The periodical of the Harley Street Medical Area Issue 14 / 2024
For decades, research into sports injuries was focused on men.
A Harley Street sports medicine group is now putting that right
Innovation matters
Professor Mark Emberton on why innovation is important and what it needs to thrive
Golden slumbers
A clinical psychologist clears up some of the myths around sleep
How does it work?
A simple guide to YAG laser capsulotomy
Our skilled audiologists will support your hearing healthcare with a personalised treatment and care plan. We o er the very latest innovation in hearing technology, cognitive support and nutritional therapy, including a new range of clinical grade functional mushrooms, available via our online shop from September 2024.
Prognosis is owned by The Howard de Walden Estate 23 Queen Anne Street London W1G 9DL 020 7580 3163 hdwe.co.uk
Howard de Walden contact Annette Shiel annette.shiel@hdwe.co.uk
Publisher Lusona Publishing and Media Limited lusonapub.co.uk
Editor
Viel Richardson info@lusonapub.co.uk
Editorial consultant
Mark Riddaway mark@lscpublishing.com
Contributers
Ellie Costigan, Gerard Gilbert, Angela Holder, Vicky Power, Christopher L Proctor, James Rampton
Design and art direction Em-Project Limited mike@em-project.com
54 Children’s hour Dr Jack Singer of the Harley Street Paediatric Group on blue couches, hovering parents and why he’s optimistic about children’s medicine
04 HSMA update
Mark Kildea, CEO of The Howard de Walden Estate, on the role innovation will play in ensuring a brighter future
09 News
New arrivals, developments and events
10 Crystal ball
The evolution of treatments for diabetes
11 Harley Street hero
The life and times of Isabel Thorne
12 How does it work?
YAG laser capsulotomy
14 Thinking aloud
The thoughts of Rebecca Bright, co-founder of Therapy Box and non-clinical director of Harley Street Physiotherapy
16 Profile of a pathogen
Dengue haemorrhagic fever
18 How to
Spot signs of hearing loss
20 A day in the life
Dr Geetha Venkat, founder and director of Harley Street Fertility Clinic
24 No-drama pharma
Karen Grace of John Bell & Croyden on the ever-evolving role of the pharmacist
26 Healthcare in the digital age Public health and AI
30 The big interview
Professor Mark Emberton on why innovation is important, what it needs to thrive and – most importantly – what it actually means
36 Level playing field
For decades, research into sports injuries was focused on men. A Harley Street sports medicine group is putting that right
42 Golden slumbers
Dr Zoe Gotts, clinical psychologist at the London Sleep Centre, clears up some of the myths around sleep
46 Q&A
Consultant dermatologist
Dr Conal Perrett on Mohs micrographic surgery
50 Patient experience
Una Dunleavy on how cosmetic dentistry restored her self-confidence
54 Children’s hour
Dr Jack Singer of the Harley Street Paediatric Group on blue couches, hovering parents and his optimism about children’s medicine
60 My Marylebone
Dr Reena Wadia, founder of RW Perio
62 What’s on
Cultural events near the Harley Street Medical Area
63 Five
Places for an afternoon out in Marylebone
64 The guide
Pioneering Marylebone residents
Sometimes I lose track of time and staff will knock at my door and say: “Your next patient is waiting,” because I’m so immersed in the whole situation. There can’t be anything better than making babies. It’s such a passion for me.
Dr Geetha Venkat, founder and director of Harley Street Fertility Clinic
20
Mark Kildea, chief executive of The Howard de Walden Estate, on the
role innovation will play in ensuring a brighter future
Through medical innovations and the changing relationship people have with their health means, the healthcare landscape is rapidly evolving. The Harley Street Medical Area (HSMA) must also evolve in order to maintain its position as a world-class healthcare hub.
We’re seeing many people taking a greater interest in the state of their health before things start to go wrong. What we call ‘healthcare’ has in reality been ‘sick care’, with most people only considering their health status when things go wrong.
Attitudes in younger generations are different, with younger people engaging with healthcare services in order to maintain good health. Our occupiers are seeing an increasing demand for services which
help people physically, mentally and emotionally.
This requires a change to the whole patient experience. We want to make sure that the HSMA is at the forefront of societal change and the wider adoption of technology linked to the growth in wellbeing. We already have many specialist clinicians and facilities, such as hospitals capable of carrying out complex surgery or providing overnight accommodation and nursing provision, but we need to look closely at how and where we can build on this existing infrastructure.
For example, while we already have outpatient and ambulatory services, we think that increasing and improving our offering in that area will sit well with the fantastic diagnostic and imaging equipment
What we call ‘healthcare’ has in reality been ‘sick care’, with most people only considering their health status when things go wrong. Attitudes in younger generations are different, with younger people engaging with healthcare services in order to maintain good health.
we have in the HSMA. We are looking at buildings that will allow us to do this on a grand scale. Number 1 Harley Street, for example, will be available next year and would be perfect for someone who wishes to operate a world-class ambulatory service from a fantastic location.
Another area that we expect to grow is ‘pre-habilitation’, where a patient works with their clinical team – a physio and dietician, for example – in the days or weeks before their procedure to ensure that they’re in good shape to get the best possible result, followed by a shorter rehabilitation. With the rehabilitation, rather than staying in hospital after their procedure, they might go to a step-down facility offering infection control, pain relief and other nursing services.
I believe the HSMA can also play a significant role in supporting the NHS. We saw this during Covid, when our private hospitals treated patients to help ease the extraordinary pressures on the system. But there is another area which I think has even greater potential: our ability to innovate. By offering space that facilitates innovation and fosters networking among clinicians, we can create an environment from which innovation and new and effective treatment pathways emerge. We want to work with the NHS and independent healthcare groups to create exemplars of best practice that can be used much further afield. We want NHS trusts to come to Harley Street to understand how clinics and hospitals here are getting such high-quality outcomes
One area that we expect to grow is ‘pre-habilitation’, where a patient works with their clinical team in the days or weeks before their procedure to ensure that they’re in good shape to get the best possible result.
and how this practice could be applied within the NHS.
Research – including the emergence of AI – is another area where we are well placed to thrive in this new landscape. There are many kinds of clinical research that do not need wet lab facilities but would benefit from the proximity to a wide array of world-class clinicians dealing with complex conditions. We want to help make connections between researchers and clinicians. There is also the important relationship with venture capital and the role that it plays in funding clinical research. We see the potential in aggregating sources of funding close to where innovation and research is undertaken.
The HSMA already has world-class facilities which attract both patients and clinicians from across the world. Our role as landlord is to help provide an environment that allows the area to continue to thrive in the new healthcare landscape.
The Howard de Walden Estate 23 Queen Anne Street London W1G 9DL 020 7580 3163 hdwe.co.uk
27 - 30 January 2025
ABHI hosts the largest and most visible group of UK companies at Arab Health. Our stand is home to a busy four-day programme of live surgical simulations and dedicated partnering events. Be sure to visit us to learn more about the best in UK healthcare and HealthTech. For more information, write to enquiries@abhi.org.uk.
17 Country Pavilions
3,450
110,000+ Healthcare and Trade Professionals
180+ Countries Represented
The Howard de Walden Estate will host its biennial Healthcare Conference 2024 at the Royal Society of Medicine in Marylebone on Thursday 31st October 2024. Chaired by the Rt Hon Lord Kakkar, the conference will bring together leading experts, innovators and policymakers to explore the topic of innovation in healthcare. The one-day event will showcase expert panels and keynote addresses from industry leaders including Farhad Karim, CEO of Blackstone, and Professor Dame Molly Stevens from the University of Oxford’s Institute of Biomedical Engineering.
hdwe.co.uk/healthcare-conference
The London Clinic has opened its new Rapid Diagnostics Centre at 142-146 Harley Street. Located within a new six-floor purpose-built facility, the centre will focus on urology (including prostate, bladder, testicular and renal), gynaecology, breast and dermatology. Patients will have access to appointments that happen within 24-48 hours of booking, meaning that stressful waiting times are eliminated from the process. Results will be reported directly to the doctor or consultant within 72 hours of testing. When required, the centre will offer same-day access to radiological and endoscopic procedures, as well as minor surgeries to visualise tissue and take biopsies.
thelondonclinic.co.uk
Pharmacierge, a leader in private e-prescription app and delivery services, has opened a cutting-edge 5,500 sq ft dispensary on Wimpole Street. This ambitious project involved transforming two 18th-century Georgian properties into a streamlined clinical space, integrating cutting-edge software and pharmacy design. The facility, which includes areas dedicated to controlled, refrigerated and biological medications, features a 10-metre multi-arm dispensing robot, equipped with machine learning-driven stock management, which allows staff to focus on complex tasks, enhances efficiency and minimises medication wastage.
pharmacierge.com
HCA Healthcare UK has opened a new outpatient centre on Harley Street dedicated to the care of women. With 16 consulting rooms, four treatment rooms, three ultrasound rooms, three mammograms and its own 3T MRI and DEXA scanner, this £13.5m six-floor facility allows for all aspects of women’s healthcare to be accessed in one location, including gynaecology and breast screening services and expertise in menopause. The centre provides a full range of specialist care, drawing on the expertise of leading consultants from The Harley Street Clinic and The Princess Grace Hospital, as well as GPs who specialise in healthcare for women.
hcahealthcare.co.uk
Moorfields Private has been named Hospital of the Year in Doctify’s Patient Voice Awards. This award honours the hospital that has done most to collect and integrate patient feedback in order to enhance services, build trust and foster transparency. Moorfields Private offers every patient the opportunity to provide anonymous feedback via Doctify. The results are shared monthly with every member of the team and each department has an action plan to improve services based on this feedback. The Doctify judges found that the group responded to 99% of patient feedback and had established a seamless process for sharing insights across the organisation.
moorfields.nhs.uk/private
Cleveland Clinic London has become the first private hospital in the UK to successfully perform laser lead-extraction procedures to remove infected and malfunctioning wires from cardiac devices. Pacing leads are insulated wires that run between the heart and a pacemaker or implantable cardioverter-defibrillator. Extracting one of these leads to combat an infection or malfunction is a complicated procedure, requiring the careful navigation of tough scar tissue around the lead. The most common reason for lead extraction is an infection of the blood that spreads to the lead. Heart valves may also become infected. Such infections can lead to serious complications if not treated promptly.
clevelandcliniclondon.uk
Dr Ralph Abraham of the London Diabetes Centre on the possibility of eradicating a common disease
With type 2 diabetes, the situation is more complex. Weight, lifestyle, ability to exercise, ability to understand glucose readings, and underlying issues like hypertension and high cholesterol, alongside other factors, all need to be considered to get the best outcomes. The way to the best outcomes is for patients to be really engaged with their treatment. Studies show that patients who fully engage with their condition and treatment do so much better than those who simply follow a regime of medication.
On the horizon
State of play
Diabetes is not just about blood sugar levels. It can impact the eyes, heart, kidneys, liver, nerves and skin, among other areas. It is truly a whole-body disease. As a result, treating it well often needs a team of specialists working together. When talking about the gold-standard treatment, there’s a distinction between type 1 and type 2 diabetes. For type 1, the gold standard is a system called closed loop hybrid technology patch pumps. The patient has a small container of insulin attached to a means of delivering a measure of insulin. They wear a glucose sensor that connects to an app in their phone. The sensor monitors their glucose levels and automatically tells the system when to deliver an appropriate dose of insulin.
There are a number of things that I think will have a real impact in the near future. Glucose sensors will become almost universal in the detection and self-treatment of diabetes, particularly in type 1 patients. This in turn will create a huge role for artificial intelligence software. This really matters, not least because diabetes is a high-volume disease and there currently aren’t enough clinicians to match the demand.
A much bigger role in type 2 diabetes will be a type of drug called a GLP-1 agonist. These are the world’s most powerful diabetes drugs and they tackle several different issues. They increase the body’s insulin production and reduce the amount of glucose the liver makes. They slow the absorption of food into the system and therefore the rate that sugars enter the bloodstream. They can suppress appetite, helping with weight loss. They also work on the gut-brain connection, which we are just beginning to understand but are realising is hugely important. In some
There are two modalities – gene therapy and stem cell therapy – which I think have the potential to completely transform the way we approach diabetes.
ways, they are already here – but their impact is just beginning.
In the distance
This is where I think things get really exciting. There are two modalities –gene therapy and stem cell therapy – which I think have the potential to completely transform the way we approach diabetes. The use of mRNA techniques could introduce genes that give your body the ability to produce hormones like insulin and glucagon-like peptide (GLP1), actually curing the disease without side effects such as hypoglycaemia. With stem cell therapy, humanised pancreatic beta cells from animals can be produced on a mass scale, and this has been shown to treat patients successfully by making them independent of outside insulin. These developments hold out the promise of the patient having a regular top up and their type 1 diabetes being effectively cured.
We’re also at the beginning of a brave new world where you can identify a person with a particular blood profile, which means there’s a possibility of prescribing medication to people who are at risk of developing type 1, thus reducing the chances of that happening. The blue-sky hope is that in the lifetime of people alive today we will have the power to consign diabetes to history.
The London Diabetes Centre
49 Marylebone High Street London W1U 5HJ 020 7467 5470 londondiabetes.com
Words: James Rampton Image: Wellcome Collection
A resident of 148 Harley Street for many years, Isabel Thorne was a rebel with a cause. A very strong cause indeed. Born in London in 1834, Thorne was the third daughter of Thomas Pryer, a solicitor, and attended Queen’s College in Marylebone. She had an eminently respectable Victorian upbringing. What turned her into such a rebel, then?
A burning sense of injustice that, despite impeccable medical credentials, as a woman she was barred from qualifying as a doctor in this country. Enraged by this manifest iniquity, Thorne became a key player in a groundbreaking campaign. Many years prior to the suffragette movement of the early 20th century, Thorne was a highly influential feminist trailblazer. Her impassioned – and extremely courageous – efforts transformed the face of medicine in Britain forever. In 1856, she married a tea merchant named Joseph Thorne and went to live with him in Shanghai. While in China, one of their children died, and that tragedy persuaded Isabel of the imperative that women and their children be treated by female doctors. Returning to Britain in 1868, she put her passion into practice. She replied to an advert placed by Sophia Jex-Blake asking for women to study with her at the University of Edinburgh and try to become the first female students in the UK to attain medical qualifications.
Thorne and Jex-Blake were joined by Mary Anderson, Emily Bovell, Matilda Chaplin and Edith Pechey, a group who came to be known as the Edinburgh Seven. They became the first group of matriculated undergraduate female students at any British university. And
yet, in spite of their hugely impressive academic achievements – Thorne won first prize in an anatomy examination – the septet encountered ferocious, sometimes violent resistance.
Matters came to a head at four o’clock on the afternoon of Friday 18th November 1870 when the women went to take an anatomy exam at Surgeons’ Hall. As they drew near, their route was blockaded by a crowd of several hundred angry protesters, many of whom threw rubbish, mud and insults at them. As the female students approached the main entrance of the hall, the gates were shut with a bang – until one sympathiser managed to force them open again. After sitting the exam, the seven refused to depart unobtrusively through a side entrance; instead, they defiantly marched out of the main gates.
The Surgeons’ Hall Riot, as it is now called, proved to be a turning point. The riot generated massive worldwide coverage and gained the female students many new supporters, including Charles Darwin. Their highprofile campaign eventually helped bring about the UK Medical Act in 1876. Despite the ardent opposition of Queen Victoria, the act enshrined the right of women to practice medicine.
Having been stymied by the courts in their efforts to qualify as doctors in the Scottish capital, the Edinburgh Seven went on to set up the London School of Medicine for Women, and Thorne became its honorary secretary. In 2015, The Seven’s campaign was memorialised with a plaque at Edinburgh University. Four years later, Edinburgh Medical School held a series
of commemorations to pay tribute to their accomplishments. These included awarding the septet the posthumous honorary degree of MBChB. Seven female students went up to accept the certificates on behalf of their revolutionary predecessors.
Another legacy of Thorne’s pivotal work is the fact that her daughter May went on to become a surgeon after backing her mother’s campaign as a young woman. The enduringly powerful story of these pioneering women has also been celebrated in Charles Reade’s 1877 novel A WomanHater and a 2022 musical entitled Seven Against Edinburgh.
Thorne, who died at her home on Harley Street in 1910, is remembered as an inspirational pioneer who bravely faced down fierce hostility to establish a fundamental right for women. She was a true Harley Street hero.
It would be naive and complacent to assume, however, that Thorne’s outstanding work in combating sexism in education is now complete. Sadly, in many countries young women are still forbidden from going to school or university. Janey Jones, whose book on the Edinburgh Seven was published last year, sounds a warning note: “We see across the world, in countries like Afghanistan, that women accessing education is a major problem. I’m still seeing patriarchal sentiment out there in the top echelons of society, and that was the Edinburgh Seven’s problem. I don’t want women today to sleepwalk through that existing prejudice.”
It’s an assertion with which Isabel Thorne would no doubt have passionately agreed.
YAG laser capsulotomy
Mr Amir Hamid, consultant eye surgeon at Optegra, on a simple laser treatment for a common but distressing condition
Interview: Viel Richardson
Posterior capsule opacification (PCO) is a condition that can sometimes occur after an intraocular lens implant has been fitted during cataract surgery.
The lens of your eye has two main parts: the capsule, which is transparent, and an inner filling. During a cataract procedure, we make a circular opening on the front of the capsule, through which we remove the cloudy inner filling and insert the lens implant.
During the surgery we need to remove the vast majority of the inner filling, but some cells – known as lens epithelial cells – do need be left behind to maintain the health of the capsule. The problem is that when it recognises that a lens is missing, your body automatically begins to produce more of these cells and migrate them across the capsule in an attempt to replicate the absent lens. This process can lead to a barrier of cells building up between the posterior capsule wall and the artificial lens. When light hits this part of the lens capsule, instead of passing through the capsule wall and forming a sharp image on the retina, the lens epithelial cells scatter the light, meaning that a cloudy, fuzzy image reaches the retina instead, compromising the patient’s vision all over again. This is what we call posterior capsule opacification.
There are certain things we can do to reduce the possibility of posterior capsule pacification occurring after
surgery. Prior to removing the cataract, there is a process we use called hydro dissection. Using a wave of fluid, we separate the filling from the lens capsule. We spin the lens during this process, which increases the amount of lens epithelial cells we can remove.
We also aim to ensure that the continuous curvilinear capsulorhexis – the opening we make at the front of the lens capsule – is perfectly circular and exactly the right size. If it’s too small, it can cause issues during the operation and reduce the amount of light travelling through the eye after the procedure. If it’s too large, it won’t completely overlap the edges of the artificial lens. This can allow the migration of lens epithelial cells to the posterior capsule, causing the cloudiness.
Another factor that can reduce the occurrence of PCO is the design of the artificial lens. Having a lens with a square edge can significantly reduce the possibility of lens epithelial cells from migrating across the eye and building up in a way that impacts the vision. But that benefit is negated if the circular opening is too large and the edge is not in contact with the anterior capsule. Lens materials also matter – certain materials are better than others at reducing the risk, and here at Optegra we are very particular about using the right lenses.
Posterior capsule opacification can be very distressing. The cloudy vision that results from PCO can be similar to that of the initial cataract, so patients often think their condition has come back. This can be very stressful, as having enjoyed the life-changing benefits of the initial surgery they realise that their vision has started to deteriorate again. Like the emergence of a cataract, this can happen gradually over many months and may not be noticeable for quite some time. This is why we recommend that patients have regular eye tests at their
local opticians after cataract surgery. We suggest every two years at least, because the opticians can spot PCO early if it starts to develop.
Because cataract surgery is one of the most common procedures in the world, PCO has the potential to affect huge numbers of people. The great thing is that it’s easy to treat. Using a YAG laser we can completely restore the patient’s vision to where it was before PCO started to develop. Using the laser, we cut a hole in the back of the capsule at the point there the light passes through it. This lets the light pass through without being scattered by the lens epithelial cells on their way to the retina. The patient’s experience is very simple. Once they’ve been made comfortable, we use drops to dilate the pupil. We then bring the laser equipment into position and start the procedure. From the patient’s perspective they are simply looking at a point of light. With an experienced surgeon, around five minutes for each eye is the longest it should take and in most cases it is considerably shorter. The patient doesn’t feel any pain and no anaesthetic is necessary. The vision will remain blurred until the medication used to dilate the pupil wears off, which may take several hours. They can go back to normal activities as soon as the vision is back to normal.
This is an extremely a common procedure and complications are exceedingly rare. However, as with all surgical procedures there are risks that the patient needs to be aware of. It is possible to cause damage to the intraocular lens – the artificial lens used to replace the natural one – during the procedure, leading to it needing to be replaced. It is also possible to tear the lens capsule when placing the new lens. Retinal detachment could occur, as could elevated pressure in the eye. But all of these are extremely rare. To give you some context, I’ve been carrying out YAG laser procedures since 2000 and have never had a serious complication, and there are many other surgeons who could tell a similar story. When patients come in, they are obviously very worried. It’s wonderful to be able to relieve that anxiety with a simple diagnosis and the knowledge that we can alleviate their symptoms with a quick, painless procedure. Finally, it’s very gratifying to be able to reassure them that once the procedure is finished there is no bridge left for the cells to cross, so the issue can never re-occur.
25 Queen Anne Street
London W1G 9HT
0800 077 3727
optegra.com
Rebecca Bright, co-founder of Therapy Box and non-clinical director of Harley Street Physiotherapy, on bringing the benefits of digital technology to new patients
Interview: Ellie Costigan
I’m a speech and language therapist by background. I’ve worked a lot with people after brain injuries, strokes or neurodegenerative conditions, and from that I identified a need for people with little or no speech to be able to communicate. My husband and I launched a text-to-speech app to address that in 2011. That’s how our tech business, Therapy Box, started.
Technological solutions don’t have to be complex – sometimes it’s the simple things that make the most meaningful difference to people’s day-to-day lives. It could be appointment reminders or the ability to fill in forms online, small steps that make the process easier and allow things to run more smoothly, for clinicians and their patients.
Harley Street Physiotherapy has been around for 30-odd years and is run by two fantastic physiotherapists, Lizzie and Pippa. They’ve built amazing relationships with patients during that time, some who’ve been with them for three decades, with three generations of their family passing through.
Just like our tech business, our approach at Harley Street Physiotherapy is about listening to people and thinking how we can better meet their needs. Getting feedback from the people who use our apps and services every day is really important. We work a lot with them and our clinicians to identify what’s working and what more we could be doing to make a difference.
The world of technology in medicine has changed a lot since we first began. Clinicians have embraced it and seen how it can help with productivity, whether that’s recording their notes and having them auto transcribed, or giving their patients exercises to do at home. It’s not something that’s ever going to replace a clinician, but it’s a tool that can make them more productive.
You don’t just treat the physical symptoms; you listen to the person. We need to find out what they want and what their goals are. Often things are more complicated than they might look from the outside, which is why the whole experience of the patient, not just the actual physiotherapy, is so important.
We clicked with Lizzie and Pippa straight away. It helped that we’re all antipodean, so we have a bit of a shared background. They’re amazing physios who absolutely want the best for their patients and we share their vision for the business. We want to ensure the legacy of what they’ve built continues. We want to ensure the next 30 years are just as successful.
We’ve won sevaral awards, including the Queen’s Award for Enterprise for medical innovation. It’s nice for the patients and people who use our apps to be able to see that the products they use are well regarded. They have that stamp of approval. It’s also lovely for the team to have their hard work recognised.
Sometimes you get bogged down in the day to day and lose sight of the big picture but a bit of recognition and positive feedback does wonders for the team. It helps them keep on going.
Dengue haemorrhagic fever sits in the Flavivirus genus of viruses in the family Flaviviridae. This family includes viruses such as yellow fever, West Nile fever and Japanese encephalitis, making theirs a family reunion you’d have every excuse to avoid.
There are two distinct presentations of dengue. Infection always starts with the less serious dengue fever, and many people experience no symptoms at all. If they do occur, symptoms include a high fever alongside any of the following: headaches, muscle pain, bone or joint pain, nausea, vomiting, pain behind the eyes, swollen glands or a rash. Patients usually recover within a week or so, and it is often mistaken for other illnesses such as flu.
But sometimes the condition worsens and develops into dengue haemorrhagic fever, also called severe dengue or dengue shock syndrome, and this is potentially fatal. This happens when the blood vessels become damaged and leaky and the number of clot-forming platelets in the bloodstream drops. This can lead to shock, internal bleeding, organ failure and eventually death. And it can develop quickly, with symptoms appearing a day or two after the fever
passes. These include severe stomach pain, persistent vomiting, bleeding from the gums or nose, blood in the urine or stools, bleeding under the skin (which can be mistaken for bruising), difficult or rapid breathing, fatigue, irritability or restlessness. This varied array of symptoms means dengue haemorrhagic fever can be difficult to diagnose for those not used to dealing with it.
Dengue viruses do not have a particularly ancient lineage. Scientists believe they only jumped from primates to humans in southeast Asia or Africa around 1,000 years ago. There have been sporadic reports of a dengue-like disease for centuries but it was in 1907 that PM Ashburn and Charles F Craig, studying an outbreak on US military base Fort William McKinley, established several facts about the disease. Among these were that it was caused by an – at the time – non-filterable agent transmitted in the blood. It was not a bacterial infection. Some individuals developed immunity and could not be re-infected while others did not. Also, it was not transmitted between humans. They believed – correctly – that it was transmitted by mosquito bite but were unable to prove this conclusively.
Genus A biological classification ranking, placed between family and species. It consists of either a group of related species or a single isolated species that contains unusual levels of differentiation within it.
Flaviviridae A family of enveloped positive-strand RNA viruses which mainly infect mammals and birds.
Serotype A way of grouping cells or microorganisms, such as bacteria or viruses, based on the antigens or other molecules found on their surfaces.
It wasn’t until 1943 that Japanese scientists Ren Kimura and Susumu Hotta isolated the dengue virus when studying blood samples taken during an outbreak in Nagasaki. They had isolated the virus now referred to as dengue virus 1 (DEN-1), but that was not the end of the story. It was subsequently discovered that dengue fever is caused by four related viruses, with DEN-2, DEN-3 and DEN-4 later isolated. These four viruses are called serotypes and while they share approximately 65% of their genomes, there is significant genetic variation.
However, infection with any of the serotypes results in the same disease. Where having these four serotypes makes things tricky is with immunity. A person infected with one of the serotypes is likely to be protected for life against that one serotype, but protection against the other three is partial, temporary or absent. This makes dengue a hard virus to control and protect against and is a significant reason that no reliable treatment or vaccine is available.
Worryingly, dengue fever is spreading. All four dengue serotypes circulate in tropical and subtropical regions around the world. The issue is that as the climate warms the range of these climate zones expands, and so too does the extent of the area where the disease has the potential to become endemic.
A warming climate is going to present us with many different challenges in the future. The growth of dengue haemorrhagic fever is a stark reminder that disease control will not be the least of them.
HCA UK Women’s Health Centre
Demonstrating our commitment to improving women’s experience of healthcare, our new centre at 27-29 Harley Street brings multidisciplinary consultants and pioneering treatments together – all under one roof.
Our Women’s Health Centre provides:
• GP-led health screening
• Outpatient appointments
• Minor treatment rooms for day case procedures
• Bone density scanning (DEXA)
• 3T MRI scanners
• Two phlebotomy (blood testing) rooms
• 16 consulting rooms
• Ultrasound facilities, and;
• 3D contrast-enhanced mammography.
For referrals and enquiries, please contact: T: +44 (0)20 7034 5175
With rapid access to 35 leading consultants and medical teams over six floors, patients can access end-to end care for a range of symptoms and conditions, as well as bespoke support for menopause, endometriosis, breast and gynaecological cancers.
The new Women’s Health Centre complements HCA UK’s existing health services for women at Chelsea Outpatients, 272 King’s Road, and The Portland Hospital.
Adam Shulberg, senior audiologist and managing director, The Wellbeing by Cubex
What are the initial signs of hearing loss?
There can be various indicators. Struggling to hear high-frequency sounds like birdsong or an alarm from another room. Random asides in conversation sounding muffled and vague. Difficulty hearing one-on-one if the speaker turns away, which can reveal an increased reliance on lipreading and body language. Becoming forgetful is another sign, because hearing loss has a knock-on effect on cognition. Also, tinnitus and hearing loss can often co-occur.
Does this usually lead to changes in behaviour?
A person might unknowingly start withdrawing from social interactions and challenging situations, like gatherings in noisy environments. Understanding speech in these situations can become tiring, as the brain has to work much harder to process conversations, and this can result in feelings of isolation and withdrawal. Depression and anxiety can become an issue. Constantly asking colleagues and family to repeat themselves or talk louder can cause shame and embarrassment and change how we interact with people.
Why is forgetfulness an indicator?
The brain and the ears are interdependent, so hearing loss can impact cognitive function. If a patient is becoming forgetful or finds it hard to complete memory-reliant tasks, this could be linked to hearing loss. There is a close and complex relationship between hearing capabilities and cognition.
Do these signs always mean that there is a clinical issue?
Not necessarily, but it’s important to have a thorough clinical assessment. Other causes of hearing loss might include obstructions in the ear, which can be easily dealt with. We recommend earwax removal at least once a year, and we always recommend that firsttime patients book an ear canal exam and micro-suction before we do the full clinical examination.
What are the likely causes of hearing loss?
There are two main types of hearing loss. Conductive hearing loss is caused by issues in the outer or middle ear that prevent soundwaves from reaching the inner ear efficiently – earwax buildup, middle ear infections and perforated eardrums are some examples. Then there is sensorineural hearing loss, which is caused by damage to the inner ear (the cochlea) or the auditory nerve, which transmits sound signals to the brain. These could be caused by things like aging, loud noise, medication or genetics.
Problems not directly related to the ear’s physical structures include auditory processing disorder (APD), a neurological condition where the brain has difficulty processing the sounds it receives. Stress, anxiety or depression can also sometimes manifest as perceived hearing loss.
What should I do if I’m concerned about my hearing?
Book an appointment with a specialist audiologist. There are so many aspects to be assessed which go far beyond
a simple hearing test. Here, we do a thorough examination of every aspect of your hearing health – physiological, emotional and cognitive. We encourage the involvement of a family member as they can add another perspective.
How long does an assessment take? There’s simply no substitute for time. A thorough, empathic clinical examination should involve a first consultation of at least 90 minutes. There is just so much to consider. It’s only in examining the detail, in conversation with the patient and their spouse or partner, that you get to uncover what’s really going on. Only then can you work out a way forward that will stand the patient in good stead going into the future.
What is the biggest misconception about dealing with hearing loss?
The biggest fallacy is that hearing loss is only physiological. It can hugely impact cognition, emotional health and all-round wellness. Studies show that using hearing devices reduces the risk of cognitive decline, including dementia and Alzheimer’s. That’s remarkable! Missing out on the minutiae of life – the birdsong, the sound of rain – has a subtle but significant impact on a person’s inner world. Our clinic was one of the first to offer a person-centred approach that addresses and treats all the various complexities of hearing loss.
Dr Geetha Venkat, founder and director of Harley Street Fertility Clinic
Interview: Vicky Power
Portrait: Christopher L Proctor
Making babies is the best job in the world. In fact, I wouldn’t even consider it a job – it’s my life. After working as an IVF doctor for about 20 years I decided to set up my own clinic in 2010 so that I could apply the good practices I had learned from the wonderful clinicians I had worked alongside. My focus was never on making money – I was already a senior doctor and had a good salary. But my passion was to set up a clinic where we would look after patients the same way we would look after guests at home, and where they would leave feeling that we had done everything we could for them.
There are so many huge IVF clinics in Harley Street, so getting started was a challenge. We began in four basement rooms with only four staff members – me, a nurse, a receptionist and a
support person. But with god’s grace it developed well, people heard about us, and our reputation grew. Most of our clients came via word of mouth. Within three years, we moved to a bigger building at 134 Harley Street and now we have six floors. We do everything in the same building – we have an IVF laboratory where we test and mix the sperm and egg, and a theatre to do the egg collections and IVF. We also store the eggs, sperm and embryos there. Everything happens in one place and now we have 35 to 40 employees.
I always take a detailed history from my clients. In some other clinics a junior doctor will take the history, with a senior clinician only getting involved in some of the stages. I want to know the patient from the beginning; it’s the same with our other doctors who have their own
I recently had a 42-year-old patient who had gone through eight miscarriages after IVF treatments. We discovered that her immune system was the issue. We took her through a treatment regime and the next IVF treatment resulted in a beautiful little girl. It is so satisfying.
us the best chance of a healthy baby. Our success rate is 71% over all the age groups if we test the embryos. If we don’t test the embryos because the patients don’t want us to, this falls to 60% over all the ages. These are extremely high rates. As a result, we get a lot of women aged 40 and over.
I see patients all day on Mondays, Thursdays and Fridays. When I start the day, I sit for a few minutes as soon as I come in and pray – I do believe the creation of life is sacred work. I say: “Please let this be a very good and productive day.” Then I always start with a minute’s silence to clear my mind of all thoughts, so that I’m completely present and mindful.
myself up to date with all the latest fertility information. In the evenings and at weekends I will read papers and go to conferences to keep abreast of new equipment and other innovations. Recently we have introduced to our clinic a new technique called CHLOE, an artificial intelligence system for selecting embryos. It’s one of the factors which has increased our success rate.
patients. I believe real attention to detail is very important in IVF. I am from South India and speak Tamil, Hindi and Gujarati, which is why a lot of Asians come to me – they feel more comfortable talking in their own language. And we also have doctors who speak French, German and Dutch. Harley Street Fertility Clinic is an international clinic.
We get a lot of patients who have endured three or four unsuccessful attempts before coming to us and it is important we know what happened in those treatments. Sometimes certain tests had not been done, so we’ll arrange for them to be carried out so that we can modify the patient’s protocol. Testing the embryos for chromosomal abnormalities is a key point in our success rate. If we test the embryos, we can transfer the one that will give
On Tuesdays and Wednesdays, I do management activities and other things. There’s a feeling that I should spend more time in management, but my heart is always with the patient. To help, I brought my son Suvir in as a manager and we have another managing director as well.
At one o’clock we have meetings with all the doctors, senior nurses and senior embryologists to discuss cases. We present our cases and the embryologists will say: “Last time this happened; how about doing this to make it better?” The nurses will tell us how the patient is coping – if she is under a lot of stress, we will arrange for her to see the counsellor. Everything about the patients is discussed during those meetings, and at 2pm the nurses will make the relevant phone calls. We also have a nutritionist and acupuncturist on our staff, because IVF works better if the patient is in good health and her stress levels are low.
It’s also very important that I keep
We have also recently taken on Dr George Ndukwe, a world-renowned specialist in reproductive immunology. When a patient comes to us after multiple failed IVF treatments, often it’s an immunological issue that makes their body reject the embryos. We can now treat that. I recently had a 42-year-old patient who had gone through eight miscarriages after IVF treatments. We tested her embryos and they were chromosomally normal, but we discovered that her immune system was the issue. We took her through a treatment regime and the next IVF treatment resulted in a beautiful little girl. It is so satisfying. We think this immune treatment will be the gamechanger for us.
When I see patients, I put 110% of my concentration into their care. Sometimes I lose track of time and staff will knock at my door and say: “Your next patient is waiting,” because I’m so immersed in the whole situation. There can’t be anything better than making babies. It’s such a passion for me.
Harley Street Fertility Clinic
134 Harley Street London W1G 7JY
020 3376 8378 hsfc.org.uk
Glasses and contact lenses didn’t fit into Evgeniya’s active lifestyle, leading her to feel she was missing out. After laser surgery, she’s not missing out anymore.
“I have worn glasses ever since I was in high school, before switching to contact lenses due to my active lifestyle. But contact lenses gave me dry eyes and glasses weren’t practical for me - I wanted to be able to see better when going about my daily life.
I spoke to a number of companies offering vision correction but, due to an issue with my cornea, I didn’t feel comfortable having the procedure with them. Then I went to see Moorfields Private.
They were able to assess my eyes and find a solution I feel I would not have found anywhere else.
My surgery has improved my quality of life incredibly. I enjoy my daily activities more and I no longer feel like I am missing out on life.
Find us at: City Road EC1 New Cavendish Street W1
I feel a lot safer, especially when driving, as it’s improved my peripheral vision. I don’t remember ever being able to see as well in my life. I wish I’d done it sooner.”
For over 200 years Moorfields has pioneered research, employed the brightest minds, and delivered visionary eye care. We offer the full range of ophthalmic care including cataract, vision correction, glaucoma and complex eye conditions.
To find out more or book your consultation: Visit moorfields-private.co.uk/contact-us Or call us 0800 328 3421 (Monday – Friday, 8am – 6pm)
Interview: James Rampton
Portrait: Christopher L Proctor
I’m passionate about my new job as business development manager at the iconic Wigmore Street pharmacist, John Bell & Croyden. I have discovered a true sense of community here.
My role is to oversee the operations of the pharmaceutical wholesale and services team. We source and sell drugs and medical equipment to clinics and hospitals, and ensure that those orders are bespoke for every institution. I am bringing 21 years of pharmaceutical experience to conversations with doctors, nurses and pharmacists, to understand their ever-changing medication needs. I particularly love the problem solving needed for patients to receive the best medication. Over the years, we’ve developed a breadth and depth of suppliers to enable us to achieve this.
My team is also responsible for managing stock and tracking expiry dates, which is particulary important for large hospitals providing sevenday-a-week care and complex or unique procedures. One of the characteristics of this area is that our clients often inhabit older buildings, so we’ll advise them on storage regulations and compliance elements that might not be needed in more modern purpose-built facilities. A good percentage of my team are qualified dispensers or pharmacists so are also able to act as independent auditors for our clients.
Another of my responsibilities is to develop the relationships we have with the local medical community, which is rapidly evolving. There isn’t a week goes by where we don’t get asked to help set up another new clinic. They may also need guidance on how to get through
their initial CQC inspection. We can help prepare them for success.
An important part of this job is advising clinics and hospitals. Given where we are based we can respond in person. For example, a clinical director from a local hospital recently emailed me with a governance question and within 15 minutes we had solved their problem.
I am aiming to expand the business, particularly in the area of education. I feel really strongly about that. We’re currently looking at how can we set up cohorts of doctors to cover certain topics, so we can educate one another on emerging areas of medicine. There is so much expertise in this area, and we all understand that sharing our learnings improves clinical services and patient treatment options. I will also be increasing our communication, advertising and engagement, so we can share our goals with the broader community.
Our pharmacutical services are ever-evolving as the private healthcare market undergoes a rapid transformation, with a shift towards personalised medicine, preventative treatments and procedures that underpin longevity. By partnering with innovative healthcare clinics, we’re well-positioned to meet the changing needs of the Harley Street Medical Area.
In the future, we would also love to be running pharmacies within hospitals – we certainly have the expertise in our team to do that. The people we work with enjoy working with us, as we are a dependable, personal and trusted patient centred wholesaler. We are known for seamlessly intergrating into hospital teams as a critical partner.
When a patient is treated in a clinic, or visits us at our Wigmore Street pharmacy to pick up their prescription, everything works in harmony. There is a confidence that John Bell & Croyden offers a continous healthcare service, alongside the clinics for everyone who lives and works in the district.
There’s so much about this area that you just can’t replicate. There is a prestige and a heritage that’s palpable every day. Imagine you’re a doctor. If you’re practicing out of Harley Street, that’s the very pinnacle. You’re practicing at the very highest level. Patients in this area can really build up a long-term relationship with those exceptional doctors. I find nothing more satisfying than working with clinicians who are making a real difference to patients’ lives. It’s really inspiring.
Our pharmacutical services are ever-evolving. The private healthcare market is undergoing a rapid transformation right now, and we are witnessing a shift towards personalised medicine, preventative treatments and procedures that underpin longevity.
The potential impact on healthcare of evolving technologies is vast. In this series, experts from within the diverse community of the Royal Society of Medicine offer their unique perspectives on digital health
Professor Kevin Fenton, president of the UK Faculty of Public Health, and Dr Nicola StingelinGiles, council member of the RSM Epidemiology & Public Health Section, explore the great potential and significant challenges of the use of AI in medicine
We need a transparent regulatory framework. We need laws that have caught up with the technology. We need rigorous testing of the AI algorithms. We need to have closer collaboration between government and the private sector. We need to find ways of re-building public trust in the positive role AI has to play.
Professor Kevin Fenton
Professor Kevin Fenton
Health inequality – systematic, unfair and avoidable differences in health, either across populations or between different groups within a society – is one of the defining issues we as a nation need to tackle. It’s important to be clear that we are talking not just about inequalities between ethnic or religious communities, important though those are, but also class and socio-economic status.
People with poor healthcare access simply live shorter lives – it’s that stark. But there is also an economic cost. Poor public health weakens economic performance and therefore lessens the country’s wealth. Public health policy aims not only to provide a universal health service, but also to ensure culturally competent support which allows our whole society to access these services.
AI is already being applied in many areas to help clinicians make better clinical decisions. We’re using AI in drug development to help develop medications more quickly. AI is extremely common in imaging, where AI algorithms trained on millions of MRI, x-ray and CT scans have a higher level of diagnostic accuracy
than human clinicians and perform at greater speeds. AI is being used to support patients as well, helping them become more engaged with their health conditions using medical apps translated into their native language. It is already having a positive impact.
If we zoom out, public health is not one person’s – or even one department’s – job. It is about building partnerships. We are beginning to see AI being used in public health departments to strengthen multi-factorial surveillance. For example, clinical data may show people in a neighbourhood are less likely to be active, be higher consumers of alcohol and have higher smoking rates, while crime data reveals real trouble with youth violence. This could signal a particularly vulnerable community and suggest the need for targeted interventions, providing the support they need to be much more articulate and effective advocates for their clinical conditions and their physical and mental healthcare environments. AI’s data analytic capabilities also enable a concept called precision public health, which involves using population data to identify pockets within communities at higher risk of specific conditions. The potential benefits are huge.
But the use of AI poses significant challenges. The National Health Analysis and Assessment division carried out an assessment of the emergence of AI and four key risks that we need to be concerned about: bias and inequalities within the data used to feed the AI; the lack of diversity of the people working on the algorithms; an erosion of trust in the government health institutions and their management of personal data; and misinformation or disinformation from malicious use of AI.
We have already seen incidents involving all these issues. The challenge is that to mitigate these risks, we need a strong, transparent regulatory framework. We need laws that have caught up with the technology. We need rigorous testing of the algorithms. We need to have closer and clearly regulated collaboration between government and the private sector. We need to find ways of re-building public trust in the positive role AI has to play. At the moment, I would argue that none of those frameworks are as robust as they need to be. I’m more cautious than optimistic about how this will play out – time and time again, I’ve seen technology run ahead unchecked and we pick up the scattered pieces later.
However, there are some really good people working very hard in this area and if we do get the balance right AI gives us the ability to fundamentally change the health of our nation for the better.
Public health is the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society. It also considers principles of social justice and equity, promoting and protecting better health for all, leaving no one behind. This means that public health holds a resolute focus on tackling inequalities in health, including those driven by racism and discrimination. I believe we have entered a data innovation era, with the huge increases in computing power, emergence of vast health datasets and sophistication of modern software placing us in a new space for public health policy.
If you look at big data and AI algorithms in the medical field, there’s been a huge amount of guidance and law focusing on individual rights and personal privacy. But from the perspective of population health, the situation is very different. With this, you’re not talking about individual illnesses but about preventing population health issues. This is a completely different framework through which to consider the ethical issues.
This is where the role of the public health ethicist is vital. Their job in this emerging landscape is to peg out a framework and identify the issues we need to think about. We have this huge store of knowledge about ethics, surrounding decision making, medical treatment, research and governance. But are we seriously applying it in this area of big data in public health interventions? To my knowledge there isn’t much discussion here in the UK.
The first and biggest issue is the quality of the data. How representative is it of the population as a whole and to what resolution is it reliable? You can’t just use raw data – to be useful, it has to be processed and of a very high quality. Then there is the issue of ownership, though I don’t really like the word. Even if it’s anonymous data now, at one stage it wasn’t, it was yours or mine. Ethically, the clean thing to do is on some level give permission as a society to use our data for the public good. In the UK there are sound arguments for saying that through our support of the NHS there is a societal agreement that we’re okay
There’s been a huge amount of guidance and law focusing on individual rights and personal privacy. But with population health, you’re not talking about individual illnesses but about preventing population health issues. This is a completely different framework through which to consider the ethical issues.
Dr Nicola Stingelin-Giles
for them to use it for health-related issues. We also live in a representative democracy, where we elect the people who represent us, so the idea is that at some point in the process our interests are considered when decisions around the use of our data are taken.
Let’s look at vaping, for instance. There’s a huge amount of data available across social media about what young people think about vaping. Why do they vape? What vaping ads do they watch? This data could be extremely useful for public health agencies who are very keen to stop kids vaping. But it sits on platforms like Instagram or TikTok, which monetise their content, and the vaping lobby also wants access to the data for marketing purposes. How can this landscape, comprising both public and private entities, be regulated? And who, if anyone, is representing the wider public’s views in any discussions? This is just one of a multitude of examples I could give.
The nation’s health is the result of the complex interplay between things like economic status, educational attainment, employment opportunities, housing, social networks and many others. The promise of AI is that it gives us the ability to really grapple with and make headway in dealing with these issues. But we need strong ethical and legal frameworks as we cross this new frontier, or the chance to improve the lives of millions of people could be lost.
Royal Society of Medicine
1 Wimpole Street London W1G 0AE
020 7290 2900
rsm.ac.uk
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Professor Mark Emberton has spent a career as a urologist at the cutting edge of clinical research. He talks about why innovation is important, what it needs to thrive and – most importantly –what it actually is
Words: Viel Richardson
Portraits: Christopher L Proctor
Innovation matters. Everywhere from engineering to fashion design, innovation is the life blood of industry. It pushes things forward, expands the frontiers of knowledge – and in the world of medicine can literally be the difference between life and death. An eminent haematologist I once interviewed told me that a condition that had essentially been a death sentence when he started training had been converted into a chronic condition treatable with medication and that several patients from the clinical trial he helped run were alive and well several years later. Innovation matters.
“The process of clinical innovation is really important, and by clinical innovation I mean changing the way that we practice medicine,” says Professor Mark Emberton. A distinguished urologist, he is very clear about what innovation means. And he should know. His career has seen him develop several clinical innovations which have changed the way conditions are treated, not only here in the United Kingdom but across the world. A brief list of some of his current and past roles includes dean of the Faculty of Medical Sciences at University College London (UCL); professor of interventional oncology at UCL; senior investigator at the National Institute for Health and Care Research (NIHR); research lead for the British Association of Urological Surgeons; founding pioneer of Prostate Cancer UK; and director of the Clinical Trials Unit (Surgery) at UCL. He has spent a professional career immersed in clinical research
alongside his clinical duties, and his experience as a clinician-scientist has shaped his view on the concept of clinical innovation. No matter how radical, insightful or ground-breaking an idea may be, it is not innovative until it makes it out of the research bubble and starts helping patients in the real world.
“Innovation in medicine can take several different forms,” Prof Emberton explains. “The classic approach is bench-to-bedside. Somebody invents something in a lab – let’s say a target for a new drug. They work with the drug development people who then work with a pharmaceutical company. Once the early onset work is done, it progresses through clinical trials and, if successful, maybe 10, 15, 20 years later, a new drug is delivered.” This the best-known approach, partly, the professor points out, because it is the one that has been most written about. It has produced some fantastically effective medications but is not actually the most common way clinical innovation takes place.
“What’s more common is a change in thought process or a response to new technology. For example, with the proliferation of smartphones, millions of people now carry devices capable of delivering medical apps. These allow them to communicate with their doctor, monitor their blood pressure or manage glucose levels. This technology allows us to do things differently, but it also requires us to work with patients in new ways. It pushes clinicians to think of new protocols and ultimately to prove that working with the technology is better. In other words, that confers
Innovation takes much more than a disruptive mindset. You need the freedom to operate and develop your ideas. You need concrete support along the way. You need a boss who is favourable to innovation and colleagues who share your vision.
more health gain not just clinically but also economically. For every pound spent, you’re maximising the outcome.”
While the economic viability of a new treatment may not be high on many people’s agenda, the cold fact is that an expensive drug or treatment may only help the tiny minority who can afford it. Or indeed it might never get out of the lab to anyone at all. Both of which scenarios fail the professor’s innovation test.
As a urologist Prof Emberton treats patients with prostate conditions and has been involved with several major innovations in patient care, the first of which was a self-help method of managing a patient’s urinary symptoms. “That came from watching nurses and continence advisors advise patients on what they could do to improve their symptom control,” he says. “Things like caffeine avoidance, drinking less before you go to bed, eating earlier, practicing peeing on a full bladder because bladders tend to shrink if you let them.”
While there was anecdotal evidence that all this worked, there was no research to support it, so at the time it wasn’t official practice to offer a patient such practical advice. Instead, the gold standard treatment was to manage their prostate with medication. “What we did over a five-year period was look to see what bits of advice worked. We reviewed the evidence and then tested bits of advice, working with patients and nurses. This was the collaborative development of a system of care. We developed a video that was shown to patients by one of our
Academy of Medical Sciences
Professor Mark Emberton is a Fellow of The Academy of Medical Sciences. The Academy, based on Portland Place, is an elected fellowship of medical researchers. It has over 1,300 fellows, about half of whom are clinically qualified, the other half being laboratory scientists in a range of disciplines. The Academy, which seeks to promote excellence in research,influence policy to improve health, promote careers in medical research, and foster links between academia, industry and government, is a registered charity that relies on philanthropic funding. To support its work and make a donation please visit: acmedsci.ac.uk/support
nurses along with practical advice. We tested that against the standard care in a proper clinical trial. The two groups were the standard care plus the video sessions versus the standard care.”
The results were dramatic. There was a halving of the urinary symptoms score in the people who were offered the video intervention, which was a better result than could be achieved with drug therapy alone. “That was the first study to definitively show that practical advice can work wonders in terms of reducing frequency, urgency, getting up at night, all the urinary problems that patients were suffering from,” Prof Emberton explains. “After the results were published in the British Medical Journal that protocol was written into guidelines across the world, so now every man is offered lifestyle
I still remember the day when we looked at that first MRI and we could see the cancer for the first time. That was the aha! moment. Then the question became, how are we going to use this to help men with their care?
advice as first-line therapy. That all came from me observing great nursing and wondering about the men not lucky enough to have the wonderful nursing care I saw every day. We bottled that good nursing and turned it into an intervention that could be rolled out everywhere.”
This is a kind of innovation based firmly in the clinic: someone noticing another colleague’s good work, sparking a train of thought – and, more importantly, action – that led to an improvement in the treatment that can be offered to patients.
“Another project that led to a new treatment protocol was the development of MRI for prostate cancer,” the professor tells me. At the turn of the 21st century, magnetic resonance imaging (MRI) was a rare, expensive procedure mainly used to examine the brain. Working alongside consultant radiologist Dr Claire Allen, Prof Emberton decided to see if the technology could be used to see a tumour in the prostate. At that time, the standard test was a random biopsy that had a 48% chance of finding a cancerous tumour if it was there.
“It was 1999 and we were possibly the very first to try this. Doctors had been treating prostate cancer for a century without being able to see it. Everybody said you could never see it,” the professor recalls. “I still remember the day when we looked at that first MRI and we could see the cancer for the first time. That was the aha! moment. Then the question became, how are we going to use this to help men with their care?”
That first test had been carried out outside of trial conditions, with
Gordis Epidemiology, 7th Edition
D
Where Good Ideas Come From: The Seven Patterns of Innovation
the cooperation of the patient, but the result was convincing enough to allow them to then run a full clinical trial. That study, called ‘Promise’, definitively showed how well MRI worked. By using MRI, that 48% figure rose to a 93% chance of finding clinically important prostate cancer if it was there. Other trials followed and in April 2019 the National institute of Clinical Excellence (NICE), the regulator that determines what drugs and medical procedures can be used in the UK, recommended that all men have an MRI prior to a prostate biopsy.
“After this NICE recommendation, all the other guidelines around the world said the same, and wherever possible every man around the world now has an MRI before their biopsy. There are, of course, resource-poor environments around the world where sadly men don’t get an MRI, but we’re doing quite a lot to address that.”
That paradigm shift in diagnostics then led to further innovation in the treatment of prostate cancer. “The MRI allowed us to go from treating the whole prostate to treating the cancer, because the scan finally allowed us to accurately locate the cancer. Before this, we had to treat the whole prostate with a radical prostatectomy, which is removal of the entire prostate gland. This procedure carries a 10-20% chance of incontinence, over a 70% chance of erectile dysfunction, and risk of infertility and in some rare occasion bowel issues, any of which would be clearly very distressing to the patient.”
But the use of the MRI scan changed all that. “Seeing the tumour allowed us to target the cancerous
I think true innovation requires people who like to disrupt the status quo. In medicine there
are two types of
originality: make a
diagnosis
that nobody else has made before or create new ways of treating patients that are better than the old ways.
tissue for treatment, leaving the healthy tissue intact. With this form of treatment, the risk of incontinence virtually disappeared and the chances of erectile dysfunction dropped to 5%.”
Having been approved by NICE, this protocol spread across the world, but this time without a clinical trial like Promise to support it. The core problem is that you would need enough men to agree to receive the old treatment that carried a hugely increased chance of distressing side effects, when another much better one was now available. There were attempts to run significant trials, but they didn’t succeed. It was decided that waiting for a large clinical trial to be run before approving use of the treatment would not really be in the best interest of patients, which clinical trials are there to protect.
So what does it take for innovations like these to thrive? “It starts with a mindset,” says Prof Emberton. “I think true innovation requires people who like to disrupt the status quo. It’s very easy to get comfortable in the ‘this is how things are done’ way of thinking, and this can be a good thing, especially when the stakes involved in changing things can be so high. But innovators are people who get vicarious pleasure from disruption. Engineers who want to build longer bridges. Artists who pioneer new styles of art like impressionism or surrealism. In medicine there are two types of originality: make a diagnosis that nobody else has made before or create new ways of treating patients that are better than the old ways.”
Prof Emberton freely admits that he gets great pleasure in disrupting the clinical status quo by finding new more effective ways of treating patients. “But it takes much more than a disruptive mindset. You need the freedom to operate and develop your ideas. You need concrete support along the way. You need a boss who is favourable to innovation and colleagues who share your vision.”
Modern medicine is very much a team sport. While it can still happen, the days of the lone scholar beavering away in a lab and delivering a discovery that will change the world are long gone. Even if the idea is brilliant, without the support of others it is unlikely to get very far. “I’ve been very lucky over the years to have had bosses who allowed me to innovate.
Professor Brian Ellis was one of the first urologists who really encouraged me to do so. When I started at Middlesex, Professor Anthony Mundy actually charged me to innovate. Here at UCH, I have always been given the space as well,” says Prof Emberton.
The first words he uttered during this interview were “innovation matters”. In 1800, nowhere in the world had an average life expectancy of above 40 years. According to the World Health Organisation (WHO), in 2019 global life expectancy was 73 years and healthy life expectancy was 63 years. Clinical innovation has played a major part in increasing both the length and quality of our lives.
Innovation is a buzzword found in the soundbites of companies wanting to project a modern, forward-looking
image. But true innovation goes beyond bright ideas. It takes determination: all of the innovations Prof Emberton has talked about involved years of work. It needs funding: as medical treatments become increasingly complex the trials to test them get more expensive, sometimes costing millions of pounds. But perhaps the most important thing is the environment: fostering an atmosphere where the disruptors feel supported and able to express their ideas to the fullest. This will involve calculated risks, educated guesses and blind alleys, and in environments where every penny is counted, the temptation is to rein those instincts in and let someone else do the work. But if that were the prevailing approach, people across the globe would still be fortunate to reach their 50th birthday. With so many issues still to be faced down, from microbial-resistant disease to increasing economic disparities, I ask our arch disruptor if we can innovate our way through these challenges. Is he optimistic?
“I believe we can. In fact, I don’t think you can be an innovator unless you’re an optimist, unless you believe that you can change things for the better, because it’s a long process,” the professor says with a wry smile. “From an idea to NICE approval can be a 10-to-15-year journey. If you’re a pessimist, you won’t last the stretch. There is also so much to love about the work – collaborating with extraordinary people, expanding the boundaries of knowledge and knowing you are being the agent of benefit to many more people than you could ever help as an individual.”
For decades, research into sports injuries and approaches to rehab were almost exclusively focused on men. A Harley Street sports medicine group is now putting that right
Words: James Rampton
Vittoria Marin was quite simply moved to tears. She is one of the top physiotherapists at Isokinetic, a leading international medical group for the prevention, diagnosis, treatment and rehabilitation of sports and orthopaedics injuries. Working out of the Isokinetic clinic on Harley Street, Marin has been instrumental in aiding everyone from professional footballers to ballerinas in their recovery from major injuries, notably damage to the anterior cruciate ligament (ACL).
Marin recalls the very emotional message she received after her cutting-edge rehabilitation programme helped a ballerina return to the stage following four gruelling years of treatment for a serious knee injury. When the dancer took to the stage again, “she wrote to me: ‘I have imagined this moment countless times over the years – what it would feel like to be back dancing again. That was the one thing that really kept me going through all these years. But needless to say, I could not have got to where I am today without an extraordinary amount of encouragement, patience, unconditional love and ongoing support from everyone around me. That gave me the strength and the hope to keep fighting in those darkest times. So, thank you very much, everyone who helped me continually break my barriers. I never thought it would be possible.’”
Marin attended the ballerina’s first comeback show after her four years out injured. What was the physiotherapist’s reaction in the theatre? “I cried – obviously!”
The ballerina is not an isolated case. Isokinetic boasts an enormous number of such success stories. The clinic, whose motto is “where you return to play”, is at the forefront of treating female-specific sports injuries. As women’s professional sport has grown massively around the world, so sadly has the number of female athletes suffering injuries. In the past, injured sportswomen were treated in exactly
the same way as men, but thanks to pioneering work at Isokinetic, all that is now changing. Previously, only 6% of research into sports injuries was aimed at female athletes. But with doctors at Isokinetic now leading state-of-the-art research into female-specific injuries, groundbreaking discoveries are now being made about why women are more likely than men to sustain damage to their ACLs.
Dr Matthew Stride, one of the top consultants in sport, exercise and rehabilitation medicine at Isokinetic, explains: “We know that women are about three to four times more likely to have an ACL injury than their male counterparts. There are both intrinsic factors and extrinsic factors behind this. You can go into quite detailed analysis. Intrinsic factors are linked to the biology of the individual. Men and women have anatomical differences – the major and most obvious being that women have a wider pelvis than men, so this creates different forces that go through the knee joint.”
In addition, he explains, women tend to be a little bit looser through their ligaments. “This is compounded by the influence of hormonal aspects within the menstrual cycle. During the period of menstruation, the ligaments are even more lax. The anatomy of the female knee joint is a little different as well. So anatomical predispositions and differences from men mean that ACL injuries are more prevalent in women.”
Added to that are extrinsic factors. “These are related to training load, weather, rule changes, and the size of the pitch.” But the major external element is the humble – and seemingly innocent – football boot. Up until now, football boots have had a one-size-fits-all approach, and it is thought that footwear not specifically designed for women has added to their risk of sustaining an ACL injury.
I imagined this moment countless times over the years – what it would feel like to be back dancing again. That was the one thing that really kept me going through all these years.
“That has to change,” asserts Dr Stride. “Nike have launched a new boot called Luna. It’s a firm boot designed to take into account the female foot. A lot of football boots have in the past been designed on a male foot from 50 or 60 years ago. But now at last they’re designing a boot for women.”
Isokinetic, a FIFA Medical Centre of Excellence, has for many years blazed a trail in treating women’s ACL injuries. Dr Stride outlines why: “A professional women’s football club may see one, maybe two ACL injuries a season, whereas I see five to six ACL injuries a week, so I have a lot of experience and expertise in the management of this particular injury. Isokinetic has been going for more than 35 years as an education and research department, and we’re among the world leaders in the management and knowledge of this particular injury.”
One study published by the group analysed video of more than 50 ACL injuries that occurred in professional women’s football to see whether biomechanical factors may have led to the injury. “We discovered that there are biomechanical differences between men and women in terms of how they land and how they manoeuvre on the pitch,” says Dr Stride. “If you’ve got a greater understanding of why these injuries are happening, the hope is that this will lead in due course to prevention or risk minimisation programmes and reduce the likelihood of the injury happening in the first place.”
Dr Stride details how this is achieved. “We have developed training programmes to help reduce this risk of ACL injury. These are largely based around neuromuscular control. That means taking patterns of movement and retraining players so that when they make those movements on the football field, they are in better condition and are better prepared. One of the main areas of concern is what’s called a cutting manoeuvre,
which is the way a player changes direction by 90 degrees while running at high speed. What we’re looking at is trying to train footballers to do that more safely.”
Isokinetic has also evolved an extremely successful systematic method of treating athletes with ACL injuries. The Harley Street facility includes a gym, a hydrotherapy pool and a biomechanical ‘green room’, where state-ofthe-art filming helps doctors and patients assess their recovery. They also make use of an area within Regent’s Park for physical training. “So, you have those four different environments to help the patient. The physiotherapist delivers the plan and executes the exercises.”
The treatment female athletes are given is very different from that offered to men. Marin, who is studying the treatment of injured female athletes, says: “I love reading about the female body and trying to understand how best to rehab women. One thing we have finally overcome is the stigma that females can’t use the gym. Women can lift weights. It’s a huge topic because when you lift weights, you have to think about so many different things. You have to think about where you are in your menstrual cycle. You have to think, too, about how your mood is affected by that, but also by other factors. Is, for instance, your pelvic floor strong enough to take the load that you’re lifting?”
When rehabilitating a woman as opposed to a man, Marin has a completely different relationship with the patient: “I ask women really private questions because that is very much part of their rehabilitation. I can go deeper with a female in understanding how they feel internally.”
There is evidently a great sense of fulfilment that derives from working with injured patients at Isokinetic, as Dr Stride
If you’ve got a greater understanding of why these injuries are happening, it will lead in due course to prevention or risk minimisation programmes and reduce the likelihood of the injury happening in the first place.
testifies. He recollects an event at a recent Isokinetic conference in Madrid where a Scottish professional footballer was eager to relay the excellent experience he had had undergoing rehabilitation at the clinic after four ACL procedures. “This patient paid for his own flight and his own accommodation in Madrid. He went up on the stage, and he did a 10-minute speech about how grateful he was for the treatment that he had had. Everybody in the room was welling up. It was just an absolutely incredible moment.”
He continues: “The person chairing the session said, ‘This is why we work in rehab.’ It is very humbling and it is very rewarding knowing that you’ve helped someone. You are not physically saving someone’s life, as you might be in A&E. But I do believe you are helping change people’s lives. If I can make a difference and give someone their movement back, it’s fantastic. It’s also emotional. I love the sense of satisfaction when I see a patient going back to the sport they love. That’s what we live for.”
It is clear, then, that Isokinetic provides a very special service to its patients. But don’t just take my word for it. Alessia Ciocan, a highly promising teenage footballer, suffered a serious ACL injury while playing for her college in Brighton a couple of years ago. At the time, she was on the verge of an England age-group trial.
After six months with little or no progress, the young player was in despair until someone recommended that she visit Isokinetic for treatment. There she met Dr Chris Jones, formerly one of the clinic’s principal sports doctors. She remembers: “I loved him immediately, and my mum loved him as well! He was so sweet, and he really related to me. At that point, I was still a little bit in denial and very much not wanting
to go through this whole process. But he instantly understood where I was coming from and helped me every step of the way.”
Under Dr Jones’s supervision, and with the invaluable assistance of Filippo Picinini, head of late-stage rehabilitation and sport science at Isokinetic, Ciocan returned to full fitness after a year’s rehabilitation at the clinic and recently helped her Loughborough University team win the National Cup Final.
The student, a prolific striker, beams: “I was so happy because this journey had taken a year and a half out of my life. It was such a relief that it was over. I could just start enjoying football again without thinking of anything else. It was just the biggest weight off my shoulders really.”
The 19-year-old smiles broadly. “When we lifted the National Cup trophy, I sent a photo to Filippo. He put it on his story and captioned it: ‘It’s amazing seeing all of the achievements of the people that I’ve worked with, and finally seeing that their effort is paying off. You can’t help but just be happy for them.’”
As a sign of her gratitude, Ciocan bought presents for everyone who had helped her recovery at Isokinetic. “I gave some Italian wine to Filippo and a little teddy bear to Chris. I still keep in touch with them on social media. I spent 12 months trying to get out of the clinic, but sometimes I wish I could be back at Isokinetic – not because I want to be injured, but because it’s such a nice environment to be in. I loved it there!”
Isokinetic London 11 Harley Street London W1G 9PF 020 7486 5733 isokinetic.com
by LaingBuisson
Cleveland Clinic London was named ‘Hospital of the Year’ by LaingBuisson, awarded for being a hospital of the future. The 184-bed hospital at 33 Grosvenor Plance and the Cleveland Clinic Portland Place in the Harley Street Medical area has offered private healthcare to thousands of patients.
The latest facility, Cleveland Clinic Moorgate Outpatient Centre, just opened its doors in the heart of London’s financial centre, offering its unique model of care to more patients than ever.
Specialties include:
· Cardiology
· Dermatology
· Digestive Diseases
· Gynaecology & Urology
· Neurology
· Ophthalmology
· Orthopaedics & Sports Medicine
· Women’s Health
This location offers swift access (often same day or next day) to London’s leading consultants and specialists, with the very latest technology to enhance quality, safety and patient experience. Cleveland Clinic London welcomes all patients, whether using private medical insurance or self-funding, and offers extended hours during the week.
Considering that sleep plays such a major part in our lives – taking up an entire third of our existence if you extrapolate the oft-quoted figure of eight hours a night – it’s rather surprising how relatively recently it has become the object of serious scientific inquiry. In fact, pioneering systematic studies only really began in 1960s America.
In recent years, however, sleep (more pertinently, the lack of it) has become something of a public obsession –spurred on by the widespread use of such technical devices as digital sleep trackers. Perhaps surprisingly, Dr Zoe Gotts, a clinical psychologist with the London Sleep Centre, is not at all enamoured with these increasingly common gadgets.
“They can be a real problem,” she says. “Their accuracy for measuring sleep is questionable, and people start becoming obsessed with how much sleep they’re losing. There is a new concept that has been described by some researchers – orthosomnia. It is the desire to obtain perfect sleep, driven by the use of a sleep tracker. It’s not yet an established sleep disorder, but researchers are working hard to better understand it.”
Dr Gotts then quickly and firmly dismisses the idea that we all need the same amount of sleep. “Definitely not,” she says. “One of the biggest myths is that we need the same amount of hours for optimal function. We actually each need different amounts. It would be detrimental to try to get eight hours, for example, if you only need six. To sleep too much can also have negative impacts on you.”
Our brains, she says, are all wired up differently. “There are environmental, genetic and geographical reasons –where we live and how much sunlight we get can factor into the quality and quantity of sleep we obtain – and the different hormones involved in sleep can differ in each of us.”
Unlike sleep trackers, which don’t measure sleep directly but often measure inactivity as a surrogate for measuring sleep, The London Sleep Centre conducts rigorous trials – such as a recent in-depth retrospective study of 200 patients’ sleep disturbances and psychological and health symptoms. What then are the health problems linked to such sleep problems as insomnia (difficulties falling or staying asleep), parasomnia (which
Sleep is one of the most widely discussed factors in mental and physical health – but unhelpful myths abound. Dr Zoe Gotts, a clinical psychologist at the London Sleep Centre, separates the fact from the fiction
Words: Gerard Gilbert
encompasses disruptive disorders such as sleep walking and night terrors), or other disorders, such as restless legs syndrome or sleep apnoea?
“There are two main functions of sleep and they relate to different stages,” she says. “The psychological role of sleep occurs in the REM stage, the rapid-eye-movement period – the brain is very active during this phase. Polysomnography (PSG) is a multiparameter form of sleep study which records brain wave outputs. Using these you can see there’s a lot happening: emotional processing, dreaming, memory consolidation.”
Slow-wave sleep, which is considered deep sleep, is vital for physical restoration of the body, but REM sleep is considered important because it restores the brain – the psychological function. “Sleep plays a reciprocal and vital role in mental health. If somebody is having a difficult time emotionally and their sleep is disturbed, this can impact their ability to emotionally regulate during the day.”
What form might this take?
“Depression is the biggest one,” says Dr Gotts. “Mood is so affected by not sleeping. People who come to us with insomnia worry about their sleep, so
anxiety is also a real problem. A lot of the time it might be that other factors in their life have caused sleep to become a problem – for example, going through stressful life events. But when sleep becomes disturbed these people can shift their attention to the sleep problem which then becomes the cause of the psychological issues. It’s a vicious cycle. The irony is that the more you focus on sleep, the less able you are to do it. It should be an unconscious process.”
So, does Dr Gotts have a personal strategy for getting back to sleep if she wakes in the middle of the night? “Yes I do, and I repeat it to my patients endlessly. If I’m not back to sleep within a few minutes, or I find myself becoming irritable, I get myself out of bed and do something. It’s a spiral to disaster if you just lie in bed, restless and awake.”
Shakespeare called sleep “Nature’s soft nurse” and that’s certainly true when it comes to its physiological benefits. For the physically active its benefits might include muscle repair, while sleep is prescribed to those with illnesses such as flu or Covid for a very good reason. But what about the converse – the potential for physiological problems as aresult of sleep deprivation?
When sleep becomes disturbed, people shift their attention to the sleep problem which then becomes the cause of the psychological issues. It’s a vicious cycle. The irony is that the more you focus on sleep, the less able you are to do it.
“When we don’t get enough sleep, it can compromise our immune system,” says Dr Gotts. “Long-term sleep deprivation can mess around with blood sugar levels. There’s research that says it might lead to type-2 diabetes and people get really worried about that. But if your blood sugar levels are dysregulated and you are also feeling tired, this can lead to poor nutritional choices. It’s very unlikely to be a direct effect of bad sleep.”
In fact, Dr Gotts is notably cautious about directly linking certain health conditions to sleep issues. “The relationship between sleep and diabetes is complex and there are often more factors at play. More research is needed,” she says. “The risk of developing dementia is talked about, but again, the evidence about how they are linked is weak. The same with kidney disease. I try to tell patients who are worried about these consequences not to be, because the links are not always direct. I believe it’s much healthier not to worry about your sleep because the worry and stress themselves cause more problems.”
Dr Gotts completed her PhD in sleep psychology on the role of sleep in chronic fatigue syndrome. She
went into the homes of 25 patients, hooking them up to PSG monitors and left them to sleep. She did this for three consecutive nights, also taking saliva samples to look at cortisol levels. “Cortisol has an important role to play in the morning,” she says. “It should peak in the morning to naturally wake you up. Anyway, the results showed that the nature of sleep complaints was not universally similar in chronic fatigue syndrome.”
The study of sleep is a fast-moving scientific area. “Researchers are becoming more interested in the unconscious processes,” says Dr Gotts. “There’s more research into the intricacies of people’s brainwaves. And researchers in America are looking for stronger evidence surrounding the idea of sleep impacting diabetes and heart disease.”
And then there is the much-discussed impact of social media and screen time – although Dr Gotts is quick to stress that screens themselves are not as much of a problem as the content being viewed. A good book on your Kindle might be better for your sleep than doom-scrolling on X, for example. Meanwhile, new sleep-inducing
drugs are being researched, with one effective new medicine, daridorexant, having recently been approved by the National Institute for Health Care Excellence (NICE). “Rather than slowing down brain activity like existing sleep medications – benzodiazepines and z-drugs – daridorexant works by reducing levels of wakefulness. I envisage that researchers might start investigating these other mechanisms in treatment studies.”
It’s an exciting field, with that excitement constantly fuelled by intense media interest in the subject. It seems that a day rarely goes by without a news item about how much sleep we should be getting and the problems associated with not achieving enough.
As for the overall importance of shuteye, we know it matters but we’re still in the early stages of figuring out the how and the why. Dr Gotts likes to quote the American sleepresearch pioneer Allan Rechtschaffen, who, in the 1960s, conducted some of the first laboratory studies into insomnia and other sleep disorders. “If sleep doesn’t serve an absolutely vital function,” he wrote. “Then it’s the greatest mistake the evolutionary process ever made.”
Conal
consultant dermatologist and founder of The Devonshire Clinic, on an old technique that remains at the leading edge of skin cancer surgery
Interview: Viel Richardson
Portrait: Justin Wood
What is Mohs micrographic surgery?
It was first developed by Dr Frederic Mohs in the late 1930s and early 40s as a way of removing certain types of skin cancer. It aims to remove the minimum amount of healthy surrounding tissue while removing the entirety of a tumour. It has become the gold standard technique for removing skin cancer tumours.
What was it that attracted you to this field?
I’ve always had a fascination with cancer. Why does cancer occur at a DNA and molecular level? What is the relationship between genetic susceptibilities and environmental factors? The drugs given to transplant patients can significantly increase
the risk of skin cancer. This shows the importance of skin cancers in the susceptible groups of patients and the need to fully understand the whole disease and treatment pathways. What, for example, is the role of medications such as immunesuppressant drugs in increasing the risk of patients developing cancer, and how can we combat it? Mohs surgery is the gold standard for treating basal cell cancers which are the most common cancers globally, so this is a field that impacts huge numbers of people.
Does Mohs surgery require extra training?
Once you qualify as a dermatologist you can apply for a consultant post or go on to do a fellowship in your
chosen field. But in order to practice this technique you have to complete a Mohs surgery fellowship, which lasts at least two years. There are a series of different techniques involved in a successful Mohs procedure and you need to understand and be able to apply them in an interconnected manner in order to get the best outcome for the patient.
When would this technique be used?
It is suitable for all skin cancers but is especially suited to high-risk areas. These are locations where there is a risk of compromising a bodily function or leaving the patient with unsightly scarring in sensitive places once the tumour is removed – places like the neck and face, particularly around the eyes, ears, nose and mouth, and the genitalia and fingers. Also, for potentially recurrent or more aggressive tumours.
What makes Mohs so effective?
To understand this, you have to first look at the usual process for removing a tumour. In a standard excision surgery, we cut out the tumour with a safe margin of around 6-7mm to try to ensure we remove all the cancerous cells. This is then sent to a pathology laboratory, where a pathologist examines the edge of the specimen to see if there are any cancer cells present. Unfortunately, because of the way the tumour specimen is prepared, the pathologist only examines about 1% of the tumour. With Mohs micrographic surgery the whole of the tumour is examined, giving you a much more accurate result.
Take us through the Mohs procedure.
It breaks down into two sections: surgery and pathology. We give the patient a local anaesthetic and mark out the site with 1mm leeway around the margin of the tumour. We then take high-resolution photographs. I’ll remove the tumour and put a dressing over the area, and the patient will be taken to a special waiting area. A specialist biomedical scientist from our pathology laboratory will take and prepare the specimen, which I’ll then examine under a microscope. I will examine the entire margin of the tumour. If it’s clear, we will show the patient a picture of the wound and discuss different options for reconstructing it. Once we’ve made a decision, I will reconstruct the defect, cover it with a dressing and the patient can go home.
What happens if the specimen is not clear?
This is where we come to the heart of what makes Mohs so effective. If there is still some tumour present, I can identify exactly where this residual tumour is located. The patient is then brought back into theatre, I will explain the results of the first stage of Mohs surgery and then remove more tissue from the identified place, again taking as little skin as possible. We then repeat the pathology process. If it’s clear, we reconstruct the defect. If the specimen is still tumour positive, we repeat the tissue removal. This continues until the specimen is tumour free. The whole procedure can take several hours, but while this can make it
Mohs is suitable
for all
skin cancers but is especially suited to high-risk areas, where there is a risk of compromising a bodily function or leaving the patient with unsightly scarring in sensitive places once the tumour is removed.
time and resource intensive it is well worth it for the increased effectiveness.
What is the success rate of this technique?
If you have Mohs micrographic surgery for a skin cancer, it gives the lowest risk of recurrence – the risk of the cancer returning is less than 1% in five years. In terms of cure rate, it’s close to 100%. For more complex tumours, that rate comes down, but not by much at all. If you compare that number to radiotherapy or to the standard excision surgery, the risk of recurrence for those procedures is around 10% within five years. You can see that for the patient, it’s really worth giving up the extra time this procedure takes.
Why is it that you go to such significant lengths to remove so little tissue?
As I mentioned, these procedures can often take place in the head and facial areas, so it’s important to remove as little tissue as possible in order to minimise the cosmetic and functional impact on these important anatomical sites whether that’s eating, drinking or facial expressions. We have to remove the skin cancer, but we must also remember that those functional and aesthetic outcomes can have a significant impact on the patient’s quality of life after the procedure.
What size of wound is a patient likely to be left with ?
On average, most on the head, neck
and mouth are about 1-1.5cm, but it is possible to have much larger defects – I have seen some that were 10cm across. Although some skin cancers grow very slowly – the commonest one, basal cell carcinoma, is a really slow grower – any growth at all is significant. On the face, even a few extra millimetres matters. Your nose, for example, is a very small area, so a few extra millimetres means that the wound can require a more extensive reconstruction.
Do you have a clear sense before the operation starts of what the eventual size of the defect will be?
No, you don’t. It can be very difficult to judge the spread of the cancerous cells. It is possible to have a small spot on the surface but find that the tumour has spread much wider under the skin. It is something we warn people about when discussing the possibilities. What looks like a tumour a few millimetres across could lead to the removal of several centimetres of skin tissue.
How do you go about repairing the holes?
The simplest option is to pull the skin in from either side and stitch it closed, which can work very well. Sometimes that doesn’t work, as it may impact nearby structures, such as distorting an eyelid or a lip. In this situation, we might do what’s called a flap repair. This means you take nearby skin –think of it as using a skin reservoir –and move it to close the hole left after tumour removal. This can be very effective. Alternatively, we can carry
out a skin graft, taking some skin from behind the ear or the arm. Sometimes we simply leave a wound to heal on its own – that’s called secondary intention healing and all it requires is regular dressings. It works very well in certain parts of the body.
What about for larger defects?
On the rare occasion that I feel the post-surgery defect is too large to reconstruct under local anaesthetic, we will arrange for the reconstruction to be undertaken under general anaesthetic by one of the consultant plastic surgeon colleagues in the practice. This happens either on the same day or the next day. If we know beforehand that we’ll need a plastic surgeon or head & neck surgeon, they will be programmed into the schedule when we plan the procedure. Whatever the level of defect repair, the patient will come back to have the wound checked and dressings changed until it is completely healed.
Is there anyone for whom this procedure would not be viable?
If a patient is very frail, we might consider if this is the right option. They could be in and out of theatre over several hours, or even a whole day, which can be physically and mentally wearing. In such circumstances, we might instead arrange for radiotherapy with one of my clinical oncology colleagues. Or we might perform a traditional removal – this may have a higher risk of recurrence, but the risk is still relatively small.
What about patients who also have other conditions?
We often work closely with a patient’s other clinicians, especially in the realm of medications. I once had a patient with very severe Parkinson’s disease who was denied surgery previously as their involuntary movements would have made the prodecure quite challenging. We liaised with their neurologist to adapt the medication regime so that during the operation there was virtually no movement at all. It worked very well, the tumour was removed, and the patient’s Parkinson’s treatment wasn’t compromised.
What do you enjoy most about what you do?
I work mainly with patients with complex cancers and really enjoy participating in research. It’s intellectually stimulating to be at the cutting edge of the field. I also enjoy operating. I really like the immediacy of the process – the patient has a tumour before the surgery, and afterwards it’s gone. But it is the relationships you develop with your patients that are really special. I’ve known some for 15 or 20 years because their condition means new tumours inevitably develop. Getting to know them and seeing their lives develop over the years is a hugely satisfying part of my job.
The Devonshire Clinic 16 Devonshire Street London W1G 7AF 020 7034 8057
thedevonshireclinic.co.uk
Interviews: Ellie Costigan
Before my treatment, it was easier to tell you what was wrong with my teeth than what was right: size, colour, erosion, bite, general shape, I wanted to change it all. The main problem was the erosion that had occurred due to stomach issues I’d had as a teenager – and, I’ll admit, from drinking too many fizzy drinks.
I like to do my research before I make any decision, but especially something so serious. I spent a lot of time looking for the best clinic for my treatment.
When I read Dr David Bloom’s bio I thought, he’s 100% who I’m looking for.
I felt in safe hands as soon as I walked into the Harley Street Dental Group’s clinic. I had an idea of what I wanted treatment-wise – mainly that I didn’t want braces or anything that would take too long, as I wanted it sorted as quickly as possible – but otherwise, I
was happy for them to take the lead. They talked me through the plan and were very honest about what I could expect at each stage – what was going to happen, how it would feel and the recovery time, which is very important because it meant my expectations were managed. I’d much rather that than have them underplay it and not know what I was in for. The treatment was a lot quicker than I thought it would be –I was over the moon when they said it would only take three or four months from consultation to completion.
The first thing Dr Bloom did was a gum lift and bone graft, which involves lasering away part of your gum to extend your tooth, then surgery so that they don’t grow back down. I’ll be honest, it was a bit painful, but it
was never unbearable. I even went travelling with a friend on the day I had the procedure, and the recovery time was just a few weeks.
The next thing was fitting the veneers and crown. You’re able to try on your new smile before committing to the treatment, which is brilliant. It’s all in your hands and they can make any tweaks or alterations you’d like, it’s your decision and your choice: you’re in charge of the aesthetic, but you’ve got the experts advising you and making sure everything is safe medically. It’s very reassuring, particularly when you’re making such a big investment. When I tried on my mock up, it was like a different person looking back at me in the mirror. I just couldn’t believe that was how I’d look in just a few weeks’ time. I didn’t even
Bulimia An eating disorder and mental health condition. Sufferers binge eat food then purge the food from their system either through vomiting or laxatives.
Oesophageal reflux A condition where acid from the stomach leaks up into the oesophagus.
Dentine A layer of material that lies immediately underneath the enamel of the tooth. Its primary function is to support the structure of the enamel.
Dr David Bloom, cosmetic dentist at Harley Street Dental Group
want any tweaks – it was perfect. That’s how good Dr Bloom is.
The final result is better than I could ever have imagined. It doesn’t look fake, it’s very natural, which is what I was going for – while I think he’s lovely, I didn’t want the Rylan Clark look! My confidence has done a 180-degree turnaround, I’m a completely different person. Before, I was embarrassed to even eat in public because I was worried someone would see my teeth. I’d barely opened my mouth for 20 years. Now, I smile with my mouth open in pictures. I even went to a festival recently and someone I don’t know said: “Wow, you’ve got such lovely teeth!” It’s had that much of an impact. I also can’t stress enough how comfortable Dr Bloom made me feel. In fact, all the staff at the clinic were fabulous. I was a very nervous patient, but the moment I met him and the team, it felt like they put their arms around me and looked after me. They calm you down, make you feel welcome and reassure you through every step of the process. You know you’re not on your own. You’re also welcomed back to the clinic after a few weeks to see how everything is going, check your gum health and that you’re happy. The receptionist then called again a few weeks later to make sure I was okay. It’s what makes it such a wonderful place and sets them apart: you don’t feel like just a number, they really care. While it wasn’t entirely pain free it was always manageable, and some short-term discomfort is worth it for a lifetime of happiness. My only regret is not having the treatment done a very long time ago.
Una came to me with palatal erosion and attrition, which is dissolution of the teeth due to exposure to acids and wear, leading to the need for several veneers and a crown. She was very unhappy with her smile and it was deeply affecting her self-confidence.
The main causes of tooth surface loss are grinding and acid erosion. It’s commonly seen in people with bulimia, acid reflux and oesophageal reflux, and is probably a lot more common than people think – anyone with heartburn is potentially at risk.
The problem can be caused by internal factors such as reflux and vomiting, or external factors such as fizzy drinks and fruit teas, which have a low pH. Salad dressings can also be quite acidic, so you can suffer from it even if you’re generally eating healthily. This can lead to thinning of the enamel, which is when teeth start to chip. When you lose the enamel, it exposes the dentine, which is darker. Una had quite severe erosion on the back of some of her top teeth, which were getting chipped.
First, we carry out a thorough diagnosis. Then, we send moulds or a scan of the teeth to make a ‘wax up’, which is often done digitally. This allows us to produce a mould of how the teeth will look – a ‘trial smile’. This requires no tooth preparation and can be adjusted from a functional or cosmetic perspective, be it tooth length, bite realignment or any other request the patient may have. It’s a big investment and can have a significant impact on the patient’s quality of life, so it’s important to get it right.
We try to do things in a way that is as
minimally invasive as possible. We plan additively, meaning if the patient has lost tooth substance, we replace it and then look at the position of the teeth. Classically you’d be looking at a veneer or a crown, but it doesn’t have to be an aggressive procedure. Because Una had lost enamel on the inside of her teeth, by planning correctly and changing her bite, we could cover it without doing any drilling. She also showed a bit more gum than was ideal, so we did what we call a gum lift, which is where we increase the length of the teeth, resulting in a less ‘gummy’ smile.
Once the veneers are bonded, we do a final review and check the patient is happy. We also make sure they know how to look after their gum health and understand the preventative measures required to protect their new smile and avoid any future problems. We may refer the patient to a gastroenterologist to understand the cause of the erosion – it wasn’t necessary with Una, because she had a good idea of the cause, but we do take a physician’s approach and work in conjunction with medical colleagues.
Una was quite teary when she first saw the results – they were tears of happiness and relief, thankfully! She said the procedure had changed her life, which is lovely. This is a very rewarding job; that’s why I’m so passionate about what I do.
Harley Street Dental Studio 52 Harley Street London, W1G 9PY 020 7636 5981
harleystreetdentalstudio.com davidbloomdentist.com
Dr Jack Singer of the Harley Street Paediatric Group on blue couches, hovering parents and why he’s optimistic about the future of children’s medicine
Words: James Rampton
Dr Jack Singer, founder of the Harley Street Paediatric Group, loves his job: “Paediatrics is fun,” he declares. “When it’s no longer fun, it’s time to quit. We have a little motto in our brochure: ‘We never say no to a sick child.’”
The physician, a consultant paediatrician with a particular interest in neurodevelopmental paediatrics and allergy, elaborates on why he so relishes his work: “I like children more than anything. They are lovely to deal with. With adults, all you do is prop them up from one illness to the next, as Old Grandfather Time inevitably catches up. Paediatrics is a wonderful speciality as it’s the only one where you have to run after your patients because they keep running out of the door and you have to constantly bring them back!”
He also loves the lack of sophistication in a child’s armoury. “When you ask them a question, you get a direct answer without the gloss that adults put on it. That’s marvellous. The other nice thing is that in paediatrics, you can achieve tangible results. Patients generally get better.”
There are many other major differences between the treatment of children and adults. Dr Singer, also an honorary senior lecturer in child health at Imperial College, emphasises the enormous importance of setting the right tone. Gentleness, he says, is everything. For example, the manner in which the doctor approaches injections – always a sore point – is crucial. “Our children never cry when we give them injections because it’s all about how you do it. Our patients see that it’s a very non-threatening atmosphere here. We’re trying to help them. They know that, so they cooperate.”
If a child starts screaming hysterically, that’s probably because every time they’ve gone to a doctor in the past, they’ve had a terrible experience with a big needle. “Some doctors will sit the child on their lap, take the needle, and the
child will watch the injection happen. In that case, it doesn’t take long for the child to acquire a screaming sensitivity to needles because they connect injections with pain. That doesn’t happen here. If you take the child and you sit them on the examining couch and the parent puts their arm around them, they feel much more relaxed. They’ve got the comfort of the parent holding them. The parent turns the child’s head away from the needle, then I rub the spot hard and do the injection very quickly. They don’t even feel it. That child doesn’t then have a needle phobia for the rest of their life. We take all these things into consideration.”
One of Dr Singer’s principal rules is to never use force. “If a child is happy and relaxed, examining them is easy,” he says. “The problem is when they start thrashing around and kicking. If that happens, you just back off and say: ‘Come back another day.’ You always want the child to cooperate properly, without feeling coerced.”
Another thing that de-stresses the children visiting the clinic is the fact that there is a magnificent fish tank in the reception. “It’s a saltwater reef, which is a complete ecosystem. It’s got Nemo and Dory and all these other lovely fish in there. The children sit there for ages transfixed by it.”
The young patients continue to be soothed when they come upstairs to Dr Singer’s consulting room, which is laid out to appeal to children, rather than adults. He explains: “We have lots of toys spread out on a table at the back of the room. It is separate from all the places where we do the examinations. There are chairs in front of me where the parents sit, and behind those is the play table. All that is by design because I can talk to the parents and at the same time watch the children play. That way, I can gather a lot of
With adults, all you do is prop them up from one illness to the next, as Old Grandfather Time inevitably catches up. Paediatrics is a wonderful speciality as it’s the only one where you have to run after your patients because they keep running out of the door and you have to constantly bring them back!
information about them and how they’re interacting.”
With a wry grin, Dr Singer adds that it is not the kids who are difficult to handle. “Children are easy – it’s often the parents who are the problem!”
The doctor, who clearly understands very acutely the delicate psychology required when dealing with children and their parents, goes on to outline other ways in which the treatment of young and adult patients differ. “First of all, my examining table is made for children and not adults. It is blue, which is a very calming colour. I sit the children so that their knees are over the table, and then I work around them. I tell them what I am going to do beforehand, and I make it fun.”
Again, Dr Singer’s people skills come to the fore. “If parents try to hover, I tell them to sit down on the other side of the room, while I examine the child on the couch. I tell them that we’ll put on a ‘hover charge’ – not a cover charge. The whole approach is about focusing on the child and taking them seriously. There should be no such thing as a child who’s stressed out and screaming hysterically while the parents run around the room trying to catch them and undress them.”
There are also differences in the ways doctors medicate children and adults. Dr Singer observes: “The course of treatment, how you deal with the condition, how you approach it, the algorithms of the treatment, and the blood tests that you get are all basically the same. But there are still very distinct ways of treating children. For example, the antibiotics we use for children tend to be different, and there are certain tests that you might not do with adults.”
Children can also respond very differently to medication. “For instance, leukaemia in children is a curable disease now. With young people, we are working with an organism that’s still growing. So a condition could flatten an adult completely and
leave them in hospital for a week or two, but children with the same condition are running around and playing immediately after the operation. Children are like the Duracell Bunny. They hop, hop, hop, and when they’re exhausted they go to sleep. Then, when they’ve slept for a couple hours, they get up and start hopping again. You can’t stop them. Whereas, during the same period, adults would just stay in bed.”
Huge advances in medical science have vastly improved the life chances of children with certain illnesses. Dr Singer notes: “There are now all kinds of new treatments, such as monoclonal antibody therapy, specifically for certain diseases. These are now treatable and curable in a way that they weren’t before. And of course, the earlier you catch it, the more effectively you can treat it.”
The treatment of childhood diseases in this country has made great strides thanks to the work of Dr Singer and his colleagues. “In this practice all our consultants are drawn from the teaching hospitals in London. It’s by invitation only, and they are the lead professors or the heads of department in all the paediatric specialties in London. The key thing, and this is absolutely central to our success in treating children, is that we work as a team. Paediatricians are a limited resource in the UK, but we have brought together the best here.”
All that is now changing, though. The specialism was recently formally recognised by the formation of the Royal College of Paediatrics and Child Health in 1996. To put the term ‘recently’ in context, the Royal College of Physicians of London was founded in 1518 by King Henry VIII and the Royal College of Surgeons in London in 1800.
Dr Singer is an American who trained at the Children’s Hospital Medical Centre and Havard University, Boston. He has held roles at the National Institute of Child Health and Human Development; the National Institutes of Health – Bethesda Md; the Rockefeller Foundation – Population Council, and the Paediatric Research Unit at Guy’s Hospital. He is an honorary senior lecturer in child health at Imperial College, London. Dr Singer has published many research papers helping to drive real progress in his field.
Dr Singer’s prognosis for the future of paediatrics? Very optimistic. “When I started training, I was told by a professor that there was no future in genetics. But gene therapy is now really important in paediatrics. Medicine changes very dramatically and very quickly, and that is brilliant.”
He signs off by reiterating how much pleasure he takes from his work. “I give every child a sticker which says: ‘I’ve been brave.’ I never give it to the parents. They don’t deserve it! They have only brought the child to see me. The children stand there and say, ‘Where’s my sticker?’ They won’t leave until they’ve got one. That’s marvellous because it demonstrates the rapport we have. It’s wonderful when even the toddlers, the four to five-year-olds, say: ‘Thank you very much’. The thanks we get from the children and from the parents – you just can’t put into words how much that means.
When I
started training,
I was told by a professor that there was no future in genetics. But gene therapy is now really important in paediatrics. That shows you that medicine changes very dramatically.
Dr Singer explains: “Paediatrics in the US was the first specialty in medicine to be recognised, whereas in the UK it was the last.” With a laugh, he suggests: “Perhaps that can be explained by the British attitude to children, which is that they should be seen and not heard.” Often when it came to both physical and mental ailments, children were simply treated as small adults. The Harley Street Paediatric Group
“What greater satisfaction could you have than that?”
Harley Street BID will be supporting Arab Health 2024 with a presence in the UK Pavilion and at keynote events. We look forward to seeing you in Dubai.
The Harley Street BID has been established to promote the area and represent the exciting mix of businesses here.
In November 2021 the business community were invited to vote in the ballot to develop a business improvement district and there was an overwhelming “yes” for a BID to be established from the businesses. The BID term runs from April 2022 to March 2027. With the investment that will be made through the BID this provides opportunities to deliver projects across the key themes which are set out below.
We have implemented and devised projects across our themes, identifying key priorities and building our steering group membership with our partners. Our 4 steering groups are set out below and we have a specific Medical Board in place for our business community.
If you would like more information on the newly developed business improvement district please do not hesitate to contact Nicki Palmer. Email: nicki@harleystreetbid.com Telephone: 07944 386903
Dr Reena Wadia, founder of RW Perio
have a really nice cafe with a courtyard. I just love the variety of art there.
Eat
I’m the founder of RW Perio, a periodontal clinic on Harley Street. It’s a state-of-the art clinic and one of the largest in the UK. We deal with any gum issue. The patients we treat have either been referred by their local dentist or have found us themselves and booked their appointment. Gum disease is really common, but it can have a surprisingly large impact on quality of life. For example, one of the treatments we offer is for gum recession, which can happen when you brush your gums too much. The aim of the treatment is to rebuild what’s been lost. We also offer aesthetic treatments – for example, if you have a gummy smile, where there’s too much gum on show and you want to reveal more of your teeth instead. One of our patients nicknamed it a gum lift! We also have a podcast called Life & Smile, so life is very busy at the moment.
Our clinic is a stone’s throw away from Regent’s Park, which is a beautiful place to go and refresh during a lunchtime walk, and Hyde Park isn’t too far either. But my favourite thing about working in Marylebone is the architecture. It’s really inspiring. I love to walk around the back roads on my lunch break, look at the architecture and think about the history of the area, wondering what it was like here a century ago and how different it would have felt. Whenever The Wallace Collection has a new exhibition I will go, enjoy the art and then stay for afternoon tea – they Home
I go out to eat in Marylebone all the time. Ottolenghi is a favourite, as is Home Marylebone – especially their pizza. It’s a relatively new European restaurant on the high street. It’s great for an easy lunch and it always hits the spot. We often take the students we teach to Reform Social & Grill at the Mandeville Hotel. There’s so much choice and it’s useful if you’ve got dietary requirements, as they’re happy to make things exactly the way you want them. I like their soups, or last time I went I had the chargrilled cauliflower, which was very good. I also love Home House, either for breakfast meetings or to relax after work. I could go on and on!
Community
The great thing about Marylebone is that it still has the traditional shops that you know and love and go to time and again, but there are also new things popping up all the time. This makes it a very exciting place to come to work. Farrow & Ball is a favourite of mine at the moment. We’re currently renovating our house, so I’m spending a great deal of time in there looking at their wonderful range of paints and wallpapers. One of the new spots that I really like is Sézane, which is bringing Parisian fashion to Marylebone – then there is John Bell & Croyden, a first-class pharmacy with really helpful and knowledgeable staff. One of the other good things about Marylebone for visitors is that it’s so central, which means you can visit some of London’s famous shopping spots while you stay here. Bond
Street is very close by, as is Fortnum & Mason, which is great for gifts. Selfridge’s is only a 10-minute walk away and has everything you need, or there’s Claridge’s for afternoon tea or even a business meeting.
I’m not here a lot outside of working hours, but even so it’s such a welcoming place that you really feel part of the community. It’s one of those places that whenever you go for a walk you’re bound to bump into someone you know, which is lovely. We’re also part of a medical community here, which is important because gum disease needs to be treated holistically – we might need to consult a physician about diabetes, for example, as it tends to be closely linked. There are lots of crossreferrals between medical practices, it’s a two-way thing, which makes it a fun and interesting place to work. We also attract global talent due to our central location. The Harley Street Medical Area has a very good reputation: all the best clinics are in the W1 area.
RW PERIO
75 Harley Street London W1G 8QL 020 7112 9036 rwperio.com
FIDDLER ON THE ROOF
Until 21 September
Regents Park Open Air Theatre
Regent’s Park, NW1 4NU openairtheatre.com
Celebrating its 60th birthday this year, the classic musical Fiddler On The Roof rounds off the summer season at the Regent’s Park Open Air Theatre. A musical of joy, revolution and tradition it features the glorious songs If I Were A Rich Man, Tradition, Matchmaker and Sunrise, Sunset. An exuberant celebration of love and life, this new production is directed by Jordan Fein with book by Joseph Stein, music by Jerry Bock and lyrics by Sheldon Harnick. Fiddler On The Roof concludes the 17th and final summer season for Timothy Sheader as artistic director of the theatre.
AUTUMN
INTERNATIONAL PIANO FESTIVAL
21 September – 4 October Wigmore Hall 36 Wigmore Street, W1U 2BP wigmore-hall.org.uk
Wigmore Hall presents a two-week celebration of pianists and pianism. This 14-concert festival opens with a Polish-themed recital by Peter Jablonski and features performances by luminaries such as Yoav Levanon, Alim Beisembayev, Vijay Iyer, Javier Perianes, Angela Hewitt, Saskia Giorgini, Marouan Benabdallah, Can Çakmur and Clare Hammond. Highlights include Elisabeth Leonskaja’s performance of Schubert’s final three piano sonatas, Jeneba Kanneh-Mason performing Skryabin and Chopin, and Chopin miniatures from Pavel Kolesnikov.
DEXTER DALWOOD: ENGLISH PAINTING
27 September
– 9 November
Lisson Gallery
67 Lisson Street, NW1 5DA lissongallery.com
In this inaugural exhibition of new paintings, Dexter Dalwood reconsiders his attachments with English art history and British youth culture of the 1970s and 80s to explore what it might mean to be an ‘English’ painter. In works that consider the legacies of traditional genres, from landscapes or the lowlier practice of horse portraiture to the Bloomsbury Group and Pop Art movements of the 20th century, Dalwood probes the question of whether national identity can be determined or distilled through art.
RESOUNDING SHORES: YE SACRED MUSES
27 October, 12pm
Royal Academy of Music
Marylebone Road, NW1 5HT ram.ac.uk
Jonathan Manson and Nicholas Mulroy direct the Academy Viol Consort and soprano Daisy Livesey in a rare and wonderful programme of music by some of England’s greatest composers. Combining exquisite intimacy with enigmatic melancholy, the repertoire is the musical equivalent of a fragile Vermeer portrait and includes William Byrd’s My Mistress Had a Little Dog, Henry Purcell’s Fantasia Upon One Note and Orlando Gibbons’ The Silver Swan, among other pieces.
KEEPING TIME: CLOCKS BY
27 November – 2 March
The Wallace Collection Manchester Square, W1U 3BN wallacecollection.org
For the first time, the Wallace Collection is bringing together five exceptional clocks by André-Charles Boulle (1642–1732), the most famous cabinetmaker to have worked for the court of the Sun King, Louis XIV. Join curator Alexander Collins at 1pm on the display’s opening day to learn how Boulle fused bold baroque design and sumptuous ornament with groundbreaking mechanisms made by leading clockmakers. This talk will also be broadcast live from the museum for anyone unable to make it in person. Book a free ticket online to receive a Zoom link.
1–5 York Gate, Marylebone Road London NW1 5HT ram.ac.uk/museum
Every Friday from 11am to 6pm, The Royal Academy of Music’s free museum opens its doors to the public. With two permanent galleries and a programme of temporary displays, the museum covers an array of eras, instruments and subjects. Marvel at historic instruments such as the ‘Viotti ex-Bruce’ 1709 violin by Antonio Stradivari, once owned by the personal violinist to Queen Marie Antoinette. Look out for the museum’s Object of the Month and observe skilled luthiers in their glass-walled workshop as they use ancient techniques to maintain the collection of instruments.
66 Portland Place London W1B 1AD architecture.com
newest attraction being the latest incarnation of Doctor Who, Ncuti Gatwa, along with a life-sized TARDIS. Meanwhile, true crime fans will appreciate the Chamber of Horrors, featuring infamous crimes of the past 150 years, with historical artefacts from the Tussaud archives. New for 2024, begin your visit with a glass of fizz in the 1835 Champagne Bar before taking a selfie with your favourite celebrity’s waxwork.
Outer Circle, Regent’s Park London NW1 4RY londonzoo.org
For the architecture enthusiast, The Architecture Gallery is a must. Housed within RIBA’s iconic Art Deco HQ it hosts a rolling schedule of free exhibitions, workshops and events. The exhibitions programme looks closely into architectural movements, styles and ideas, drawing on RIBA’s vast collection of drawings, photographs and models. The current exhibition, Raise the Roof: Building for Change, explores the narratives and attitudes embedded within the fabric of 66 Portland Place itself. RIBA’s world-class architecture library is also free to access.
MADAME TUSSAUDS
Marylebone Road
London NW1 5LR madametussauds.com/london
The ever-popular Madame Tussauds regularly updates its exhibitions and experiences, with the
Created for the study of zoology, London Zoo’s mission is to help reverse wildlife decline and restore the diversity of life everywhere. In the Secret Life of Reptiles and Amphibians exhibition, learn how it saved the unique mountain chicken frog species from complete extinction. Look in on this year’s batch of Humboldt penguin chicks at the Penguin Beach pool and hear three Asiatic lion cubs born in March practice their roars in the Land of the Lions habitat.
221b Baker Street London NW1 6XE sherlock-holmes.co.uk
In a splendid four-storey Georgian townhouse dating back to 1815 the Sherlock Holmes Museum lovingly recreates the gas-lit world of London’s most iconic detective. Immerse yourself in a treasure trove of items relating to Sherlock, in the very setting that inspired them. Whether you’re a devotee of the original stories or a recent Cumberbatch convert, step back in time to see where some of Holmes and Watson’s most famous cases began and imagine what life was like in a fascinating bygone era.
Elizabeth Garret Anderson
Elizabeth Garrett Anderson, the first woman to qualify as a doctor in Britain and cofounder of the London School of Medicine for Women, lived at 20 Upper Berkeley Street from 1865 to 1874. As no medical school in Britain would admit her as a student, Anderson was forced to take an alternative route to medical training, against the constant objections of male contemporaries. Starting as a nurse and studying medicine in her own time she finally obtained her medical licence from the Worshipful Society of Apothecaries by exploiting a loophole in their charter (which they swiftly closed). She qualified in 1865 and set up her first practice at Berkeley Street.
Sir Patrick Manson
Having spent his early medical career in Asia, Scottish physician Sir Patrick Manson lived out his later
years at 50 Welbeck Street. His studies of the small worm that causes elephantiasis led to an interest in the role of mosquitoes in spreading disease – and possibly malaria. While it was Ronald Ross who proved the mosquito-malaria hypothesis, scooping the 1902 Nobel Prize for Medicine without crediting his mentor’s role, Manson is regarded as the father of modern tropical medicine.
Octavia Hill
Originally called Paradise Place, 2 Garbutt Place was the location of Octavia Hill’s first foray into improving housing conditions for the urban poor in 1865. The success of this venture, funded by writer John Ruskin, led to the expansion of Hill’s social housing scheme to other areas of London. A believer in the value of open spaces for the urban masses, Hill championed access to common lands for everyone. Her campaigns to protect green spaces in London from development culminated in her co-founding of The National Trust in 1895.
Ethel Gordon Fenwick
Ethel Gordon Fenwick lived at 20 Upper Wimpole Street from 1887 to 1924. A former matron of St Bartholomew’s Hospital in London, she spent 30 years campaigning for a nationally recognised certificate for nursing and the state registration of nurses – a stance notably opposed by Florence Nightingale who believed that registration would prevent working class women from becoming nurses. When the Nurses Registration Act was passed in 1919, Fenwick’s name was the first on the register as State Registered Nurse No 1.
James Smithson
It was while staying at 9 Bentinck Street in October 1826 that the wealthy
Wealthy mineralogist and chemist James Smithson wrote an idiosyncratic will that led to the founding of the Smithsonian Institution in Washington.
mineralogist and chemist
James Smithson wrote the idiosyncratic will that led to the founding of the Smithsonian Institution in Washington. This directed that his estate should pass to his nephew. However, if his nephew died without heirs, which he did, the funds should then go “to the United States of America to found an establishment for the increase and diffusion of knowledge among men and it should be called the Smithsonian Institution”. This came as a surprise to the US government, who had never heard of him.
Emma Cons
Originally a pub, 136 Seymour Place was converted into a temperance ‘coffee tavern’ and affordable accommodation by Emma Cons in 1879, who also lived there until 1889. A friend of Octavia Hill, Cons was a philanthropist, reformer, businesswoman and social entrepreneur. Among other ventures, she founded her own affordable housing company for working class people in a precursor to municipal social housing. Cons is best known for re-opening the Royal Victoria Theatre, later to become the Old Vic, as a music hall and venue for ‘penny science’ lectures.
Simón Bolivar
In perhaps the shortest stay ever to merit a blue plaque, the revolutionary leader Simón Bolivar lodged briefly at 4 Duke Street in 1810 while lobbying British support for Venezuelan independence from the Spanish Empire – a tricky mission as Britain and Spain were notionally allies. Bolivar would eventually lead Colombia, Panama, Peru, Ecuador and Venezuela to independence. In 1825 Bolivia was named in his honour but his dream of uniting all South American countries into one nation was never realised.
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The Howard de Walden Estate’s Healthcare Conference 2024, will bring together industry leaders, cutting-edge start-ups, and pioneering researchers to explore transformative ideas and innovation in the HealthTech and healthcare industries.
The conference is free to attend and CPD certified.
Spaces are limited so registering interest is essential.
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