the pathway changes to: one pre-operative visit, surgery, one post-operative visit. The saving of patient time and trouble is three or four hospital visits, and depending on the delay for second eye
“They often ask why both eyes cannot have surgery on the same day: if given free choice 80% of patients would choose this.” surgery, at least four weeks before full visual rehabilitation. Where waiting lists approach six months, it can take over a year to complete the pathway using the conventional “one eye at a time” model. The healthcare economists note a saving of about £350 per eye if both eyes have surgery on the same day.
less than 1 person would get BSE. Even better, with improved treatment comes better visual outcomes, with about 1 in 3 eyes regaining driving vision. What this means is that if the entire population having cataract surgery in the USA had ISBCS every year, it would be once every 50 years that 1 American would not have good enough vision to drive from BSE…
So why don’t we do more ISBCS (Immediate Sequential Bilateral Cataract Surgery) – “both eyes same day”? The main answer is the perceived risk of infection, specifically bilateral simultaneous endophthalmitis (BSE). Endophthalmitis is a dreaded complication and is too frequently associated in ophthalmologists’ minds with blindness. Is this evidence-based logical thinking? The answer is undoubtedly “no”. Thirty years ago, the risk of endophthalmitis was perhaps 1 in 300, and most current consultants remember eye wards with at least one patient with an eye full of pus. However, in the 21st century the incidence has fallen to at least 1 in 3,000 and probably 1 in 5,000. With these figures it can easily be computed that the risk of BSE is 1 in 9-25 million! Put another way, if every single person in Greater London had ISBCS,
I have been a champion of ISBCS for over 10 years and I am certain that it is a better way to deliver care for most patients. “Nothing is more powerful than an idea whose time has come.” To find out more about Professor Charles Claoué please visit www.dbcg.co.uk
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GP news Round-up Patient access 7 days a week Health Secretary Jeremy Hunt, has said GP practices must ensure that, by 2020, patients can book GP appointments 8am-8pm, 7 days a week. Although it was emphasised that this doesn’t mean that every GP practice has to provide this service, each practice must offer this to their patients. Hunt suggested that this could be fulfilled by teaming with neighbouring practices, Skype appointments or through some ‘federated arrangement’. He also suggested that GPs may choose to recruit extra help in order to offer these services so that they themselves do not have to work evenings and weekends, too. However, research by the Royal College of GPs has shown that more than one in 10 family doctor roles in England are vacant – with many practices increasingly having to rely on locum doctors to deliver patient care. The health secretary also commented that he felt this was achievable by 2020. Tracking your CPD with the GMC In August the General Medical Council launched their new CPD app. The app has been designed to make it easier for GPs to keep track of their professional development whilst they are going about their daily GP duties. It works on a phone or an iPad and is free of charge to download. The app gives advice on how to plan your CPD around the four Good Medical Practice skill sets you need to achieve: 1. Knowledge, skills and performance 2. Safety and quality 3. Communication, partnership and teamwork 4. Maintaining trust
It also offers guidance on the type of learning you can undertake and how to evaluate what you have learnt, preparing you for your annual appraisal. Enquiry Helpline: 020
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Finally the GMC is able to send you regular news on the hot topics they are dealing with within general medical practice. To download the app visit the iPhone or Google Play store and search for ‘GMC CPD App’ Comment and Debate The Government have said there will be greater clarity about spending on general practice after the Government-wide Comprehensive Spending Review later this autumn. What areas are you expecting to see this allocated, and where would you like to see it go?
educational events 2016
2016 events schedule We are pleased to announce the GP event schedule for the first 6 months of 2016. In 2016 we are offering two regular monthly series, based locally to The Wellington Hospital in St Johns Wood or The Wellington Diagnostics & Outpatients Centre in Golders Green. These local series offer small lectures by leading consultants for up to 35 GPs. The third series on offer is the larger Masterclass events, located at The May Fair Hotel in central London. An altogether larger event, this sees a team of consultants offering lectures, talks or workshops for up to 150 GPs. This series of events offer a multidisciplinary view of many specialties. Educational Events 2016 Date January 21
Specialist Topic Location Hip & Knee Wellington Diagnostics Centre
February 4 Hand & Pain Wellington Boardroom February 23 AAU The May Fair Hotel February 25 Urology
Wellington Diagnostics Centre
March 3 Gynaecology March 17 Gynaecology
Wellington Boardroom Wellington Diagnostics Centre
April 14 Cardiology Wellington Boardroom April 19 GI The May Fair Hotel April 21
Wellington Diagnostics Centre
May 5 Neurosurgery Wellington Boardroom May 17 Head & Neck The May Fair Hotel May 19
Foot & Ankle
Wellington Diagnostics Centre
June 9 Colorectal Wellington Boardroom June 21 Knee The May Fair Hotel June 23 Headaches Wellington Diagnostics Centre Sign up to receive event invites or to manage your attendance at our events visit www.twhevents.co.uk
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NEWS FROM THE WELLINGTON HOSPITAL
news from we’re expanding our reach with two new centres
Bon voyage Veronica Brown GP Liaison team
Many of you will know we have an ever evolving diagnostics centre in Golders Green, which has grown to twice its original size since opening in 2007. Following the success of this centre, I am delighted to announce we are opening two further diagnostic centres. The first will be based in Elstree and will allow the hospital to provide a local service to our patients that live further to the north from us. The second will be based in Chiswick and is in an area that is currently sparse of private
healthcare providers. The large corporate market in this area has been the foundation for The Wellington’s business case to open a new centre. Our engagement with the corporate market in and around Chiswick has been an on-going project for the last 12 months and this new centre will establish us as a strong service provider. This will be a £12m investment for both centres and we hope to open them to patients in the latter part of 2017.
After five years, we are bidding a fond farewell to Veronica Brown from the GP Liaison team. Veronica is leaving us for the beautiful beaches of Norfolk. Veronica has been an avid organiser of our educational events for GPs and regularly supported the neurological rehabilitation team’s work with case managers and solicitors. The Wellington team would like to wish Veronica well for her future in Norfolk.
New Consultants Orthopaedics
Mr Matthew Bartlett, Northwick Park Hospital
Dr Reeba Oliver, Whipps Cross University Hospital Dr Jane Ashby, Central & North West London NHS Foundation Trust
Dr Arshad Rather, University College Hospital
Dermatology Dr Sweta Rai, King’s College Hospital
Genetic Counsellor Miss Monika Kosicka-Slawinska, Northwick Park & St Mark’s Hospital
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Dr Piyusha Kapila, North Middlesex University Trust
Radiology Dr Nader Khandanpour, St George’s Hospital
60 SECS WITH
When you have taken a patient from a negative experience to a very positive one and they let you know, either face-to-face or by writing in to say thank you, it’s very rewarding and heartening to hear that we made a difference – as a team
PATIENT EXPERIENCE MANAGER Claire McKinson talks to Gerry Sloan about learning from our patients and making sure they are always at the heart of everything we do at The Wellington
What changes will our patients see? If for any reason a patient is unhappy with something, it’s important that our patients know we now take a team approach to tackling them. That there is a team keeping an eye on patient experience from before they even arrive to when they leave. We want our patients to know that we are listening, that we take their concerns seriously, we will keep them informed and will follow up with them to make sure everything has been resolved, and that they are happy.
What does your role as Patient Experience Manager encompass? Although you’ve been at The Wellington for many years, this is a new role for you and the hospital, why was it created? This role came about after lengthy discussions with the chief nursing officer, Lenny Byrne, about how we could harness the patient experience. The hospital has always had weekly and monthly meetings about patient concerns, but until now we haven’t reached into the hospital, through one cohesive team, to find out: what are our patients telling us, how we respond in real time, how we make sure that our resolutions are effective, review what we have learned and how we apply this learning into the whole organisation.
It spans across the entire hospital: I speak at staff inductions about the patient experience and what we expect of our staff; I attend clinical updates, visit all the wards, and other departments who may not see patients faceto-face but still affect their experience here. I also speak directly to our patients. Part of my job is to be very aware of what is happening throughout the hospital, and respond to any concerns promptly, even if they have happened overnight, they are reported and dealt with following the 8am managers meeting each morning.
How has the feedback been so far? Now we are responding to any concerns much more effectively, we’ve seen our written
complaints fall very quickly. We still have a way to go before we are satisfied, but the next stage is to get everyone within the hospital really focused on ‘the patient experience’. So from the minute the patient arrives to the minute they leave, every staff member is making sure our visitors have a positive experience. We are a world-class hospital, we want to ensure that, as individuals, we are giving our patients a worldclass experience.
What are our future patient experience goals? We ask each patient to complete a patient satisfaction survey before they leave us. Our next focus is how do we get those patients to go from saying their experience with us was ‘very good’ to ‘excellent’. We want to find out what is excellent to a patient and make that a reality. We also want to involve patients in any big decisions we make about the hospital from now on, so we can find out what we need to focus on to make sure we get it right for our patients.
What do you enjoy most about this new role? When you have taken a patient from a negative experience to a very positive one and they let you know, either face-to-face or by writing in to say thank you. It’s very rewarding and heartening to hear that we made a difference – as a team.
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www.practicemattersmag.co.uk 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