Prognosis issue 6

The periodical of the Harley Street Medical Area Issue 06 / 2019

The drugs don’t work Why medicine is now losing the fight against bacteria and fungi Irreversible electroporation An emerging technique for treating inoperable tumours The unprecedented president The first psychiatrist to lead the Royal Society of Medicine Shoulder arthroplasty The challenges of replacing the most flexible joint in the body

The Harley Street Medical Area (HSMA) is located in Marylebone, in the heart of central London. It is a collective of world class healthcare providers with a reputation for medical excellence.

It benefits from a central London location that attracts millions of London, UK and international visitors every year, but it also has the additional benefit of being part of the desirable local neighbourhood of Marylebone Village.

@HarleyStMedArea #HSMA

HSMA’s reputation for medical excellence, innovation and patient experience has grown significantly over recent years, as has its contribution to the UK medical sector and the wider economy. This is a prestigious location for any healthcare provider or medical practice.

The Howard de Walden Estate is the landlord for a large proportion of the medical properties that sit within the Harley Street Medical Area.

To find out more about this acclaimed medical area please visit harleystreetmedicalarea.com

Harley Street Medical Area

harleystreetmedicalarea.com

Prognosis is owned by The Howard de Walden Estate 27 Baker Street London W1U 8EQ 020 7580 3163 hdwe.co.uk

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34 The drugs don’t work Why antimicrobial resistance is one of the biggest threats to global health

Estate contact Jenny Hancock jenny.hancock@hdwe.co.uk Publisher LSC Publishing 13.2.1 The Leathermarket Weston Street London SE1 3ER lscpublishing.com Editor Mark Riddaway mark@lscpublishing.com Deputy editor Viel Richardson viel@lscpublishing.com Assistant editor Clare Finney clare@lscpublishing.com Sub-editor Ellie Costigan ellie@lscpublishing.com Editorial desk 020 7401 7297 Advertising sales Donna Earrey 020 7401 2772 donna@lscpublishing.com Contributers Jessica Brown, Sasha Garwood, Orlando Gili, Christopher L Proctor Design and art direction Em-Project Limited 01892 614 346 mike@em-project.com Printing Warwick

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People still presume of psychiatrists that they just weren’t good enough to do medicine. I always say that it’s the other way round: that I’m only just good enough to do psychiatry. It’s the most difficult branch of medicine

04 Opening BID Simon Baynham of The Howard de Walden Estate on the imminent arrival of the HSMA Business Improvement District 09 News New arrivals, developments and events 10 Crystal ball The evolution of the treatment of autism 11 Harley Street hero Florence Nightingale 12 How does it work?

Irreversible electroporation 14 Thinking aloud The thoughts of Dr Charles Levinson, founder of Doctorcall 16 Profile of a pathogen Varicella zoster virus 18 How to...

Treat scarring 20 A day in the life Sundeep Sagoo, technician at Ophthalmic Consultants of London 24 A special relationship The new collaboration between Mayo Clinic and Oxford University Clinic 26 Second opinion What is the long-term solution to obstructive sleep apnoea?

28 The big interview Professor Sir Simon Wessely on unexplained syndromes, the Mental Health Act and London’s Cartesian divide 34 The drugs don’t work Confronting the gravity of the antimicrobial resistance crisis 42 A less tolerant nation Understanding the rise of allergies 48 Q&A Mr Livio Di Mascio and Mr Adrian Carlos on shoulder arthroplasty 52 Patient experience How a patient’s wedding day was saved by some stunningly succinct back surgery 56 State of play Dr Margaret Lowenfeld and the birth of play therapies

60 My Marylebone Andrew Barker, CEO of Phoenix Hospital Group 62 What’s on Cultural events near the Harley Street Medical Area 63 Five Marylebone’s most enjoyable pasta dishes 64 The Guide Marylebone’s most notable houses

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Although on the surface Dr Lowenfeld’s work was a far cry from her own wealthy London childhood, perhaps her early experiences of unhappiness, divorce and conflict shaped her later insights into traumatised children

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OPENING BID

Simon Baynham, property director at The Howard de Walden Estate, on how the proposed creation of a Harley Street Medical Area Business Improvement District is set to foster an even greater sense of collaboration between the area’s healthcare providers

The time has come for the Estate to help pull these ties even tighter by giving the HSMA’s community of healthcare businesses and institutions a clearer and more defined voice in plotting the direction the area will take in the years to come

For many years now, The Howard de Walden Estate, the landlord responsible for managing the renowned Harley Street Medical Area (HSMA), has been working hard to turn this attractive enclave of central London into a centre of international medical excellence capable of holding its own at the very pinnacle of the increasingly competitive world of healthcare providers and global destinations. At the core of our work has been a drive to create world class medical facilities, either built from scratch or accommodated within the area’s magnificent period buildings, then attract and retain the right blend of large hospitals and specialist clinics, all of them offering the highest levels of innovation and patient care.

Parallel to this, but no less important, we have been doing all we can to turn

what was previously a fairly disparate collection of providers, many of which kept themselves to themselves, into an open, collaborative and close-knit community with a sense of common purpose.

To these ends, Howard de Walden runs regular medical forums where ideas are exchanged and contacts made, we lead an HSMA contingent to the annual Arab Health conference, and we do everything we can to facilitate links, both formal and informal, between our providers. As each year passes, the HSMA is becoming more and more interwoven, with most of its hospitals and clinics fully buying into the idea that, by enhancing the area’s profile and reputation and working together to draw in more patients, making a contribution to a wider whole is of

clear mutual benefit, even though in some instances there is an element of competition as to exactly where those patients end up.

Now, though, the time has come for Howard de Walden to help pull these ties even tighter by giving the HSMA’s community of healthcare businesses and institutions a clearer and more defined voice in plotting the direction the area will take in the years to come.

And if all goes to plan, we will do this through the creation of a Business Improvement District (BID).

Many of you are probably completely unaware of the activities of BIDs, but there are few of you who won’t at some point have benefited from their activities. Simply put, and as the name suggests, a BID is a body led and funded Prognosis—5

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A BID can have many different goals, but among these might be the aim to attract investment, oversee capital projects, add to an area’s competitive advantage, improve quality of life and create a positive sense of place

by local businesses, which seeks to make tangible improvements within a defined commercial area. A BID can have many different goals, but among these might be the aim to attract investment, oversee capital projects, add to an area’s competitive advantage, improve quality of life and create a positive sense of place. In London, BIDs are well placed to unlock several centralised sources of funding, particularly when it comes to large scale public realm schemes, while also having a level of traction with councils, Transport for London and the Greater London Authoritythat goes far beyond that available to any individual business.

Last year, we commissioned a feasibility study from Primera, a highly respected regeneration consultancy with a great deal of experience in this sphere, to see whether the creation of an HSMA BID would be both possible and desirable. The resulting report was highly positive, not least because one of the trickiest parts of getting a BID off the ground is the need to foster an ethos of collaboration between local businesses, and that is something which, as previously outlined, is happening here already.

So, where do we go from here? The formalities of establishing a BID have first required us to set up a Harley Street Medical Area Partnership. Ten partners have put in seed money and each has a place on the board. The Howard de Walden Estate is a partner, as are The London Clinic, HCA, King Edward VII’s Hospital, UCLH, Moorfields, Isokinetic, Harley Street Fertility Clinic, Schoen Clinic London, and Cleveland Clinic. For

a period of around a year to 18 months, this partnership, coordinated by Primera, will work its way through the various steps needed for the BID to be ratified. In the meantime, the partnership will start work on a project or two that will set the foundations for future work, while also giving the group a useful grounding in the collective selection and management of the kind of activities that will continue if and when the BID’s creation is approved.

The partners may, for example, decide to commission a study of national and international healthcare markets to determine where else in the world we should be making our presence felt, and the approaches we should be taking in different regions. They may instead choose to start closer to home, with a detailed feasibility study of public realm and infrastructure, including for example, wayfinding, street clutter, planting and greening, waste collections and deliveries, parking and ambulance access. This will provide the group with a vision for how the area’s appearance and functionality could be enhanced to match the exemplary standards of the medical care on offer. Or they may consider employing an HSMA ambassador, an individual whose role it would be to engage with businesses and service users, identify potential improvements and gather useful data.

If all goes to plan, in early 2021, local businesses will be balloted to approve the creation of a BID company—which is not-for-profit and limited by guarantee— and agree to a proposal that outlines its initial five-year plan. If the vote proves

to be positive, these businesses will pay an annual levy based on their rateable value and will all become members of the BID. Every five years, the BID company will share a detailed proposal setting out its plans for a further term, and the members will vote on renewing its tenure.

Our activities as a Marylebone landlord have often brought The Howard de Walden Estate into close contact with other BIDs—for example, The Baker Street Quarter Partnership, Marble Arch London and New West End Company—and we have seen first-hand the positive changes they can make to the look and feel of an area, its sense of togetherness, and the strength of its voice on a wider stage. We are absolutely convinced that an HSMA BID, with its likely medical focus, can have a similar impact, not just on the physical space but on the experiences of patients and clinicians. We at The Howard de Walden Estate will keep on doing what we do best, making plans to enhance still further the medical accommodation and mix of healthcare providers on offer, while the providers themselves will continue to do what they do best: putting their skills and facilities to use in improving the health and wellbeing of their patients. Together, with the addition of a BID, we will be able to continue pooling our energy and expertise for the greater good of all.

The Howard de Walden Estate 27 Baker Street London W1U 8EQ 020 7580 3163 hdwe.co.uk

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Urgent Care Centre for Children The Portland Hospital 205-209 Great Portland St, London W1W 5AH 8.00am-8.00pm, 365 days a year Initial consultation ÂŁ150. Patients must be aged between 0-17 years old.

Just walk in or call 020 3993 2320 www.urgentcarecentre.co.uk

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NEWS

In January 2020, a contingent from the Harley Street Medical Area, led by The Howard de Walden Estate, will once again be attending the Arab Health Conference in Dubai. The team, which will include representatives of several of the area’s top clinics, will showcase their medical excellence on the HSMA stand within the UK Pavilion. A number of the medical partners will also be talking at congress as part of the event. arabhealthonline.com

Work is underway on the construction of a new HSMA facility for Private Care at The Royal Marsden, the private arm of The Royal Marsden NHS Foundation Trust, one of the country’s leading cancer hospitals. Located on the lower ground and ground floors of Harcourt House, Cavendish Square, a large, mixed-use mansion block dating from 1907, the Royal Marsden’s new unit will primarily be used as a diagnostics centre.

The landlord has now completed its work and has handed over to the Royal Marsden for fitting out. The unit is set to open in the summer of 2020. royalmarsden.nhs.uk/private-care

Two of the world’s leading names in healthcare and medical research— US hospital group Mayo Clinic and the UK’s Oxford University Clinic (itself a joint venture between the University of Oxford and Oxford University Hospitals NHS Foundation Trust)—are collaborating on the opening of a new facility in the Harley Street Medical Area. Due to launch this summer, Mayo Clinic Healthcare in partnership with Oxford University Clinic will offer preventative medicine, screening and diagnostic services. The clinic will draw on the world-class expertise of the two parent organisations, offering access to an unrivalled network of glo bal health experts and a highly personalised approach to healthcare.

Cleveland Clinic London, the British outpost of the highly regarded American non-profit multispecialty academic medical centre, has taken a lease at 24 Portland Place, where it will locate its first medical outpatient building. The new clinic, which is expected to open its doors in autumn 2020 for outpatient appointments, diagnostics and general practice appointments, will be set over six floors, totalling 28,000 square feet.

The building, owned by The Howard de Walden Estate, is within easy reach of the Cleveland Clinic London Hospital at 33 Grosvenor Place, which is also currently under construction. clevelandclinic.org

mch-ouc.co.uk 42 Harley Street

Capital Physio has opened a new performance hub at 42 Harley Street, taking over seamlessly from ESPH, which previously ran a highly regarded physiotherapy practice at the same location. In addition to standard physiotherapy care, the clinic gives patients direct access to a multi-functional, rehab-specific gym space, complete with the latest eGym and Technogym equipment.

24 Portland Place

capitalphysio.com

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As with all medical conditions, a significant challenge has been the difficulty of establishing an early, accurate diagnosis.

One of the most exciting developments is the possibility of a new physical test for autism, which is currently diagnosed just by looking at behaviour

CRYSTAL BALL

Autism treatments Dr Dimitrios Paschos, consultant psychiatrist at Re:Cognition Health, on how the treatment of autism is set to evolve

State of play Right now, there is no treatment for autism itself—all we can do is manage some of the symptoms. But things are changing. Research is showing us that the conditions we label as autism are highly complex and involve problems with a variety of the body’s systems, not just the brain. We have seen metabolic, immunological and microbiome findings that are consistent in people with autism, and this knowledge is helping with the development of treatments.

There are some drugs that are approved to deal with autism symptoms such as anxiety or repetitive behaviours.

The good news is that medicines aimed at treating the core features of autism are now undergoing clinical trials, something that was unthinkable just a few years ago.

On the horizon Re:Cognition Health is currently enrolling subjects into two international, multicentre, phase-3 clinical trials for new medications targeting core autism symptoms. One provides early access for adults with austism spectrum disorders (ASD) to receive Balovaptan, and the other is for children with ASD to access Bumetanide. The aim is to determine whether taking these medications reduces the severity of autistic symptoms and if there are any corresponding measurable improvements in everyday function.

The hope is to see changes in people with autism who find aspects of social communication, education and employment challenging in their everyday life. Results are expected in two to three years.

Other treatment trials are also underway, ranging from a phase-3 trial of CM-AT, a proteolytic digestive enzyme, to a small trial of suramin, a 100-year-old drug, originally used to treat sleeping sickness in Africa. This has been convincingly shown to reverse autism symptoms in mouse models, and a single intravenous infusion was found to temporarily but quite drastically reduce symptoms in a very small group of children in the USA. As with all medical conditions, a significant challenge has been the difficulty of establishing an early, accurate diagnosis. One of the most exciting developments is the possibility of a new physical test for autism, which is currently diagnosed just by looking at behaviour. New biomarkers are now permitting us to build a better understanding of the condition.

This could be vital, as it is believed that early intervention may lead to major improvements in the person’s intellectual and social abilities.

In the distance One of the most striking discoveries has been the link between the microbiome and autism symptoms. There is now strong evidence that people with autism have very different microbiomes from those without it, and we have known for a long time that many autistic people have severe gastro-intestinal problems.

In a widely publicised prospective study, faecal microbiota transfer was used to alter the microbiome in autistic children. Two years later, a statistically significant number saw a reduction in gastrointestinal problems and a corresponding reduction in core autism symptoms. Although we can’t say a change in the microbiome causes autism, it seems to play an important role in the symptoms and may prove an important treatment target.

I would also like to see more focus on the immune system, as this appears to have a critical role in the development of autism symptoms. I believe in the next 15 years we will have the ability to diagnose autism very early, perhaps even before birth. With what we are learning, we can look forward to a day when people with autism will have a variety of safe and effective medical treatments for all their core difficulties.

Re:Cognition Health 77 Wimpole Street London, W1G 9RU 020 3355 3536 recognitionhealth.com

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MUSEUM PIECE Waterloo teeth In the early 19th century, false teeth were in great demand.

These were often carved from hippo ivory or ox bone, but they rarely fitted, were not secure enough to eat with, and, as they started to decay, resulted in a rotten taste and terrible bad breath.

The best dentures used human teeth, which looked better, resisted wear and kept their colour. Demand usually outstripped supply— in the late-18th century a human tooth was four times the cost of an artificial one.

Teeth were bought from the poor, stripped from corpses before burial or pilfered by grave robbers. The most respectable supply came from the battlefields of Europe, as professional ‘tooth hunters’ followed armies across the continent. Even so, teeth remained in short supply.

The Battle of Waterloo in 1815 changed that. So many teeth flooded the European market that excess supplies were shipped to the USA. It was this glut that gave dentures, like these from the British Dental Association museum, their new name: Waterloo teeth.

HARLEY STREET HERO Florence Nightingale (1820-1910)

On 12th August 1853, the 33-year-old daughter of a rich landowner started a new job as the superintendent at The Establishment for Gentlewomen during Temporary Illness on Harley Street. It was her first employment of any kind, but she came to it full of brio, determined to make an impact. Her name was Florence Nightingale.

Born in Florence, Italy in 1820 during her parents’ extended honeymoon and named after the city of her birth, Nightingale was raised in a family flush with considerable inherited wealth, acquired mainly through the lead mining pursuits of her great-uncle.

Intellectually precocious and a devout Unitarian, she decided from a young age that her religious calling was to help the sick. She gained an impressive education and travelled around Europe and north Africa, all the while cultivating a burning interest in a profession then considered way below the purview of a respectable upper-class woman: nursing. While in Kaiserswerth-am-Rhein in Germany in 1850, Nightingale visited a Lutheran community renowned for its care of the sick and spent several months learning their techniques. She was, she decided, ready to get a job.

The Establishment for Gentlewomen during Temporary Illness (which over the decades was renamed with confusing frequency and is often referred to as The Institute for the Care of Sick Gentlewomen) had been founded in 1850 at 8 Chandos Street by a group of philanthropically-minded ladies as a place where respectable women of moderate means—educated, but too poor to afford private care—could seek treatment.

Through a family connection, Nightingale landed the role of superintendent, starting work mere days before the hospital moved to larger premises on Upper Harley Street (Upper and Lower Harley Street would be unified into a single street in 1866 and the building renumbered 90 Harley Street ).

Her job was unpaid— Nightingale’s father provided her with an annual income of £500, paid quarterly in advance, to cover her keep and that of a housekeeper—

but she threw herself headlong into her work, insisting on a rare degree of autonomy. “Unless I am left a free agent and am to organise the thing myself and not they [the institute’s committee], I will have nothing to do with it,” she wrote.

Nightingale took practical steps to improve the way the building functioned—a hot water supply was provided to all floors and significant changes were made to the kitchen— but her main aim was to establish the hospital as a training school for nurses and, much to her frustration, this never quite worked out. She was certainly convinced that staff development was much in need: she spent much of her time battling with nurses who, she wrote, gave her “infinite trouble” and had “neither love nor conscience”. The superintendent had no qualms about firing staff—one nurse was dismissed by Nightingale in May 1854 for her “love of opium and intimidation”.

The hospital was meant to treat women suffering from short-term illnesses, but Nightingale was concerned that some of the poorer patients were deliberately prolonging their stay for as long as possible, taking advantage of the comfortable lodgings. One of the superintendent’s major campaigns involved convincing the committee to limit admissions to the seriously ill.

After just over a year in Marylebone, Nightingale, upset by her failure to open a training centre, began secret negotiations with King’s College Hospital. In October 1854, before these discussions could be concluded, she received a communication from the War department requesting that she lead a party of nurses to Scutari, Turkey to tend to injured soldiers from the battlefields of Crimea, a recent report in the Times having stirred up a national scandal about the incompetent and inefficient treatment of the army’s wounded warriors. The nation called; Nightingale answered.

Having significantly reduced the mortality rate in the field through her pioneering insistence on what now seem like fairly basic standards of hygiene and patient care, she would become one of the country’s most famous women, known as the Lady with the Lamp. On her return, she put her high profile to excellent use, establishing a nursing school at St Thomas’ Hospital in London and writing Notes on Nursing: What It Is and What It Is Not—a seminal guide to a profession that, through her intelligence, compassion and determination, she had managed to recast in her image.

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HOW DOES IT WORK?

Irreversible electroporation Dr Steve Bandula, consultant interventional radiologist at the Princess Grace Hospital, on an emerging technique with the potential for treating inoperable tumours Interview: Viel Richardson

Interventional oncology uses minimally invasive, image-guided techniques to deliver cancer therapy directly into tumours. The primary method, known as ‘ablation’, involves setting out to cause necrosis—the death of all the cells in a tumour. There are several ablation techniques in wide use, most of which are forms of thermal ablation, meaning they use changes in temperature to destroy the tumour. For example, radio frequency ablation uses an electrical current to heat up a small area, burning away unwanted tissue while cauterising the wound; microwave ablation uses electromagnetic waves in the microwave energy spectrum to produce tissue-heating effects with the same results; and cryoablation uses extreme cold to destroy the tissue—this is performed using hollow needles called

cryoprobes, inside which pressurised gas is allowed to expand, causing cooling to below -40C. Irreversible electroporation (IRE) is a new ablation technique, which, even though it is still in the development stage, has been shown to be very effective against some tumours. The technique is based on the fact that every cell in the body is surrounded by a membrane. This membrane, which separates the internal workings of the cell from its external environment, is selectively permeable, meaning that some materials are allowed to move freely through it, while others are blocked. Regulating the passage of materials through this membrane is essential to the healthy working of a cell.

For the membrane to operate properly and ensure the cell’s structural integrity, a specific electric potential needs to be maintained between the exterior and interior of the cell.

IRE uses electrical currents to generate a strong electrical field around the cell, which disrupts this electric potential. This creates holes in the membrane that cannot be repaired. At this point, the cell cannot maintain normal homeostasis, leading to fluids and electrolytes leaking out.

As the cell ceases to function, it enters programmed cell death.

The excitement about IRE comes in part from this being a non-thermal ablation technique, meaning that no extremes of heat or cold are involved.

In situations where the tumour we want to treat is located close to an important organ or structure, such as a nerve, ablating the area using a thermal approach would carry a high risk of

damaging or destroying that structure.

There are some things you can do to mitigate that risk, but there will be cases where thermal ablation techniques are deemed to be too risky.

IRE presents the possibility of really stretching the boundaries of where we can ablate diseased tissue, although it is technically much more challenging than other forms of ablation. There is a requirement to place the needles delivering the energy in a precisely designed configuration, so mastering IRE involves a steep learning curve.

The procedure takes place in a scanning room kitted out with the anaesthetic and ablation facilities we need, manned by a dedicated team who run the systems. First, the patient has a CT scan. Those images are then used to create an incredibly precise plan for the placement of the needles. With the patient under general anaesthesia, we then insert the needles through the skin and, watching our progress on a live feed on screen, guide each one to its target.

Once all the needles are in place, we are ready to apply the voltage. The actual treatment lasts 20 to 30 minutes. After taking another scan, we may reposition the needles for a further treatment depending on what the scan shows.

Once the treatment is over, we carry out one last scan to check for complications such as internal bleeding. If everything is okay, the patient will spend the night in hospital and, in the vast majority of cases, go home the next day. There are some side effects—inserting needles into the body will create local discomfort afterwards, but simple analgesia will take care of that.

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Tumour

Tumour

IRE needles

Electric current

Ablation The removal of biological tissue.

Necrosis The premature death of all the cells in a piece of living tissue.

Membrane A selective barrier that allows some things to pass through but stops others.

Electric potential The amount of work needed to move a unit charge from one point to another against an electric field.

Homeostasis The state of steady internal physical and chemical conditions maintained by a living system.

CT scan Computerised tomography scan. This combines a series of x-ray images taken from different angles around the body, allowing the creation of cross-sectional images.

Analgesia Pain-killing drugs.

Pancreas An organ located in the abdomen, behind the stomach, the major functions of which are the creation of digestive juices and hormones, including insulin.

IRE has finally given us an ablation method that might be effective on inoperable pancreatic cancers. Pancreatic tumours present quite late, as they develop deep inside the body—and by the time they do, they can be so advanced that surgery is no longer an option.

Thermal ablation cannot be performed safely, as the pancreas is surrounded by lots of important structures and blood vessels. Also, the pancreas itself can become inflamed and one of the potential complications of injuring the pancreas is serious pancreatitis, which itself can be fatal. As IRE is a non-thermal technique, there is a much lower risk of unwanted tissue damage, giving us a potentially effective tool to fight this extremely difficult to treat group of cancers.

While IRE is still a developing technique, there have been some published studies that provide grounds for considerable positivity. Cohort studies have followed the progress of up to 200 patients, and on the face of it the data suggests they survived longer than those who just had standard care or chemotherapy.

However, without proper controlled randomised trials, we can’t yet conclude that IRE is more effective than standard care. If this was a new chemotherapy

agent, moving on to a full phase 2 set of clinical trials would be a no-brainer, but as yet we have not had these for IRE. The treatment of pancreatic cancer is where most of our efforts are focussed, and we urgently need some really robust randomised trial data to give these even greater credence. If this technique can be shown to provide a genuine survival advantage that can be measured up against chemotherapy agents, then there has to be a real case for making IRE more widely available.

I don’t see IRE replacing other ablation techniques, but rather complementing them. Thermal ablation is very well established, with good trial data showing it is effective at treating certain cancers. IRE may develop a separate and distinct role, as the example of pancreatic cancer seems to show. I have no doubt that its use will increase as we move forward. It will become another important tool at our disposal in the expanding field of interventional oncology.

Princess Grace Hospital 42-52 Nottingham Place, London W1U 5NY 020 3130 6833 hcahealthcare.co.uk Prognosis—13

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THINKING ALOUD Dr Charles Levinson Founder of Doctorcall Interview: Ellie Costigan Portrait: Orlando Gili There’s an awful lot of very painstaking attention to detail involved in my job: audit, checking, trying to understand how processes can be improved.

That’s quite a grind, but I like the rigour involved in making sure everything is spot on. Sometimes I feel like the captain of a ship—everything has to be ship shape.

After qualifying, my plan was to be a specialist. As a junior doctor, there were a couple of teaching hospital consultants who I revered. They were so terribly bright and conscientious—but they seemed deeply disillusioned with their jobs. I thought, to work so hard to get to the top and then not be happy is a mistake, so I left and set up Doctorcall: a visiting doctor service.

However much things have changed, I’m struck by how little the fundamentals of this job have shifted in the years I’ve been practising—it remains a matter of keeping your diagnostic skills sharp and building a referral network.

There is a lot of human interest in this job: you’re endlessly going to see people who are in the middle of something important.

Sometimes it’s quite dramatic. It might be a singer who needs to be on stage, and their ENT specialist is on the phone from LA trying to get you to give them all sorts of things. Doctors tend to either love it because of all the human interest... or hate it because of all the driving!

There’s a big demand these days for instant solutions. We all cram in so much, and we expect things to move rapidly. If you open your bathroom cabinet and you’ve got no blood pressure pills, you want them quickly. We offer that convenience.

Newly qualified GPs are rather deskilled these days. Because of the way medicine has changed, they don’t know how to do things like take blood or measure blood pressure—they can’t remember how to because the nurse does it, and they haven’t tried since medical school. The GPs who qualified 10 or so years ago are used to doing all that stuff—even if they don’t do it so much now, they are able to.

Above all else, GPs need rigorous attention to the principles of medicine.

It’s terribly important that our diagnoses are as accurate as possible.

My great love has always been horses. If I didn’t go into medicine, maybe I would have been a racehorse trainer.

The compliance rate is appalling— something like a third of medicines that are prescribed by doctors don’t get taken. I think that’s due to a lack of communication. You need to be able to relate to your patients on equal terms. For GPs, engaging the patient is the most important skill.

I like the challenge of trying to stay ahead of the curve and anticipating the direction things are going, both in terms of our capability and what the world wants—being inventive and creative about finding ways to deliver what patients want before other people do.

In days gone by, patients always wanted antibiotics, even when they didn’t need them. Now, it’s rather the other way around. They’ll say, “My herbalist or my yoga teacher says I shouldn’t take antibiotics.” In the end, you have to say, “Okay, you don’t have to—but I would.”

Usually that makes them sit up.

We’ve been in Wimpole Street and Harley Street for 15 years, so half of our existence, and it is a brilliant place for us to be. We have the whole campus of the Harley Street Medical Area available. Patients can walk down the road and have any kind of scan or see any type of specialist they may need.

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Doctorcall 121 Harley Street London W1G 6AX 034 4257 0345 doctorcall.co.uk Prognosis—15

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PROFILE OF A PATHOGEN

Varicella zoster virus Varicella zoster is a common virus that occurs exclusively in humans.

Few people know its name, but almost everyone will be familiar with the illness it causes: chickenpox.

Descriptions of chickenpox have been around for thousands of years.

The ancient Greeks wrote about a disease with similar symptoms, but close readings suggest that they, like many who followed, considered it a variation of the unrelated and altogether more terrifying smallpox. In fact, it wasn’t until 1767 that the English physician William Heberden demonstrated that the two were different diseases. Even then, we had to wait until 1952 before American virologist Thomas Weller isolated the Varicella zoster virus. Weller’s work paved the way for the creation of a live attenuated vaccine, which was developed in Japan in the 1970s.

Varicella zoster is extremely infectious, with transmission usually occurring either through the airborne route—via respiratory droplets when infected people cough, for example—or through direct contact with a skin lesion.

It has spread to all parts of the world, and the World Health Organisation (WHO) states that in places without a vaccination programme, most of the

population show signs of having been infected to some degree.

The first symptoms generally appear after an incubation period of 10-21 days. These include fever, sickness and the appearance of characteristic itchy rashes, called vesicles. These gradually develop crusts, but the patient will remain contagious until all the vesicles have crusted over. The vesicles generally start to disappear around five to seven days after they appear.

The story may not end there, though. The varicella zoster virus can remain dormant in a person’s cranial nerve and dorsal root ganglia for decades, before reactivating as the herpes zoster infection, better known as shingles—a very painful and potentially debilitating condition.

While the initial chickenpox symptoms usually resolve with no long-lasting effects, in some people infection can occasionally lead to severe complications. These can include infections of the skin and soft tissues, streptococcal infections, pneumonia, infections or swelling of the brain, and bloodstream infections like sepsis. Those with an increased risk of complications include young infants, pregnant women, those with weakened immune systems through illness, patients who have had transplants or are on chemotherapy and those taking immunosuppressive medications or steroids.

Occasionally, a patient can become so sick from the chickenpox infection itself that they need to be hospitalised, and in rare cases the disease itself can lead to death. While this is extremely unlikely, the risk is much higher in adults than it is in children, even if they are generally

healthy individuals with no underlying medical conditions.

In the UK, the chickenpox vaccine is not part of the routine child vaccination programme. The belief is that by reducing the presence of chickenpox in areas where the majority of children have been vaccinated, unvaccinated children from those same areas will be more likely to be exposed to the virus for the first time as adults, when infection is likely to be more severe and potentially dangerous. As a result, the vaccine is mainly used to immunise people whose personal or professional circumstances mean they are likely to pass the infection on to someone who would be at risk of serious complications from chickenpox.

So, while chickenpox is often dismissed as a minor childhood disease, something we all routinely go through, the varicella zoster virus needs to be respected. It has the ability to turn from a few unpleasant childhood days into something very nasty indeed.

Cranial nerves Nerves that emerge directly from the brain and the brainstem Dorsal root ganglia A cluster of nerve cells in the spinal cord Shingles A viral infection that causes a painful rash. it most often appears as a single stripe of blisters that wraps around either the left or the right side of your torso Live attenuated vaccine A vaccine that uses as its basis a weakened (attenuated) form of the germ that causes a disease

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HOW TO...

Treat scarring Prof David Dunaway, plastic and reconstructive surgeon at The London Scar Clinic

What is a scar?

It is the body’s way of healing an injury.

New blood vessels grow into the damaged area to provide the energy to make new tissue—that’s why new scars appear red. Then, gradually, new collagen gets laid down, and that’s what gives the scar its strength. If this happens in an organised way, the scar ends up looking very similar to normal skin. But often either the blood vessels don’t go away when they’ve done their job, so the scar remains red, or an excess of collagen means it becomes raised and lumpy—we call that a hypertrophic scar. If you don’t make enough collagen, the scar ends up wide, thin and a little papery—these are called atrophic scars.

What determines scar quality?

Surgical wounds, which are very cleanly incised, make the best scars, whereas severe abrasions, lacerations or burns tend to make worse quality scars.

Another major factor is skin type: if you’re dark skinned, you’re more likely to get hypertrophic or keloid scars—a severe form of hypertrophic scar—whereas pale skin is more likely to get scars that remain red or become stretched and atrophic.

Wounds in areas where the skin is under a lot of tension tend to make worse scars.

Luckily, this means that scars on the face tend to heal better than most other parts of the body. The very worst areas are the shoulders and the front of the chest. Also, skin has a natural grain to it, and if the wound is lined up with that grain, you get a better quality scar.

Is there anything that can be done to aid the progress of a scar?

Early scar management is really

important. It is vital that you keep the scar hydrated—something simple and bland like aqueous cream or an ordinary moisturiser will do just fine. Lots of scar treatment creams claim to improve scar maturation, but the ones that have been shown to be effective are silicone creams, products like Dermatix or Kelo-Cote.

Many scars don’t make pigment, which is the skin’s defence against ultraviolet light, so cover them with sunblock if they’re exposed. If you go into the sun unprotected, your scar will burn and redden, but because there are no nerve endings you won’t feel any discomfort.

What are the most exciting new developments in scar treatment?

Something that is starting to come onto the market is 5FU (fluorouracil), which is a chemotherapy agent that can be injected into really bad scars, causing the fibrous tissue to be reduced. Another promising development is the use of lasers to drill tiny holes into the scar while you apply medication on the surface, which introduces the treatment into the scar itself. Then there are products made from your own blood—platelet-rich plasma, for example, which when injected into scars can change their characteristics.

How do you go about treating scars?

There are many different approaches, depending upon the nature of the scars and what the patient’s main concerns are. These are usually about appearance, but they can also be about function: some scars feel tight and uncomfortable, are tethered to deeper structures, or restrict the movement of joints.

If it’s a small scar, we might excise it by surgically removing it and replacing it with a neater surgical wound, or if you have scars that cover a much wider area, we may consider skin grafting, or a technique called tissue expansion.

Laser treatments are the most common approach to changing the surface colour and texture of scars: if the scar is very red, we might use something called a pulsed dye laser, which will make it paler; if there’s an irregular surface, we can use a CO₂ laser to resurface it; and there are different lasers that deal with fibrous tissue and tethering. A lot of the scars we see are hypertrophic or keloid, and in some cases we can inject steroids into the scar, which help to dissolve away excess scar tissue.

How important is it that you address the psychological impact of scarring?

With some people, it’s essential. We have psychiatrists and psychologists who work with us, and everyone who comes to the clinic is guided to reflect on how the scarring affects their life. That’s a really important part of scar treatment, but often it’s a bit neglected. Sadly, it’s not always possible to fully treat scars, so you do see people who are seeking more and more treatments when actually the best way of helping them is to encourage them to understand and think about their scars in a more positive way. There are some non-medical treatments that can help—we have an expert in camouflage makeup, a medical tattooist, and a team of hair transplant people. Things like that can have a very positive effect.

The London Scar Clinic 152 Harley Street London W1G 7LH 020 7467 3005 152harleystreet.com/the-london-scar-clinic

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A DAY IN THE LIFE

Sundeep Sagoo, technician at Ophthalmic Consultants of London Interview: Clare Finney Portraits: Christopher L Proctor

The look on a patient’s face when they get up after surgery and realise they can see clearly—it’s like no other expression.

You just can’t imagine what it’s like to go from not being able to see well, to having really good vision for the first time in a long time—perhaps ever. That’s the best part of this job for me: when the surgeon says, “Get up and take a look around,” and they are suddenly just overwhelmed.

I worked at an opticians’ before coming to Ophthalmic Consultants of London, a clinic specialising in laser and lens vision correction surgery, which opened in the Harley Street Medical Area earlier this year. It is just so much more interesting here on the laser side.

We will often receive referrals from opticians for eye health check-ups that go beyond the standard checks of

pressure and vision, as the diagnostic equipment we have here allows us to see so much further into the eye.

I’ve learnt so much about the anatomy of the eye since being here, and I already knew a fair bit! The scanners can pretty much give you a global view of the eye, and you can detect things you just can’t see otherwise, like scarring or holes in the corneal epithelium, which are early indicators of more serious eye issues.

My day usually starts at 8:30am. I like to get here at least half an hour before clinic starts to set up the scanners, make sure everything is in order and go through the schedule so we know which patients are coming and what scans they will need. If there is surgery scheduled for that day, I’ll make sure all

the scans have been exported for the laser machines. By the time that’s all done, I’ll need a coffee to set me up for the day—then it’s either into the clinic, where I talk to the patients and carry out the necessary scans, or into the surgery, where I help the surgeon operate the laser machines.

In essence, my role during surgery is just to press the right buttons on the

Laser eye surgery The use of lasers to reshape the cornea. Used to correct short-sightedness, long-sightedness and astigmatism.

Lens surgery The implantation of an artificial lens to replace or enhance the patient’s natural lens.

Corneal epithelium The outermost layer of the cornea, which acts as a protective barrier.

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Engaging with the patient through every step of the process is so important.

It’s quite common for the patient to be nervous: a laser eye clinic can be a daunting place, especially if you are squeamish about your eyes, which a lot of people are

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The look on a patient’s face when they get up after surgery and realise they can see clearly—it’s like no other expression. You just can’t imagine what it’s like to go from not being able to see well, to having really good vision for the first time in a long time—perhaps ever

laser machine when the surgeon tells me to, but it can still be quite a daunting job. The surgeons here are so friendly, though, and they make sure that their instructions are clear and precise and that I fully understand every step of the process. Everyone here is really friendly, actually. It makes such a difference—it makes you want to come into work each morning. My colleagues are like a work family, and that makes your job so much better. I think it makes a big difference to the patients, too.

As well as doing any additional scans the surgeon needs during surgery, another major responsibility on surgery days is preparing the drop bags of steroids and antibiotics. The nurse will check these before I give them to the patient, and there are very clear written guidelines that come with the drops, but it’s important that I go through everything in person with the patient to ensure they fully understand the dos and don’ts of their aftercare. Little things can make all the difference: asking how they’re getting home, if they have any allergies, if they have any questions about their treatment or anything else. I am a technician first and foremost, but patient care is also a huge part of this kind of role.

In fact, engaging with the patient through every step of the process is so important. When patients arrive in clinic, I’ll always ask them why they are here, even if I’m confident that I already know, and I will take in as much information as I can from them so I can share it with the surgeon and ensure that we’re all on the same page. It’s also quite common for the patient to be nervous: a laser eye clinic can be a daunting place, especially if you are squeamish about your eyes, which a lot of people are. Even I was a bit wary at first, looking at the internal shots on the scans! Having a friendly approach when patients come in, explaining clearly what each machine does, talking them through what will happen and asking them to let us know if they’re ever uncomfortable at all—all this can help the patient feel more at ease.

This isn’t a nine to five job. Clinics and surgeries can run over, and if the surgeon needs additional scans, I will stay behind to do them. I don’t mind at all—I’m one of those people who likes to be busy and occupied during the day, then just melt when I get home. Before I leave work, I will shut the machines down, tidy up, and get myself organised for the following day: I will look at which

patients are coming tomorrow, make sure we have their files and that their scans are exported. I enjoy it all—it’s actually the train journey home that’s the most exhausting part of the day!

My priority when I get home is Skittles, my pet parrot. He’ll greet me with “hello baby!” and ask for a kiss, so I have to kiss his beak. I live with my family, so Skittles can be out of his cage pretty much all day, and he even has his own little routine: he listens to Kiss radio in the morning, then watches Tipping Point, The Chase and music channels in the afternoon. He eats dinner at the same time we do, and he won’t start until everyone in the family has sat down. He needs to be asleep by 9.30pm, so even if I’m out I have to get home by that time as he can’t sleep until we’ve all said goodnight to him. I don’t think my colleagues here believe how much he can say and how big his personality is, and I want to be able to show them, but every time I try to record him he goes quiet and looks away!

Ophthalmic Consultants of London 55 New Cavendish Street London W1G 9TF 020 3369 2020 oclondon.com

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A SPECIAL RELATIONSHIP

Dr Stephen Cassivi, medical director of Mayo Clinic’s transatlantic partnership with the Oxford University Clinic, on a collaboration that aims to raise the bar for patient care Interview: Viel Richardson

Mayo Clinic is a US-based medical organisation that provides patient care, undertakes research and runs educational facilities. We are best known for our expertise in diagnosing difficult medical cases and devising the often-complex treatments that these conditions demand. Over time, we have developed a reputation for being the place to go when answers are needed to medical issues that have defied explanation elsewhere, or where the symptoms the patient is presenting with are such that you need to get to the right explanation quickly, at the first attempt.

The core of Mayo Clinic’s philosophy is the fact that we are a not-for-profit organisation. All money remaining after operational costs goes back to support our three core principles: patient care, research and education.

This has allowed us to create a patientfocussed, science-based culture that runs throughout the whole organisation. For example, I am a thoracic surgeon, and it is not unusual for me to be operating alongside a neurosurgeon, a gynaecological surgeon and a gastroenterologist in the same procedure. This is a multi-disciplinary approach based on the idea of accessing whatever expertise the patient needs at that precise point in time. This deeply collaborative way of working is in the Mayo Clinic DNA, and it is the philosophy we will be bringing to the new Portland Place facility, which is opening as part of a unique partnership between Mayo Clinic and Oxford University Clinic.

One of the great things about this partnership is that many of the values underpinning Mayo Clinic are also there within the Oxford University Clinic

Every clinical decision we take is evidence based.

Every year at Mayo Clinic we go through the process of refining our protocols— each process is rigorously assessed, based on the outcomes it has produced in the previous year and the application of any new, relevant scientific knowledge

environment. We all have huge respect and reverence for the Oxford side of the partnership—they bring a level of scholarship and research that in my opinion is second to none; they are really at the top of the field. We will clearly learn from our partners at Oxford, but hopefully we are bringing some new knowledge and approaches as well, in an atmosphere of collaboration and friendship.

While Mayo Clinic has research collaborations with other countries, this is the first time we will be supplying patient care outside of one of our US facilities.

At Portland Place we have created a state-of-the-art screening and diagnostic centre with equipment such as MRI scanner, CT scanner, dual-energy x-ray absorptiometry (DEXA), mammography

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and endoscopy. We are also staffing the facility with people who have expertise in our style of ‘executive health’ screening and diagnostics. This is a programme that is not simply about pushing people through the latest scanning technology on fishing trips to see what we can find; it is about evidence-based, individualised risk assessment and scientifically-driven screening of patients.

Every clinical decision we take is evidence based. Every year at Mayo Clinic we go through the process of refining our protocols—each process is rigorously assessed, based on the outcomes it has produced in the previous year and the application of any new, relevant scientific knowledge. Procedures that are no longer valid or have been supplanted are discarded and ones proven to provide a better set of outcomes are adopted. The aim is to produce actionable findings. We want to be able to say to every patient: “This is what we have found, this is what we can do about it.”

Another major benefit of this partnership is Oxford University Clinic’s intimate understanding of the legal, cultural and ethical frameworks of the British medical landscape. As we work on our protocols and procedures for the UK we have excellent guidance as to how to blend what we are bringing from the US with what is expected here. This has been a very collaborative process, which, as well as being exciting and rewarding, has also been a great deal of fun.

Mayo Clinic Healthcare in partnership with Oxford University Clinic 15 Portland Place London W1B 1PT 020 3861 3934 mch-ouc.co.uk Prognosis—25

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1 The field of ENT surgery has plenty to offer OSA patients

Professor Bhik Kotecha Obstructive sleep apnoea (OSA) is caused when some degree of anatomical obstruction in the upper airway—anywhere between the nose and the larynx—occurs during sleep. If this blockage begins to cause oxygen deprivation, the body is shocked into waking up, leading to fragmented sleep.

The treatment recommended by the National Institute for Health and Care Excellence (NICE) is continuous positive airway pressure (CPAP). This requires the patient to wear a mask connected to a small generator, which directs a controlled current of air down into the throat, creating a positive pressure that holds their throat open and allows them to breathe more freely.

CPAP can be very effective, but it is also cumbersome and inconvenient, requiring

SECOND OPINION

What is the long-term solution to obstructive sleep apnoea?

the patient to wear a mask every night.

Around 30-40% of OSA sufferers can’t use CPAP—some can’t tolerate the air pressure, while others find that the mask disturbs their sleep even more than the sleep apnoea. In many such cases, surgery can be the correct path for the patient to take.

I have led a team in developing a system called drug induced sleep endoscopy. This involves mildly sedating the patient to replicate deep sleep, then using an endoscope to examine the upper airway during OSA episodes to identify the cause of the problem and provide site-specific surgical treatment. In simple cases, the patient might have a grossly deviated septum, or their nose may be full of polyps. Some patients have very large tonsils, or there might be a very long, floppy uvula. In some cases, the tongue is the main problem. If particularly bulky, it can fall back into the throat during sleep, causing a serious obstruction.

This is a complex area and the cause is rarely a single issue, so patients with severe OSA will usually need multilevel surgery. This means operating on different parts of the upper airway to solve the various problems. My approach is to start with minimally invasive techniques first, like radio frequency thermotherapy. This uses heat to stiffen

the soft tissue and can be very effective for patients without a severe problem.

Issues like a deviated septum or polyps can require minor surgery. At the other end of the spectrum, reshaping the back of the tongue is a very invasive procedure that requires robotic surgery techniques.

All surgical interventions carry some risk. With more involved cases, the patient can suffer from pain, swallowing difficulty and taste disturbance, and there is a risk of post-operative bleeds and infection, but all those things tend to recover in about three or four weeks. With minimally invasive radio frequency surgery, the picture is much better—patients have far fewer post-operative issues and can be back to normal in a week to 10 days.

Surgery should never be undertaken lightly, but there is a lot it can offer. It may alleviate the need for using CPAP. It mayfacilitate better utilisation of CPAP. And in many scenarios we can cure the problem permanently, allowing the patient to move forward without a need for further medical intervention.

Prof Bhik Kotecha is a consultant at the Royal National Throat, Nose and Ear Hospital and Harley Street Medical Centre and past president of the Sleep Medicine section at the Royal Society of Medicine

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2 We need a cascade of treatments tailored to each individual

Professor Joerg Steier We are at a stage in our understanding of OSA where I don’t think there is a single approach anymore. We now understand much more about different phenotypes— the patient’s set of observable characteristics—and, depending on their phenotype, there are treatments that are better or worse for each individual.

CPAP is the recommended first-line treatment for moderate to severe sleep apnoea, and for mild to moderate sleep apnoea, a mandibular enhancement device—a type of gum shield that brings the position of the lower jaw forward, opening up the airway—should be used.

The international consensus is that unless the patient has a significant abnormality in their airway, such as adenoids or polyps, you should think very carefully before recommending surgery—

the European Respiratory Society’s assessment of non-CPAP therapy was very conservative in advising patients towards surgery, citing a lack of good data from randomised controlled trials. In the 1990s, for example, one widely used surgical intervention was uvulopalatopharyngoplasty, in which tissue in the throat is removed or remodelled to widen the airway. Studies have since shown limited long-term benefits. This was because it is the loss of neuromuscular tone when we fall asleep that causes the airway to narrow, and that happens with a wider airway just as much as with a narrow one.

One recently developed potential treatment involves electrical stimulation—an area I have been working in for some time. Controlled electrical currents can make any muscle contract.

If applied to the upper airway in the correct fashion, they can stimulate the appropriate muscles and reverse the loss of neuromuscular tone, thus keeping the airway open. The challenge is to deliver this at night, without waking the patient.

We have developed a technology called transcutaneous electrical stimulation in obstructive sleep apnoea (TESLA), which involves attaching patches to the patient’s neck when they go to bed,

connecting these to a transcutaneous electrical nerve stimulation device, and using a low-level current to keep the upper airway dilator muscles in tone. We can make TESLA work for single nights in our clinic and have now started a trial to evaluate how well it works at home. The trial is looking to report back in 2020.

Another promising approach works a bit like a heart pacemaker. A sensor implanted in the chest monitors the patient’s breathing and if it senses a narrowing of the airways, it sends a current to a tiny pad placed on the hypoglossal nerve, which contracts the muscle, keeping the airways open. We are now working with ENT specialists—including Prof Kotecha—to bring together the kind of team required to perform this procedure in the UK. In my opinion we need a cascade of treatments. We really are moving into the area of individualised care for OSA, from CPAP through to surgery. I’m obviously biased, but I believe electrical stimulation therapy will have a major role to play, too.

Prof Joerg Steier is professor of respiratory and sleep medicine at King’s College London and a consultant at the Lane Fox Unit, the Sleep Disorders Centre and Guy’s & St Thomas’ NHS Foundation Trust Prognosis—27

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04/07/2019 10:39

THE BIG INTERVIEW The unprecedented president Professor Sir Simon Wessely, the first psychiatrist to be president of the Royal Society of Medicine, on unexplained syndromes, the Mental Health Act, and why the Cartesian divide is located in Camberwell Words: Mark Riddaway

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Soldiers are a tribe alone, and it takes them years before they trust you.

You’re not one of them— you’re the boffin. They call you ‘sir’, but they make it a six-syllable word, loaded with dry contempt

To most people, Denmark Hill is a mundane stretch of road that cuts through the unlovely environs of Camberwell, south London. But the form it takes in Professor Sir Simon Wessely’s telling is something altogether more auspicious. According to him, the A215 is nothing less than a pure manifestation of the Cartesian divide: the separation of body and mind described in the 17th century

by René Descartes, who believed these two essential components of human existence to operate on entirely different planes.

In 1984, Prof Wessely began his career at the Maudsley, the famous psychiatric hospital located on one side of Denmark Hill. When, shortly after completing his training, he was seconded to work as a liaison psychiatrist at King’s College Hospital—an institution located directly across the road and set very much on the bodily plane of Descartes’ formulation—he and one of his colleagues were the only clinicians from these two vast medical establishments who regularly set foot on both sides of the street. “That road was the Cartesian divide, and we were the only people crossing it—not one person from King’s ever came to the Maudsley,” he says. “If you had a medical problem on a psych ward, you either had to deal with it yourself or take the patient over to A&E. That was before they put the traffic lights in, so you could quite easily get killed doing so.”

Prof Wessely’s point—delivered, as all his stories are, at length and with engaging wit—is that psychological medicine, in which field

he ranks among the country’s most prominent figures, has always been a marginalised pursuit, cut off from the nucleus of healthcare by an abiding belief that illnesses of the mind are somehow fundamentally different from illnesses of, say, the kidneys, the heart or the throat. He, though, is not a man who likes to feel constrained. His career has been driven by a conviction that this division is both artificial and unhelpful, that the health of the mind and the health of the body are often inseparable, and that illnesses with a psychological element need to be approached with the same intellectual rigour as those in any other field.

Rather than being two sides of a straight road, the brain and body form a wildly complex spaghetti junction, and it was on some of their many intersections that Prof Wessely made his name. “A lot of the areas I’ve worked on have been on the boundaries of medicine and psychiatry,” he explains.

“There are a lot of disorders that lie in this hinterland—they’re not the great psychoses, but neither are they things that can be uncovered with an x-ray or a blood test, where clearly it’s a physician’s business. They’re sometimes called ‘contested diagnoses’, because in some minds they’re neither fish nor fowl.”

His exploration of this no-man’sland, as he calls it, began with his pioneering—and, in some isolated circles, highly controversial—work on chronic fatigue syndrome (CFS), a condition that appears to have a biological, organic trigger and presents with clear physical symptoms, but which as a direct

result of Prof Wessely’s pioneering research is now treated by the NHS using a form of cognitive behavioural therapy (CBT). In 1993, he completed a PhD in epidemiology, an area in which relatively few psychiatrists have substantial expertise. “That changed my life,” he says. The disciplines involved—the study of populations, the identification of patterns, the application of controls, the awareness of biases, the crunching and recrunching of data—informed his work on CFS and were central to his ground-breaking investigation into another contested diagnosis: Gulf War syndrome.

After the Gulf War, which ended in 1991, reports began circulating of combat veterans displaying unexplained symptoms, accompanied by rumours of depleted uranium exposure, dodgy vaccination programmes and government coverups. “It was obvious to everybody that the MoD were making a balls of looking into it, because they didn’t have any capability in population medicine,” says Prof Wessely, who had noticed parallels between Gulf War syndrome and CFS and was keen to help. Faced by reluctance on the part of the British government (“I went to see the minister for the armed forces, Nicholas Soames, and said, ‘You need to do research— big population research.’ He just said no. He said, ‘In my experience, doing research just makes things worse’”), he managed to secure the necessary funding from the Pentagon to carry out detailed research. “I came back from the States and said, ‘We’ve got the

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Professor Sir Simon Wessely Current posts President, Royal Society of Medicine Regius professor of psychiatry, Institute of Psychiatry, Psychology and Neurosciences, King’s College London Honorary consultant psychiatrist, King’s College Hospital and South London and Maudsley Hospital.

Director, King’s Centre for Military Health Research Director, NIHR PHE Health Protection Research Unit into Psychosocial Aspects of Emergency Response Consultant advisor in psychiatry, British Army Previous posts Chair, Independent Review of the Mental Health Act (2017-18) President, Royal College of Psychiatrists (2014-17) Vice dean, Institute of Psychiatry and South London and Maudsley Trust (2010-14) Professor of psychological medicine (2009-17) Professor of epidemiological and liaison psychiatry (1996-2009)

money now, you’re going to have to help.’

And they did.”

Working with the military had its ups and downs. “On the one hand, it’s epidemiological perfection. We know exactly what the sample is: we know exactly how many soldiers were sent to the Gulf, we know their names, we know their histories. On the other hand, they are a tribe alone, and it takes them years before they trust you.

Nobody is better than the armed forces at saying yes when what they mean is no. You’re not one of them—you’re the boffin. They call you ‘sir’, but they make it a six-syllable word, loaded with dry contempt.”

That contempt has certainly softened over time. “The research went really well and we got really big impacts,” says Prof Wessely.

“We showed that it wasn’t a unique syndrome, but we showed that something had definitely gone wrong in the Gulf, so that guaranteed all the lads their pensions.” While the pattern of symptoms was shown to be normal, the incidence of them was significantly heightened, so something about the operation had clearly gone awry. “We were able to show that the medical countermeasures weren’t to blame, that it wasn’t depleted uranium or smoke from the oil fires, that it wasn’t any of the individual vaccines.” As well as the chance that some kind of anxiety disorder was involved, sparked by the significant and highly justified fear of Saddam Hussein’s proclivity for chemical weapons, Prof Wessely could not rule out the possibility that the rushed and poorly recorded delivery of multiple

vaccines in a short period of time might have played a part. When in 2003, the Iraq War started and “they essentially went and replayed the Gulf War: the same enemy, the same terrain, the same countermeasures”, vaccinations were delivered in a more considered way and the management of information about the health of the troops was markedly improved.

“There was no Iraq War syndrome,” says Prof Wessely.

The unit set up by Prof Wessely to research Gulf War syndrome has since morphed into the King’s Centre for Military Health Research, which continues to provide vital insights into the health and wellbeing of servicemen. “Nowadays, if you’re an academic, you have to show ‘impact’,” says Prof Wessely, and one of the most rewarding things about working with the military is that, if recommendations are accepted by the top brass, a genuine impact can be felt almost immediately. “When we published the first set of results on the Iraq War, we showed that the mental health of our regular forces is actually very good, and the simple act of deploying to Iraq was not associated with an increase in PTSD [posttraumatic stress disorder]. Deploying there was no more psychologically damaging than anything else the forces were doing elsewhere in the world, which came as a surprise to many people. But what we did find was that reserves were having a doubling of PTSD—it had gone up from 3% to 6%. We published in the Lancet in the morning, and in the afternoon the secretary of state stood up and made

a statement saying that on the back of independent research from King’s he was setting up a new programme for the mental health of our reserves.

There was impact.”

There has been impact too from his parallel work on how populations beyond the military respond to severe adversity—in short, much better than you’d think—and what the authorities can best do to help in the immediate aftermath of a disaster.

For example, he has helped shake the received wisdom that providing rapid, single-session counselling to everyone caught up in an incident must be beneficial. “Whether civilian or military, it used to be that within 24 hours a trained counsellor would come along and say ‘How was it for you?

How are you feeling? What happened?’

This was absolutely standard.” The presumption was that having a friendly professional voice asking you how you’re feeling is automatically beneficial. “My colleagues and I would say, why? We were able to show that not only did it not work, it made things worse. Actually, what you should be doing in those first few days is not asking people, ‘What was it like to see someone blown to bits in front of you?’ Well, it was bloody awful, obviously.”

Instead, he says, the best thing that the authorities can do for the mental health of all concerned is focus all their efforts on providing essential practical support: safety, shelter, food and—most notable—communication.

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SIMON SAYS

check they were okay, and the ones who couldn’t get through were more anxious than those who could. No shit, Sherlock.

The surprise was that we followed them up six months later and the ones who couldn’t get through on that first day were still more anxious.” As a remedy against trauma, being able to connect with your family is, Prof Wessely says, much more powerful than any cursory psychological debriefing. “I was really pleased to see when Grenfell happened that the local authority brought in big sacks of plugs, chargers and spare mobiles. That makes an impact.”

Last year, Prof Wessely became immersed in a major project that required him to march rapidly back from the no-man’s-land of unexplained symptoms to a place he calls “the bedrock of psychiatry”: the treatment of people with severe mental illness. The Mental Health Act is an important piece of legislation, one of the key elements of which is the power it gives to the state to ‘section’ people whose mental illness presents a risk to themselves or others.

“Essentially, we have the authority to detain people who have done nothing wrong; they’ve just become very seriously ill. You haven’t killed anyone—you might be at risk of harming someone or more likely yourself, but you haven’t committed a crime, and yet we are still going to detain you against your will” After Theresa May announced a review of the efficacy and fairness of the act, Prof Wessely was tasked with leading it, despite, he says, being “way off the pace in all the areas of psychiatry where the mental health act is used”. In fact, somewhat counter-intuitively, this

lack of experience was one of his main qualifications for the role. “The laws of British political life say that if you want to have an expert review, you have to bring in someone who is not an expert,” he explains. An investigation was carried out to ensure that his ignorance of the workings of the Mental Health Act was as marked as he claimed. “You can see the point,” he says. “If you know a lot about something, you inevitably have views, and nobody could find that I had any views at all.”

After a year spent completely immersed in the subject (“They told me it would be one-and-a-half days per week; it was one-and-a-half days per day!”), during which time he heard the accounts of hundreds of patients and professionals, Prof Wessely certainly has no shortage of opinions now. Those views have formed the basis of a set of recommendations that have been warmly received by most interested parties, including the government, and are highly likely to be implemented in full once the fetid fatberg of Brexit has been cleared from the legislative pipelines.

At the heart of the panel’s report is a desire to reset the balance between compulsion and choice, and in the process make the experiences of patients who need to be detained less uniformly miserable. “What really influenced me was the service users who said: ‘Looking back, I can see why I needed to be detained, I understand that it saved my life, but why did it have to be so fucking awful?’,” Prof Wessely says. He agrees with the premise that it can sometimes be appropriate to deny a seriously ill person their liberty,

Professor Sir Simon Wessely on psychoanalysts I have always liked the idea of the incredible wisdom of the analyst. I think there’s still a huge place for them. When I became president of the Royal College of Psychiatrists, they were becoming an endangered species within the NHS, and I was determined to protect them.

They have very complicated training regimes, really complicated, and they don’t see many patients because they need to see them for an hour a day, and the NHS can’t cope with that. They’re a bit like pandas— quite delightful, but they only eat bamboo and have sex every eight years and then wonder why they’re becoming extinct.

What they are good at though is working with difficult patients because they understand about but he also believes they should have the right to retain as much agency as possible. “Just because you’ve been detained shouldn’t mean you no longer have a choice over anything. We heard ridiculous stories about people not being given a choice of having sugar in their tea—that’s just petty, but it applies to the bigger things too. You should be able to say, ‘I’m ill, but I know that the last time I had that drug I had this awful side effect, so I’d rather not take it.’ Now, we tend to just ignore you.”

The changes recommended in the report should ensure that service users’ views and choices are given more weight. Its aim is that each person be treated as a rounded individual rather than an aggregation of risks, and that every decision taken about their detention

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people—much more than any of my colleagues, including very experienced psychiatrists.

On the mental illness ‘epidemic’ Rates of mental illness haven’t changed, apart from rates of anxiety, depression and self harm in young women aged 16 to 24. There has been no change in the rate of any men’s mental illness, no change in the rate of any severe mental illness, but you would think from the press that we are facing an epidemic, to be blamed on social media.

I’m very concerned about that.

The epidemic may well be in labelling—we have more than enough mental illness already without over-diagnosing it.

colleagues know very well when to use medication, when to use psychological therapies and when to use family therapies.

Medication has a role to play in the treatment of depression or psychosis. It just does. But that does not mean that other things don’t have a role. For example, with eating disorders, family therapy is the treatment of choice. It’s horses for courses.

All the best results come when you combine all three elements.

On medication That ridiculous stereotype— “Oh, you’re all wedded to the medical model”—absolutely gets my goat. Nobody really believes that the only intervention for anything is medication.

Any psychiatrist knows that psychiatry is about the balance of the physical, the psychological and the social. My

On anti-psychiatrists I love that within psychiatry we have people who are ‘antipsychiatrists’, who believe that all psychiatry is damaging.

I don’t share their views, but I like the fact that we have a militant tendency. I will go to their conferences, and as long as they’re not nihilistic or abusive, which to be fair very few of them are, I will happily debate with them. There is a good critical school in psychiatry that is welcome, that questions what we do and makes us think.

I’ve never heard of anything called ‘anti-cardiology’ or ‘antiknee surgery’.

has a clear therapeutic benefit, based on the understanding that locking them up is part of a process not just of safeguarding but of treatment.

When the last review of the act took place in 2000, in the wake of the Michael Stone and Christopher Clunis murders and with the Labour government still seeking to prove its toughness to the popular press, such a humane approach would not have been palatable, but political responses to mental illness have undergone a change in the past two decades. “That review was run by the Home Office; our one was run by the Department of Health—these things tell you a lot,” says Prof Wessely. “Politicians today have the general view that our mental health services should be doing more to help the most vulnerable, not less. And it’s

all parties—this is not a party-political issue.”

Underpinning this change is the ongoing evolution, slow but perceptible, of public attitudes towards mental illness—the growing understanding that the mentally ill are sick people who need care and empathy, not monsters who should be shut away. “People’s attitudes have definitely become more tolerant,” affirms Prof Wessely. “Not as much as you might like to think—we’re only as good as the next Daily Mail headline— but it has improved, particularly with young people. When young people are asked what they think the most important issue for the NHS is, in poll after poll they say mental health.”

The bifurcated world of medicine is also starting to change. In 2017, when

Prof Wessely was appointed president of the Royal Society of Medicine, he became the first psychiatrist to lead the institution since its foundation in 1907 (and, indeed, since the foundation of the RSM’s precursor over a century earlier). “It’s another infinitesimally small straw in the wind,” he says. “Not that long ago, there were people who did not believe— genuinely did not believe—that psychiatrists should be members of something called the Royal Society of Medicine.”

As president of the Royal College of Psychiatrists, a role he fulfilled for three years before moving to the RSM, Prof Wessely spoke at every one of the 37 medical schools in the UK, and he is determined that bright young medics should see psychological medicine as a field with genuine depth and status. “There is still a lingering presumption that most psychiatrists just weren’t good enough to do medicine,” he says. “There are two things people say behind your back: if they don’t like you, they’ll say that you weren’t good enough for medicine; if they like you, they’ll say you’re too good to be stuck doing psychiatry.

Each is demeaning in its own way.

I always say that it’s the other way round: that I’m only just good enough to do psychiatry. It’s the most difficult branch of medicine.”

Even the hard border on Denmark Hill has started to be breached. “It’s different now,” says Prof Wessely. “A lot of my Maudsley colleagues can now be found on the other side of the road.” This same shift is being seen throughout the country, with hospitals showing a growing acceptance of the role that psychiatry can play in improving the health and wellbeing of patients with all sorts of physical conditions.

“We were among the pioneers in putting psychiatrists into all the medical clinics in King’s, but it is a pattern that we are seeing develop across the NHS. If you look at Oxford, probably the leader in integrating psych medicine, they have consultants in nearly all their clinics now, and that is a really positive change.” The Cartesian divide hasn’t gone away, but for as long as he still has a voice, Prof Wessely will keep cajoling his colleagues to bridge it.

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THE DRUGS DON’T WORK The harnessing of antibiotics was one of the greatest medical breakthroughs of the 20th century, but our overuse of these vital drugs means that antimicrobial resistance is now one of the biggest threats to global health. Professor Alison Holmes tells Prognosis what needs to be done to address this looming crisis Words: Viel Richardson Portrait: Orlando Gili

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In 1928, when Alexander Fleming discovered a benzylpenicillin culture thriving in history’s most famous petri dish, he began the process that gave the world antibiotics—a tool for controlling infections that has in the intervening decades completely transformed medicine and saved countless lives. Nearly a century later, however, these vitally important drugs are now losing the battle against bacteria. And if this trend continues, it could prove catastrophic for us all.

Dr Marc Sprenger, director of the Antimicrobial Resistance Secretariat at the World Health Organization (WHO), lays out the problem with a clarity that defies misunderstanding: “Some of the world’s most common, and potentially most dangerous, infections are now proving drug-resistant,” he says. “Antimicrobial resistance (AMR) is a serious threat to global public health. Simply put, if we don’t address this problem now, we will no longer be able to treat common infections in the future.”

Antimicrobials—agents that kill microorganisms or stop their growth—include antibiotics, which target bacteria, and antifungals, which are used against fungal infections.

Penicillin is the most famous antimicrobial, but it is by no means the only one. The whole edifice of global infection control is based on a wide variety of antimicrobials, including aminoglycosides, carbapenems, cephalosporins, tigecycline, glycopeptides and many besides.

Most antibiotics are highly specialised, effective only against specific bacteria. If a strain of bacteria develops resistance to a particular antibiotic, then another drug needs to be developed to tackle it, or else the infection becomes essentially untreatable. The problems is that, according to the UK five-year action plan for antimicrobial resistance, published this year, no new classes of antibiotic have been discovered since the 1980s.

“The pipeline is drying up,” says Professor Alison Holmes, professor of infectious diseases at Imperial College London and a fellow of the Academy of Medical Sciences, who served for nine years as an expert member of the Governmental Advisory Committee on AMR and Healthcare Associated Infection. “Out of about 40 drugs being developed at present, there is only one new antibiotic. There has been this idea that when an antibiotic loses efficacy we

I believe that ingrained cultural pressures are driving over-prescription and we must tackle them if we are to change prescription behaviours.

People think that having a policy is enough.

It is not

will simply develop another one— we believed that there would be a neverending supply of new antibiotics. That faith is proving to have been hugely misplaced.”

Several WHO investigations confirm that the foundations of our infection control edifice are beginning to crumble. The organisation’s Global Antimicrobial Surveillance System (GLASS) published its latest report last year, analysing the incidence of AMR in 68 countries around the world, the findings of which made truly disturbing reading. Resistance to specific antibiotics varies from country to country—in a global version of a postcode lottery, whether some of the most effective weapons against infection we have ever known will cure your illness depends on where the bacteria that infected you originated—but any complacency on the part of those countries where AMR is currently lower can be addressed

by Dr Sprenger’s observation that “pathogens don’t respect national borders”. Taken has a whole, reports from the field the world over are telling the same terrifying story: antimicrobial resistance is on the rise.

The root cause of the problem is clear: the overuse of antimicrobials both in humans and in the animals we eat. “Society needs a whole new relationship with antimicrobials,” Prof Holmes insists. “We have been handing them out like Smarties, and we really need to start treating them as the extremely precious commodity they are. But we have to ensure that this in no way compromises access to these drugs

for those who need them, especially the poorer sections of society.”

She takes pride in the fact that the UK has taken a global leadership role in this sphere: “It has been very impressive. We were one of the first countries to establish a National Action Plan on AMR as early as 2000.” The latest UK plan, which presents a 20year vision for tackling AMR, focuses on three key aims: reducing the need for and unintentional exposure to antimicrobials; optimising use of present antimicrobials; and investing in new ways to supply antimicrobials and improve access to those who need them. The plan sets several shortterm targets, including reducing the number of specific drug-resistant infections by 10% by 2025, reducing UK antimicrobial use in humans by 15% by 2024, and reducing UK antibiotic use in food-producing animals by 25% by 2020.

These are ambitious targets, but they need to be, as the stakes are so high. The WHO estimates that AMR infections cause 700,000 deaths each year globally. That figure is predicted to rise to 10 million by 2050 if no action is taken. This comes with a cumulative financial cost of $100 trillion and threatens many of the United Nation’s Sustainable Development Goals. The World Bank estimates that an extra 28 million people could be forced into extreme poverty by 2050 unless AMR is contained.

The scale of the problem may seem daunting, but from the healthcare perspective it is almost entirely based on a simple and commonplace

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Professor Alison Holmes

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IT IS AN ABSOLUTE IMPERATIVE THAT WE GET OUR ACT TOGETHER. WE NEED POLITICAL LEADERSHIP, ON THE SAME LEVEL AS WE NEED IN THE FIGHT AGAINST CLIMATE CHANGE, AND IT NEEDS TO BE GLOBAL AS WELL AS NATIONAL. THERE IS SO MUCH AT STAKE

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Academy of Medical Sciences Professor Alison Holmes is a fellow of the Academy of Medical Sciences. The academy, based on Portland Place in the Harley Street Medical Area, is an elected fellowship of medical researchers. It has over 1,200 fellows, about half of whom are clinically qualified, the other half being laboratory scientists in a range of disciplines. It is not a major funding agency; it instead seeks to promote excellence in research, influence policy to improve health, promote careers in medical research, and foster links between academia, industry and government.

Its reports tend to review a specific topic related to biomedical science, identify where the gaps are in the research environment, and make practical recommendations for how progress might be made. Funding comes from a combination of subscriptions, donations and government grants.

To support the academy’s work, visit: acmedsci.ac.uk/support

Tackling antimicrobial resistance 2019–2024: The UK’s five-year national action plan (HM Government, 2019)

interaction: a doctor prescribing medication for a patient. As mundane as it may seem, this process is at the heart of the problem. Over time, prescribers have developed something of a dependence on broad spectrum antibiotic medications, designed to tackle several bacteria at once. These are still seen by some as a panacea for a wide range of infections, leading to their over-prescription. But this means that millions of us are coming into contact with antimicrobials that we do not need, increasing the chances of resistance developing.

“What you want to do is target the specific bacteria causing your illness.

We have now become more accurate at identifying specific bacteria and targeting them with the right medication,” Prof Holmes explains.

“There is still a place for these broad spectrum medications. When the patient in front of you is very sick, you want to get to the infection as soon as possible and they are very useful for that. But then it is incredibly important that you do not leave them on that medication. You should test to identify the bacteria present and deliver a highly targeted prescription as soon as possible.”

Prescribing is a complex social process influenced by lots of factors.

Decisions are subject to hierarchies, sometimes controlled by legal procedures and other times by cultural ones. There is precedent and peer pressure. Some doctors don’t like to change a prescription someone else has written, so patients can stay on the same script for years, despite having several doctors. As part of

the UK AMR strategy, NHS hospitals try to ensure that patients get their initial prescriptions reviewed within 72 hours—that is a hugely positive change, but we now need to replicate it in the wider world of primary and community healthcare.

“In order to achieve real change, we have to accept that prescribing is as much a social process as a clinical one, and unless we understand the pressures driving certain prescribing behaviours, we will never be able to change them,” Prof Holmes says, with some passion. “It is very important that we look at supporting clinical decision makers. We need to support them in the decision to use narrower spectrum antibiotics—they need this, as there will be some resistance from other clinicians and public alike. I believe that ingrained cultural pressures are driving over-prescription and we must tackle them if we are to change prescription behaviours. People think that just having a policy is enough.

It is not.”

Around 35% of all patients in hospital at any one time are on antibiotics. When you aggregate the millions of people who pass through NHS hospitals every year, this adds up to a huge amount of medication. As the NHS is a nationwide, interconnected medical institution, once a procedure is identified and implemented throughout the system it is possible to make a serious impact on the general population. It also gives you a wonderful data set to examine, allowing meaningful conclusions to be drawn about how a specific practice is working.

Contained and controlled: The UK’s 20-year vision for antimicrobial resistance (HM Government, 2019) Global Antimicrobial Resistance Surveillance System (GLASS) report (World Health Organization, 2018) Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis Alessandro Cassini etc al (The Lancet, 2019)

“The NHS makes it much easier to share data, share best practice, look at the information together from different fields to see how things are working,” Prof Holmes says excitedly. “Also, to share initiatives and get the feedback from those. But there are challenges in such a large organisation and being a little more joined up would always help.

Things have gone well and we are just moving in the right direction, but there is no room for complacency.”

This summer, Prof Holmes and her colleagues at Imperial College London are hosting a summit that seeks to answer some important questions about antimicrobial optimisation.

Can we use the power of artificial intelligence (AI) to help achieve accurate prescribing very quickly?

How can we analyse huge amounts of data in a way that makes decisions easier for the clinician and more accessible to the patient? When prescribing the same antimicrobial, what is the correct dose for an old woman, a young man or a child? How about if the patient is on steroids or other medications? The aim of the summit is to rethink how our healthcare systems make use of all the advances in technology, biochemistry, drug manufacture, information technology and other advances from within and outside the world of healthcare.

Such a change is going to call for innovative thinking as well as resources, and Prof Holmes is one of those leading the way in this area. “I am very lucky to have been awarded National Institute of Health w Prognosis—39

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AMR: THE PHARMACIST’S PERSPECTIVE Claudio del Duca, superintendent pharmacist for John Bell & Croyden

(NIH) research funding for a project linked to the NHS, as well as Public Health England. I am looking at the issues of antimicrobial resistance and healthcare associated infection.

My role has been to bring together research from different teams to look at the issues. What has been really fantastic is this has enabled me to take a real multidisciplinary approach. It means you can get social scientists and microbiologists working with the people in bio-engineering.”

Prof Holmes believes that this is such a complex problem, you cannot simply look at it through one lens.

For her, it is important that we bring together different fields of expertise and tackle the problem from several angles at once. “It is my belief that we have to develop researchers who are comfortable working with people from other fields. Whether you are mathematical or interested in ethnography, you can all look at the problem together. I absolutely love that. I have talked about using game designers to design really clever, very effective interfaces to help with access and education in medical and clinical matters. These people build user interfaces that get lots of complex information over to players in a quick, understandable and engaging manner, so why not use them to help patients and doctors engage with medical information? The skills and expertise these programmers possess are extraordinary and we should be using that.”

All this leads to an obvious question: are there any alternatives to the

What is your role at John Bell & Croyden?

As superintendent pharmacist, it is my job to ensure that we conform to all the many legal and clinical regulations that apply to running a pharmacy. We have a group of pharmacists and dispensers, all of whom have to work to the highest clinical standards. I have to ensure they follow all the rules set out by the General Pharmaceutical Council (GPhC) and other healthcare bodies.

What part can pharmacists play in helping to fight AMR? For a start, when someone comes in with a cough or sore throat, the pharmacist can advise them about products that are not antibiotics but which will relieve their symptoms while they recover. Often this is better for people too: broad spectrum antibiotics are like an indiscriminate weapon—they will target the bad bacteria but they will also destroy the good bacteria we need. Sometimes, the stomach aches and diarrhoea people get after their medication, or sometimes during the course of medication, have been caused by the antibiotics themselves destroying beneficial bacteria. I always try to educate people about these problems.

How aware of the problem do you find people to be?

Before I was a pharmacist, I was a researcher in pharmacology, so I have always understood the nature of antimicrobial resistance. Generally, I have noticed that people with more knowledge about health matters are

more likely to shy away from antibiotics unless strictly necessary.

I have seen a definite correlation between the level of education about health matters and the desire to take antibiotics or not. Those with an interest are definitely aware that antibiotics are not the answer to everything. They are aware that antibiotics as well as curing illness can be quite damaging. Our customer base here is perhaps a bit more educated in these matters than in some other places, but this is not an economic issue. I have noticed from working as a pharmacist in different areas that people from all backgrounds can have an interest in these matters.

These drugs clearly have their place though.

Antibiotics are a fantastic tool, but they are a tool that needs to be used wisely. You have to remember that our ancestors did very well for thousands of years without antibiotics. There are still parts of the world today where antibiotics are not used as much as they are in the West, and people there still live long and healthy lives. Of course, there are situations where antibiotics are absolutely essential, but I think there is a growing tendency, especially in the West, because of the pace and busy nature of our lives, to feel the need to be at our best all the time.

This translates into the desire for medication whenever we are feeling a bit less than 100%, and antibiotics, because they are so well-known, have tended to be our first port of call if we are feeling unwell. People will often expect to be prescribed antibiotics when they have a virus, which antibiotics have absolutely no effect on.

Are you seeing a growing awareness of AMR among both the authorities and the public?

Yes, I can absolutely say this change has happened from both sides. The government is now focusing on the AMR problem much more than before.

They now have five and 20-year plans, which is great, so we can look at the impact going over a longer time.

They also realise that they need to radically reduce the amount of antibiotics we are using as a whole, and be a lot more proactive.

John Bell & Croyden 50-54 Wigmore Street London W1U 2AU 020 7935 5555 johnbellcroyden.co.uk

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We have to develop researchers who are comfortable working with people from other fields. Whether you are mathematical or interested in ethnography, you can all look at the problem together

antimicrobials upon which we have become so dependent? It turns out that there might be. It seems that immunotherapies can have a role to play. Researchers have been looking at alternative ways to use immunomodulators to help the immune system itself fight off bacterial infections. There is work being done with bacteriophages, commonly known as phages. These are tiny little viruses that can infect and replicate within bacteria, thereby killing them. Some researchers are extremely excited about the possibilities they contain. There is also hope that we may be able to alter the microbiome in people’s bodies to promote our ability to fight infection.

For now, though, despite these promising avenues of exploration, our infection control system remains grounded in the effectiveness of antimicrobials, so our first priority must be to preserve the efficacy of the ones we have. “Antimicrobial optimisation and infection prevention have to be our priorities,” Prof Holmes says. “That means effective use of vaccines and comprehensive infection prevention in all surgery and clinical practice that reduces the possibility of infection—anything that will minimise the need for antibiotics in the first place. We have made good progress in the UK, but there is still a long way to go here, and some other countries are far behind us. A paper led by Alessandro Cassini published in The Lancet in January 2019 stated that the impact of antimicrobial resistance in the EU and the European Economic Area was similar to the impact of HIV and

tuberculosis combined, and the cause of 75% of those infections was healthcare related. That is shocking and needs to be addressed.”

Everyone agrees that a flood of new antibiotics is currently not a realistic prospect, so we need to preserve the efficacy of those we have, and the few that do arrive, for as long as possible. The idea is to stop making the mistakes we have been making for nearly a century. “It is an absolute imperative that we get our act together. We need political leadership, on the same level as we need in the fight against climate change,” Prof Holmes says, with real feeling. “This political leadership needs to be global as well as national. There is so much as stake.

We are making incredible innovations in medicine and surgery. We are developing extraordinary abilities to save and improve lives that would have been science fiction 25 years ago. But it could all fall away if we can’t control infections after operation. You simply cannot do many of the operations we take for granted without effective antibiotics.”

It is a sobering thought. Without widespread and concerted action, the picture for the near future looks troubling. The vast majority of our medical care is underpinned by the antimicrobials given to us after Alexander Fleming’s discovery of benzylpenicillin. If we squander his legacy, we are in danger of returning to the days when the phrase “the operation was a success, but the patient died because of an infection” was all-too commonly heard. Sadly, in some areas of the world this may already be the case.

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A LESS TOLERANT NATION The prevalence of allergies is on the rise in the UK and other developed countries. What is fuelling this modern phenomenon, and what can be done to address it?

Words: Jessica Brown

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Allergy The response of the body’s immune system to normally harmless substances. In most people these allergens pose no problem, but the immune system of the allergic individual identifies them as a’ threat’ and produces an inappropriate response.

Asthma A common lung condition that leads to occasional breathing difficulties, one of the causes of which can be an allergy.

Immunotherapy The ingestion or injection of occasional small doses of an allergen, usually carried out over the course of several years. Also known as desensitisation.

Antihistamines Agents that block the release of histamine, a compound involved in the inflammatory response

In recent decades, the prevalence of allergies among both children and adults in the western world has been steadily climbing. Today, around 50% of children and 45% of adults in the UK have at least one allergy, the total cost of which runs to hundreds of millions of pounds in primary and secondary care and prescriptions.

The obvious question is, why is this happening?

At present, there are several potential answers, but no clear consensus. Probably the most widely cited reason is the bacteria exposure theory, otherwise known as the hygiene hypothesis. This theory suggests that children exposed to poor hygiene in early life, and therefore more frequent low-level infections, have a lower risk of developing allergies, as a result of these infections serving to strengthen the immune system.

Adnan Custovic, professor of paediatric allergy at Imperial College London, says that in addressing this question, it is important that we don’t group all allergies together, as the precise causes for their increasing prevalence are likely to be distinctly different: “It is unlikely that the reasons for the increase in asthma cases are the same as for food allergies or hay fever, although there will be common threads.” But he believes that the hygiene hypothesis is probably an important part of the overall picture.

“This hypothesis makes sense because you can see the huge differences in the proportion of children and adults with allergic diseases in affluent countries compared to lower and middle-

income countries,” he says. “When you go to the latter, you can observe an objective increase in asthma and allergy desensitisation, so it seems to be linked to what I’d broadly describe as affluence.”

The bacteria exposure theory is a complex one to untangle, as in almost all other respects good hygiene and infection control are beneficial to our health. “We don’t want to go back to where we were 100 years ago; we want to have all the benefits of hygiene and vaccinations, but at the same time create ways in which we can expose children in early life to benign microbes,” Prof Custovic says. “We want to get to a position where we have proper balance between being clean and finding beneficial exposures to good bacteria.”

Research suggests that bringing up children in households with pets can be advantageous against developing allergies, but this only works when the children are young. Getting a pet later can indeed be problematic.

“If a child grows up with an animal, it might protect them from allergies and asthma, but if they get one later in life, it may actually predispose them to the development of allergy,” says Dr Chris Rutkowski, consultant allergist and clinical lead for adult allergy at Guy’s and St Thomas’ Hospital and a consultant at The London Allergy Clinic in the Harley Street Medical Area. “There is a window of opportunity when you can teach the immune system to accept things; if you wait too long to get a pet, you can miss this flexible period.”

Aside from the hygiene hypothesis,

another explanation for the recent burgeoning of allergies is our increased exposure to allergens.

For example, the rise in asthma cases might be attributed to air pollution and the extensive use of chemicals in our daily environment, such as fragrances, cleaning products and tobacco smoke.

The same argument goes for the rise in food allergies in the western world in recent decades: we’re simply becoming exposed to more potential allergens than we were in the past, leading to new allergies. “We used to talk about milk and shellfish allergies, now we’re talking about sesame and buckwheat,” says Rutkowski.

“These allergens weren’t prominent in our diets in the past, but they are now— especially in London, where we eat food from all around the world.

We’re simply exposed to more.”

These newer food allergies have been in the media spotlight in recent years, particularly in the aftermath of the death last year of 15-year-old Natasha Ednan-Laperouse, who tragically passed away following an allergic reaction to the sesame in a Pret-a-Manger baguette.

The general rise in food allergies and intolerances can also be partly explained by changes to how food is made and consumed. Since the industrial revolution, food production has come to rely ever more heavily on chemicals, including pesticides, fertilisers, preservatives, colourings, flavourings and sweeteners, which have conditioned our bodies’ responses.

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There is a huge difference in the proportion of children and adults with allergic diseases in affluent countries compared to lower and middleincome countries. When you go to the latter, you can observe an objective increase in asthma and allergy desensitisation

The rise in food allergies isn’t limited to newer foods: from 2001 to 2005, there was a 117% increase in the prevalence of peanut allergy, which is responsible for more deaths from anaphylaxis—constriction of the airways—than any other food allergy. This is partly attributed to parents being more likely to avoid giving children common allergens early in life, in an attempt to minimise risk. Common advice given as recently as 2000 surrounding peanut allergies led parents to avoid feeding peanuts to their children until they were three years old—as well as pregnant women avoiding them during their pregnancy—but this attitude is changing, as researchers now emphasise the importance of introducing babies to small doses of possible allergens at a young age.

“If you introduce peanuts early on, this seems to prevent the development of an allergy, because it presents the immature and malleable immune system to peanut allergens,” says Dr Rutkowski. “If you wait too long, this can promote the development of the allergy. The theory is that you have to do it at some point, and delaying makes no sense.” There aren’t many other ways to prevent the onset of allergies, Dr Rutkowski says, as their development seems to be due to a combination of genetic predisposition and exposure to environmental factors.

However, treatments are moving on quickly, says Prof Custovic. “With food allergies, up until a few years ago the best you could tell someone was to stay away from the food they were

allergic to, which is a rather lousy way to treat disease. Now we’ve moved into desensitisation, which has already been successfully used for hay fever.” The aim of desensitisation is to gradually expose the patient’s immune system to increased levels of allergens through injections or tablets. “The first desensitisation injection for hay fever was administered in 1906 at St Mary’s Hospital, and this has now evolved from injection treatment to sublingual tablets. We’re trying to use the same approach to food allergies, but it’s complex. Feeding people low doses and building up their tolerances still isn’t ready for prime time as there are issues related to safety and how to administer it into the healthcare system.”

Ongoing research into oral immunotherapy treatment for peanut allergies is showing some promise, though, according to Dr Rutkowski.

This method targets T-cells, which act as the immune system’s intermediary between our bodies and the environment, reprogramming them to see the allergen as friendly rather than hostile. Researchers at St Thomas’ and Guy’s have been giving patients small amounts of peanuts and gradually building the dose up, under observation in hospital, to improve their tolerance.

One problem these scientists are yet to overcome is that food allergies tend to come back when treatment stops. “You can make someone who is severely allergic to peanuts tolerate them, but if you stop treatment, they often lose tolerance—and we don’t yet fully understand why. With venom and pollen immunotherapy, you do three w Prognosis—45

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years of desensitisation treatment, then you’re done. But this isn’t the case with food immunotherapy—at least not yet,” says Dr Rutkowski.

Treatments are also increasingly focused on getting to the cause of allergies by targeting different biological pathways, says Dr Rutkowski. For example, rather than just treating symptoms with steroids and antihistamines, new treatments aim to pinpoint specific receptors in the body. The focus now is personalised medicine and more targeted treatment. This includes using component resolved diagnostics, an approach that seeks to identify the specific molecules causing sensitisation or allergy.

Genetic testing, which will allow scientists to determine whether a patient’s genome predisposes them to an allergy, is also on the horizon.

“The question is what we do with this information, as we haven’t yet learnt how to switch the gene off,” Dr Rutkowski says. But some patients, he adds, are probably less concerned with these advances. “Allergies to food, pollen and venom can be completely overpowering. Patients want to be well and might not care that much about the genetic mechanisms—they want effective treatments. Allergen immunotherapy can offer a more permanent solution and it is available on Harley Street as well as in some NHS centres.”

Research is currently underway to better understand how to stop asthma from developing. Professor William Cookson, professor of

If a child grows up with an animal, it might protect them from allergies and asthma, but if they get one later in life, it may actually predispose them to the development of allergy

genomic medicine at Imperial College London, wants to see if the community of microbes that exist in our respiratory tracts, otherwise known as microbiomes, could be responsible for asthma, which affects 350 million people around the world. “If you live on a farm or in an environment with lots of bugs around, you’re protected against allergies and asthma. When you move to cities in western societies, all the bugs in our airways and bowels lose a lot of diversity and good bacteria. Asthmatics seem to have bugs in their airways that live there and probably don’t do damage a lot of time, but which sometimes break through the linings of the lungs and cause disease,” he says. Prof Cookson’s research is homing in on which bacteria are good bacteria. He expects

the research to be completed within the next three years, and to influence medical treatment in the next decade.

“We have to catch the harmful bacteria, grow them in a microbial culture and work out what they’re doing. We’ve been doing this for two years now, and we’re starting to get a good understanding of what’s going on down there. We’re on a clear path towards sorting things out.”

But the often-heard suggestion that rising levels of air pollution in our cities are the cause of the growing prevalence of asthma is apparently misleading. “There are lots of epidemiology studies showing that air pollution doesn’t cause asthma, but it can certainly make the symptoms much worse. Late onset asthma is less understood, but is often diagnosed in people who have been smokers.”

Other ongoing research for preventing asthma includes looking at cocktails of drugs fed to mothers during pregnancy, Prof Custovic says. However, he concedes that this, and any other treatment, might not be applicable to all patients, and more research needs to be done to identify who benefits from any specific intervention. “The most important thing to remember is that the idea that there might be a magic bullet is certainly not the case, and different interventions will be applicable to different people.”

The London Allergy Clinic Lister House, 11 Wimpole Street London W1G 9ST 020 7637 9711 londonallergyclinic.com

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Q+A Shoulder arthroplasty Mr Livio Di Mascio and Mr Adrian Carlos, consultant orthopaedic surgeons at Schoen Clinic London, talk about the challenges of replacing the most flexible joint in the body, and innovations leading to better outcomes for patients Interview: Viel Richardson Portrait: Christopher L Proctor

Talk us through the physiology of the shoulder joint.

Mr Adrian Carlos: The shoulder is a ball and socket joint with very high mobility. In fact, it is the most mobile joint in the body. This tremendous range of movement is due to the glenoid—a relatively small saucer-like socket at the end of the shoulder blade (the scapula)—articulating with the humeral head, which is a much larger ball at the top of the arm (the humerus). The glenoid and the humeral head both have a layer of articular cartilage, which allows the joint to move smoothly.

The difference in scale between the ball and socket means that a lot of muscles, tendons and ligaments have to work together to keep the joint stable, so as well as being highly mobile, the shoulder is also potentially the most unstable joint in the body and prone to damage and dislocation.

What are the most common problems you see?

Mr Livio Di Mascio: Torn tendons due to trauma, dislocations due to instability, and an acquired imbalance that causes pain and abnormal movement. In the older population, we commonly see degenerative conditions like arthritis. These have several causes, such as wear and tear of the articular cartilage or abnormal mechanics in the joint.

This can happen if the tendons are not working properly together. If you have a significant tear in one of them, this leads to an imbalance within the joint, which can cause the development of a secondary degenerative process.

Increasingly often, we are seeing people who have deficient tendons and have developed arthritis.

Is there a component of the shoulder that is particularly susceptible to damage?

LD: The rotator cuff tendons are susceptible to wear or

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Mr Adrian Carlos (left) and Mr Livio Di Mascio

damage. They are the only tendons that arise from the scapula and attach to the top end of the shoulder joint.

They are hugely important in the initiation of motion and maintaining stability. If these are damaged, it can severely compromise joint function and create pain.

time you move your joint, the friction generates millions of microscopic bits of plastic. Those particles are biologically active, and the body reacts to them. In doing so, a process occurs where the joint starts to loosen from the bone. This requires another operation to secure or replace the implant.

What is shoulder arthroplasty?

LD: It is the replacement of damaged or worn-out articular cartilage with artificial articular surfaces. Most modern joint replacement implants comprise of a metal ball—usually cobalt chrome—and a socket made from highly cross-linked polyethylene, which is very hard, high tech plastic.

Do shoulder replacements just provide pain relief?

LD: When I was training, I was taught that shoulder replacement procedures were wonderful for relieving pain, but not for regaining function. That is largely not true anymore. We now have a much greater understanding of how to achieve improved function, and we recognise that achieving good function for the patient is an essential part of a good shoulder replacement. There are now two broad categories of joint replacement: the standard ‘anatomic’ shoulder replacement I have mentioned works extremely well, assuming you have a functioning rotator cuff muscle.

The other type is called a ‘reverse geometry’ shoulder replacement, which can improve functional outcomes when the rotator cuff is damaged.

How are these replacement implants attached?

AC: The implants are inserted into carefully prepared bone. They are then bonded in one of two broad categories: cemented, which means using cement to fix the artificial prosthesis into the bone, or uncemented, in which we initially adhere the implant by using screws, or the shape of the stemmed or pegged portion that is implanted into the bone.

The bone then grows onto and grabs the surface of the implant.

Additionally, implant coating or biologics—hydroxyapatite, for example—can invoke bone growth, increasing the rate at which the bone grows into the implant’s outer surface.

How long will the replacements last?

LD: Some have been in place for more than 20 years, but it really depends on the initial problem and the type of replacement, and how well it has been positioned and fixed in place. The long-term limitations of any joint replacement are often not the materials wearing out, but the development of particulate wear debris that builds up within the joint. Every

What is a reverse geometry shoulder replacement?

AC: As the name suggests, it involves literally reversing the articulation of the shoulder joint. You replace the glenoid—the socket on the scapula—with a sphere and then replace the ball at the top of the humerus with a socket. The technique was first developed as a treatment for irreparable tears of the rotator cuff. The aim was to change the geometry of the joint so it was inherently more stable, meaning that the muscles around the joint, like the deltoid—the muscle responsible for lifting the arm, and for the shoulder’s range of motion—could function more w Prognosis—49

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Implants are getting smaller and smaller, meaning less bone is removed.

We are developing short-stemmed implants, and some are being designed with no stems at all—the implant is fitted straight onto the bone

effectively. This meant the patient went from having an arm that did not elevate at all, to having near-normal function, despite the absence of a working rotator cuff.

It is now quite commonly used to treat shoulder fractures involving the proximal humerus. These are complex fractures which are difficult to fix. Replacing the joint with a reverse geometry shoulder gives good pain relief and the potential for a quicker return of function. But generally it is reserved for older individuals, where the expectation is that fixation of their fracture may not achieve a good outcome, so the replacement of the entire shoulder with an implant that does not rely so much on the rotator cuff and its broken attachments healing may be a better option.

Can you see it being used for all types of replacements?

AC: No. It shouldn’t be. There are plenty of situations where the traditional replacement—which is anatomic, not reversed—works extremely well. We tailor the type of arthroplasty to the needs of the patient. A younger patient will need a different type of implant than an older patient for the same type of problem because for them, longevity of the joint is more important.

will not damage the native cartilage on the remaining part of the joint; something that has properties more in line with that of the native cartilage.

LD: PyroCarbon is a very exciting material to use as a bearing surface. It is hugely biocompatible and very safe and appears to behave in a unique way when articulating with native bone and cartilage. Historically, it was mainly used for joint replacements in the hand, because existing engineering could only make small implants. But in the past 10 years or so, there has been a revolution in engineering that has allowed the creation of implants large enough for us to make a pyrolytic carbon shoulder joint. Its advantage over metal is that its tribology—which is how the material behaves as a joint surface—is probably the closest that exists to native cartilage. It allows a process called boundary lubrication to occur, which does not happen with other materials. The potential for increased use of pyrolytic carbon is very exciting, because it may be a good solution for a shoulder replacement where longevity is a concern. The aim is to remove the need for joint revisions at all in some types of replacement. There is quite a lot of research and development going on in this area.

What other advances have there been?

AC: Material engineering has been an important part of the progress we have made. The materials we build implants from have improved radically. One that we are currently looking closely at is PyroCarbon. This is a specific form of carbon that has been tailored for durability and biocompatibility. Materials like this are better for a procedure like a hemiarthroplasty, where you replace one half of the joint—usually the ball. You need a material that

Other than material engineering, where else are you seeing innovation?

LD: Implants are getting smaller and smaller, meaning less bone is removed. We are developing short-stemmed implants, and some are being designed with no stems at all—the implant is fitted straight onto the bone. The advantage of that is, if it goes into a younger person and they need further operations later on, which is more likely in this age group, there is more bone available to use. This makes the later operation easier.

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

This is a very exciting area to be working in. Because of the nature of the joint there is so much for us to work on and improve. However, the progress we have made since I trained has been transformational

Like in other areas of medicine, 3D printing is having an impact. If a patient’s shoulder has a developmental or acquired bone defect, which can often be the case in revision surgery, you can CT scan the joint and a company will 3D print a trabecular titanium implant that will fit the defect perfectly.

That is a huge advantage in some cases.

AC: Implants are now being designed to be modular.

If someone has been given a traditional anatomical replacement because the tendons were working well, but decades later these tendons fail, the person then has an implant that is no longer fit for purpose. What they now require is a reverse geometry arthroplasty. New implants have been designed so you can change components and convert to a reverse geometry replacement without having to take the whole thing out. This will open up so many treatment possibilities moving forward.

Is there still much to learn?

AC: There is always something to learn. We continuously look at our surgical outcomes and these data are closely monitored by the clinic which gives us and our patients confidence that we are giving them the best treatment.

That’s how we can ensure we get even better.

LD: Absolutely. This is a very exciting area to be working in.

Because of the nature of the joint, there is so much for us to work on and improve. However, the progress we have made since I trained has been transformational. We are much better at replacing joints in ways that both relieve pain and recover a wide range of movement. Our progress has also revolutionised the quality of treatments we can offer young people, with the prospect of a significant reduction in the need for shoulder revision operations in the future.

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Patient experience How Keith’s wedding day was saved by some stunningly succinct back surgery Interviews: Clare Finney

Exactly three weeks before the day I was due to get married, I ruptured a disc in my back, lifting sheep feed. I had to move about 40 bags of the stuff, each weighing 25kg, and I got a bit lazy and complacent when I reached the last one. Instead of bending my knees as you’re supposed to, and as I have done for years, I bent down and lifted it up with my arms. I managed to get it about four inches off the floor before I felt something give in my lower back.

The pain went away five minutes later, and I carried on through the rest of the day as normal, thinking I’d dodged a bullet. Then, later that evening, after coming out of the shower, I crumpled onto the bathroom floor like I’d been shot in the hip and groin.

Fortunately, thanks in part to the previous back surgeries I’ve had, I have a high pain threshold, so I managed to crawl to the bedroom and call an ambulance. They said they’d be four hours—we live in the middle of nowhere —so I drove the 18 miles to our local casualty centre, where I was x-rayed and told I’d pulled a muscle.

I couldn’t believe the pain of a pulled muscle could be that bad. I thought I’d go mad with it—and when it didn’t subside over the next few days, I called

Mr John Sutcliffe, the surgeon at The London Clinic who had operated on my back previously. He said, “If you can get to me, I will look at it.” I fell onto a train, into a taxi, out at Harley Street and into the hospital, where I was scanned immediately. An hour and a half later, I was in John’s office and he was pointing at disc L3 in my back saying, “Look at this massive rupture.”

John sent me home, promising to sort it ASAP—and within 24 hours he was on the phone, telling me about this surgeon called Michael Hess, who is based in Germany and who, fortunately, was free the coming Saturday to fly over to London. Michael was the only surgeon, John said, who could operate on me endoscopically.

This was now two weeks before the wedding, and we were terrified: we’d planned everything, and had guests coming from as far as Los Angeles who had booked flights months previously.

By the time Saturday rolled round I crawled into the clinic—I could hardly walk by this stage—but as usual everyone there was absolutely lovely.

The operation they run at The London Clinic is just incredible. They hold your hand through everything.

After a short wait, the door opened and Michael Hess walked in. He introduced himself to me and my partner, asked me what exactly had happened and carried out an examination. He then began to explain the surgery in great detail, which was brilliant as I am one of those people who absolutely needs to know what’s going on and why. Still, when he told me he was confident that when I woke up the next morning I would be almost back to normal, I just thought, bless your heart. I honestly couldn’t believe that anything would take away that much pain, that quickly. The last back surgery I’d undergone had required me to go through a lengthy period of recovery and rehabilitation. It was unbelievable to me that someone could make the tiniest incision, do all the necessary work and take away all that pain.

Despite my doubts, by the time Michael came to see me the next morning, the pain was reduced by about 90% and I was up and walking. There was a bit of residual pain, as John and Michael had told me to expect—the nerves had been crushed, then released, and they don’t like that—but it was nothing in w Prognosis—53

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comparison to what it had been. For 10 days I hadn’t slept more than 20 minutes at a stretch. Suddenly I was sleeping for a full seven hours. I am still in complete awe and wonder at what they’ve done. John could have given me heavy drugs or an injection to enable me to struggle through the wedding, then carried out a conventional operation later—but he knew how important this was to us, and he knew what was possible. He knew there was someone who could perform an incredible procedure and enable me to walk out like I hadn’t had any surgery at all.

Such was Michael’s level of care, before he went back to Germany he wrote down his landline, mobile and email, and told me I could contact him at any time, day or night. He and John were anxious to stress that while I was feeling good and only a tiny incision had been made, I mustn’t forget I’d had major surgery, so for a while I was so terrified of doing any further damage I was in complete lockdown. I didn’t lift a thing or run anywhere. After about a week, I felt comfortable unloading the dishwasher. Throughout all this The London Clinic was just amazing: I got calls from nurses asking how I was and if I was happy with everything, which from a patient’s point of view was just so comforting and encouraging.

I am so grateful to John Sutcliffe: for finding Michael and for driving this brilliant standard of care. I am just eternally grateful. I hope to goodness you don’t ever have to experience back problems, but if you do, I could not recommend The London Clinic more.

WHAT IS ENDOSCOPIC SPINE SURGERY?

Mr Michael Hess, consultant orthopaedic spinal surgeon at The London Clinic

The intradiscal pressure you experience when you bend forward with a round back and lift a 25kg load is about 2.5 megapascals: that is 10 times the pressure of a normal car tyre, and 500% more when compared to just standing upright. It’s a tremendous load, and unfortunately that’s what Keith put through his lower back when he lifted the very last bag of feed.

Though he had undergone disc surgery before, I really doubt this contributed towards his injury: the surgery he had five years ago was a total cohesive implant of discs two levels below the one that was injured, and the big advantage of such an implant is that it maintains and preserves motion, so there is not an increase of loads on the adjacent discs.

Nevertheless, having had this past experience, Keith knew that the pain

and the numbness in his right leg were not the result of an ordinary muscle tear.

My colleague John Sutcliffe attributed the numbness in the right leg to a specific nerve, and this clinical finding corresponded to the MRI scan which showed a huge extruded disc fragment in the level 3-4, on the right-hand side.

The size and position of the fragment made it difficult to operate conventionally. It was in the foramina, which is the part of the spine between two vertebrae, where the nerves exit to the side and run down to the legs, and this section is surrounded by bone. If the disc herniation is there, the nerve is squeezed against the bone and severely compromised, which is why Keith found the injury so painful. If you were to operate with conventional open surgery techniques, you would have to remove parts of the bone to reach the area, which could cause additional damage.

So, where the lateral, endoscopic approach has a huge advantage is that you don’t need to take away bone because you approach with just a 1cm incision, from the side.

With these techniques, I can operate on 95% of all disc herniations in the lumbar spine that require surgery.

The patient lies prone—it is done with local anaesthesia, not general, which is another advantage—and a canula is inserted in the incision and placed in the foramina, all under x-ray control. Once this is achieved, the optical system is inserted, and under direct view, with a small instrument the nerve is mobilised and the disc fragment is removed. The whole procedure takes about half an hour. Recovery is quick: when I saw Keith just one and a half hours after the procedure, he said the numbness had decreased. By the next day, the pain was 90% better. Removing the fragment had an almost immediate effect.

It is not always such a dramatic improvement. Keith had the advantage that he sought help so rapidly, so his symptoms were there for only two weeks before the operation. Some patients have pain for years and years before treatment, and then it may take several days or weeks for the pain to subside significantly. Still, this technique is beneficial and very doable, even if you’ve been struggling for a long time.

The London Clinic 20 Devonshire Place London W1G 6BW 020 7935 4444 thelondonclinic.co.uk

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Surgeon works through this tube

Cameras and other surgical equipment pass through the tube and are controlled by the surgeon

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STATE OF PLAY How Dr Margaret Lowenfeld, once a shy, alienated child, devoted her life to helping thousands of other shy, alienated children live better, more fulfilled lives through her pioneering play therapies Words: Sasha Garwood

By the time Dr Margaret Lowenfeld, pioneering child psychologist and originator of play therapy, settled down to live and practise in a flat at 92 Harley Street in the 1950s, she had established a reputation as a leading child psychotherapist on two continents. She had also been (among others roles) a house surgeon at the South London Hospital for Women; medical officer for the British Typhus Unit in Poland; a consultant for the Polish Army in the prevention of infectious diseases among prisoners of war; a researcher at the Mothercraft Training Centre; a research fellow at the Royal Hospital for Sick Children in Glasgow; a medical officer for the seminal Peckham Experiment; and perhaps most crucially, had established and expanded the pioneering Institute for Child Psychology (ICP).

Hers was a life driven by a strong belief in the need for research and evaluation in whatever field she worked in. Her residence in Harley Street represented the culmination of a career that had sought to change the way our culture understands children’s emotional needs and means of communication. Famous for her exploration of play as a necessary

developmental process (“Play is an essential function of the passage from immaturity to emotional maturity. Any individual without the opportunities for adequate play in early life will go on seeking them in the stuff of adult life...”), Dr Lowenfeld’s work demonstrated that language was often not the easiest way for children to communicate about important emotions and situations.

Her four original methodologies— the Lowenfeld World Technique, Lowenfeld Mosaics, Lowenfeld Kaleidoblocs and Poleidoblocs— all sought to find new ways of understanding children’s learning, perspectives and worlds.

Although on the surface Dr Lowenfeld’s work was a far cry from her own wealthy London childhood, perhaps her early experiences of unhappiness, divorce and conflict shaped her later insights into traumatised children. She was born in Lowdes Square, Knightsbridge, on 4th February 1890. Her father was Henry or Henryk Lowenfeld, the Jewish son of Warsaw tycoon Emmanuel Lowenfeld, who nevertheless claimed to have arrived in London in the early 1880s “with only $10 [£5] in his pocket”. Even if that were the case, Henry swiftly added

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to it: by the year of Margaret’s birth, he had regained his lost wealth with a vengeance, setting up the Kops Brewery (which exported non-alcoholic beers and ales across the world), and in 1901 becoming a theatrical impresario and building the West End’s Apollo Theatre.

His wife, Alice Evans, was the daughter of a naval captain and devoted her energies to becoming a society hostess, leaving her two daughters mostly to their own devices or the tender care of a nursemaid.

Margaret was not a happy child.

Travelling between a Polish estate, where none of her playmates or carers spoke English, and Victorian London, she was subject to “night terrors” and “screaming fits” from a young age.

She was also frequently ill, and rather than responding with sympathy her mother offered only exasperation: “Is that child ill again?” Already distressed by the emotional absence of her parents and the complex multilingual environment in which she was raised, the young Margaret felt jealous and inadequate compared to her successful and popular older sister Helena (later the pioneering contraceptive activist Helena Rose Wright).

The Lowenfelds’ marriage was not a happy one, and after much acrimony the couple divorced in 1901. Alice Evans was granted custody of her children and responded to her new independence by immediately succumbing to a series of illnesses and becoming strikingly emotionally dependent on her daughters. Fortunately for the Lowenfeld sisters and their medical ambitions and despite her husband’s

opposition, Alice took a very progressive approach to their education. Both girls attended Cheltenham Ladies’ College and then the London Royal Free Hospital School of Medicine for Women in Bloomsbury, from whence Margaret graduated in 1914.

Almost immediately, she took a succession of jobs in London hospitals: the Royal Free, Great Ormond Street, South London Women’s Hospital. Then, in 1919, she left for Poland, her father’s native country, to serve as a medical officer with the British Typhus Unit during the Russo-Polish War. Working to improve conditions for troops and prisoners of war reminded her powerfully of the sense of entrapped despair she had experienced during her childhood, and prompted her to ponder the questions that underpinned so much of her work: how did some children emerge from trauma and horror to survive and flourish, while others were crushed? And how are some humans capable of heinous cruelty to others? In later years, Dr Lowenfeld was to say that her war experience, which included all the catastrophic famine, poverty and deprivation of post-war Poland, “opened doors to an interior world I might not otherwise have reached”.

These experiences also left her sceptical of the power of language as a tool for interpersonal communication.

In addition to her childhood isolation as a young unilingual child in a foreign country, her work as a quadrilingual interpreter during the war underlined her awareness of the inadequacy of language in many situations, and its capacity for creating myriad

misunderstandings and ambiguities.

Confronted with these limitations, she developed a lifelong interest in nonverbal communication that informed a lot of her work.

Falling ill in 1921, Dr Lowenfeld returned to London, and upon her recovery tried to find work as a doctor.

However, many posts were filled by men returned from the war, and her gender still told against her in general practice. Instead, she decided to focus on research into child development, and completed her postgraduate studies at the Mothercraft Centre.

By 1923, she had obtained a Medical Research Council Fellowship to study the relationship between children’s home environments and their experience of rheumatism at the Royal Hospital for Sick Children in Glasgow.

In 1927, she published this research, but by that time she was back at the Royal Free, examining infant feeding and establishing a private practice on Queen Anne Street, Marylebone.

By 1928, though, she had tired of this orthodox research path, and broke away to establish the Children’s Clinic for the Treatment and Study of Nervous and Difficult Children in Notting Hill, then “a district filled with small shops and identical houses mostly full of industrial workers”. Her clinic materials speak directly to concerned mothers: “All children are difficult sometimes, but some children are difficult all the time.

Some children never seem to be quite well. Some children are nervous and find life and school too difficult for them.

Some children have distressing habits.

This clinic exists to help mothers in this

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More than any other child psychologist I have known, Lowenfeld was concerned with the child’s development of sense of self, with his or her body image, with the use of the body to provide metaphors, and with the child’s relationship to life, death, and the universe

kind of trouble with their children, and to help the children themselves.”

In developing this clinic into the pioneering Institute for Child Psychology, Dr Lowenfeld recalled Wells’ 1911 Floor Games, an influence on her in earlier days, and developed it into a therapeutic practice. She collected a “miscellaneous mass of material”, small toys (miniature people, houses, trees, animals, plus fantastic figures like dragons and witches), matchboxes, coloured sticks and shapes, and kept them in a box her clients referred to as the ‘wonder box’. When in 1929 the clinic moved premises, Margaret added two small trays of mouldable sand, and soon her young clients were spontaneously creating sandbox environments and stories both staff and patients started referring to as their ‘worlds’. Thus was the Lowenfeld World Technique born, the miniature controllable spaces enabling children to portray their inner worlds without the inhibiting and enculturated effects of language.

This tallied specifically with Dr Lowenfeld’s clinical observations.

She believed children “think with their hands”, more aware of their immediate environments and sensory experiences than adults. Unlike the majority of child guidance clinics at the time, which focused on diagnosis and then eliminating unconventional behaviours, Dr Lowenfeld’s ICP sought to enable each child to develop their strengths, their curiosity and a sense of inner harmony, using an interdisciplinary and holistic approach incorporating nutrition, neurology, paediatrics, play therapy, physical therapy, and social work addressing the child ’s home environment. Young patients were assigned a random therapist as a “fellow-explorer” and friend, seeking to “work together at the child’s pace” and keep focus on the child’s ‘world’. This differs strikingly from practitioners like Melanie Kline who facilitated transference to a specific therapist. In Dr Lowenfeld’s obituary, Margaret Mead, herself a pioneering anthropologist, wrote: “More than any other child psychologist I have known, [Lowenfeld] was concerned with the child’s development of sense of self, with his or her body image, with the use of the body to provide metaphors, and with the child’s relationship to life, death, and the universe.” Not a bad scope for a technique that starts in a sandbox.

Play in Childhood, Dr Lowenfeld’s first book exploring these theories and

techniques, was published in 1935, and remains influential, particularly in the USA. In the late 1930s, she presented her research to the British Psychological Society, and received a mixed reception.

Undeterred, she continued to develop and expand the ICP, evacuating it to Hertfordshire during World War II and accepting government funding from the NHS upon its return to London.

In 1948 another monograph, On the Psychotherapy of Children, introduced the Lowenfeld Mosaic Test, which used differently shaped and coloured tiles as a diagnostic and therapeutic instrument. At the ICP Margaret also developed Lowenfeld Kaleidoblocs, a psychological test involving blocks of colour, and Lowenfeld Poleidoblocs, a more general-purpose learning tool to introduce children to mathematical principles still in use in primary schools today. All these techniques seek to centre the child’s response in action and provide visible products for analysis.

The ICP became a research centre, certifying practitioners of child psychology, and Margaret Lowenfeld herself built an international profile, travelling between the USA and the UK during the late 1950s and establishing her Harley Street practice. Applicability across cultural divides was a particular focus of Dr Lowenfeld’s, and she collaborated with scholars as far afield as Turkey, Iran, Malaya and Denmark.

In her obituary, Mead described a “whirlwind intellectual atmosphere” in which ‘one enterprise merged into another; each was only partly completed before she was off on a new strenuous undertaking’.

When she eventually retired from active practice, Margaret and her long-time colleague and companion Ville Anderson moved out of London to a house in Cholesbury in Buckinghamshire.

After Dr Lowenfeld’s death in 1973, the Lowenfeld Trust continues to publish and promote her work and techniques, now in collaboration with Cambridge University, which holds the ICP Library.

In the Science Museum, a display cabinet is dedicated to Dr Lowenfeld, and she’s now also at the forefront of the semi-permanent Mind Your Head exhibition. Over a long, eventful and dedicated life, Margaret Lowenfeld had moved from being a shy and alienated child to a well-respected scholar and practitioner, responsible for helping thousands of other shy and alienated children live better, more fulfilled lives.

It’s hard to think of a better encomium.

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MY MARYLEBONE Andrew Barker, CEO, Phoenix Hospital Group

One of the great joys of my job is that I now know so many people: during the short walk between my office and Weymouth Street, I almost always bump into two or three people I know

Work I came to Marylebone in 2001. My background was in the City and I did various jobs with PLCs before joining The London Clinic. I stayed there until 2013, by which time I had come to know a lot of doctors and medical staff in the Harley Street Medical Area. I knew the doctors who set up Phoenix Hospital Group, and they asked me to help with some of their strategic direction. I was excited by the opportunity, I loved this area, and I quickly settled into the business.

Phoenix Hospital Group is quite a unique provider in that, in a market dominated by large hospitals, we remain quite boutique in the way we operate. I’ve been CEO since 2015, and I still find it incredibly interesting and dynamic. My job is joyfully varied: managing key stakeholder relationships, working with doctors to find new and better ways of doing things, ensuring the business

side stays on an even keel, and maintaining the highest possible standards of patient care and quality of service. Healthcare management is one of those areas which, once you’re in it, you’re inclined to stay.

Community The thing with Marylebone and particularly the medical area is it is so villagey. There’s a real sense of community here. When I first started at The London Clinic, Harley Street was quite disparate, so I think it is very important to recognise the excellent work The Howard de Walden Estate has done in bringing the healthcare community together. You can see it in the number of initiatives they have led, from evening networking events at the Marylebone Hotel to arranging a very impressive conference. One of the great joys of my job, having worked here for such a long time, is that I now know so many

people: during the short walk between my office at 25 Harley Street and our hospital on Weymouth Street, I will almost always bump into two or three people I know.

Shop The other joy, of course, is being so close to Marylebone High Street. Again, it has that local feel to it. The mix of big names like Waitrose and The Conran Shop with all the independent and specialist shops has worked tremendously well, and I really like the fact that the high street, Harley Street and their surroundings have such a strong identity. I love Marylebone Lane, where you can go from Oliver Sweeney, to the fish and chip shop, then to Penton’s, the wonderful hardware store.

One particular favourite is the film poster shop, At the Movies. It’s run by people with huge enthusiasm for what they do, and you can just lose yourself in there for hours. Whatever type of film you have an interest in, they can wax lyrical about the posters and the art.

One place that hasn’t changed very much in the time I have been around is Daunt Books. It’s a Marylebone mainstay: what they do, they do very, very well, and they have stuck with it. In a shop like that you can find almost anything for anyone, and a card to go with it, and many, many a gift has been bought from there over the years. On Saturday I’m at a party of a friend who loves Italy, and I know I can go there tomorrow and find him a book in the Italian section that’s a bit different. The other place that has always helped me out with last minute gifts is Ortigia, with its beautifully packaged soaps and toiletries.

Eat I am a fan of breakfast meetings. I like the dynamic, in that you meet early and are away after an hour having had a focused discussion.

I think Marylebone is fantastically well served for that, with places like Le Pain Quotidien at one end of the high street and The Marylebone Hotel at the other. I like the atmosphere in The Marylebone Hotel: it is quiet, but not so much that people could overhear what is being said. I am reasonably healthy when it comes to breakfast—berries, or porridge, which Le Pain does very well. As I go through the day, I like 31 Below for coffees or a bite to eat at lunchtime.

In terms of pubs, I like 1888 on Devonshire Street—I have a couple of good friends I’ve known for years, and we will regularly meet for a quick pint after work there. I like that villagey, local pub feel, and the fact that I will almost always bump into someone I know.

Of an evening, my restaurants of choice are 2 Veneti and Le Relais De Venise L’Entrecote. I use 2 Veneti a lot—the service is good and the Italian food is fantastic. They know me a bit in there, too, so it’s always nice to take guests.

L’Entrecote deserves the queues that sometimes build up. It is excellent. I tend go to with friends or family. I’ve teenage children, and it suits them very well.

Fresh air One of the great joys of Marylebone is that it’s so beautifully located. I walk to and from work every day from Euston station. On the odd occasion I go for a run, I will head from the office up Harley Street toward Regent’s Park, round there, then either come back to the office (making sure no one is watching me), or head to the station. I also like Paddington Street Gardens. If I need somewhere quiet away from the office, I can sometimes be found there catching up on dictation or calls.

I’ve been here 18 years, and wouldn’t want to work anywhere else, really.

It is a joy.

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31 Below Opposite: Daunt Books

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WHAT’S ON MUSIC

FILM

EXHIBITION

THEATRE

THE ST MARYLEBONE FESTIVAL 20th—26th July St Marylebone Parish Church 17 Marylebone Road London NW1 5LT stmarylebonefestival.com

APOCALYPSE NOW: FINAL CUT 22nd August The Regent Street Cinema 307 Regent Street London W1B 2HW regentstreetcinema.com

This impressive programme of music, dance and film celebrates the many artists and musicians who have been connected with the parish of St Marylebone, with profits going towards the conservation and extension of the Grade I listed church.

Highlights include a musical tribute to Judy Garland, whose marriage to Mickey Deans was blessed at the church; a performance of dance, music and spoken word devoted to ballet great Vaslav Nijinsky, who died at The London Clinic; and a jazz concert inspired by legendary New Orleans saxophonist and clarinettist Sidney Bechet, who spent time here in 1922.

Forty years after its original release, audiences will get the chance to experience Apocalypse Now Final Cut, a never-before-seen and newly restored cut of Francis Ford Coppola’s Palme d’Or-winning cinematic masterpiece in a way that the director believes looks better than ever and sounds better than ever. Restored from the original negative for the first time ever, this is the version of his 1979 classic—a haunting journey into madness in the blood-soaked jungles of Vietnam—with which Coppola professes to be most satisfied: a final coda to a famously problemstrewn production.

AN ENQUIRING MIND: MANOLO BLAHNIK AT THE WALLACE COLLECTION Until 1st September The Wallace Collection Manchester Square London W1U 3BN wallacecollection.org

EVITA 2nd August—21st September Regent’s Park Open Air Theatre Inner Circle London NW1 4NU openairtheatre.com

Apocalypse Now: Final Cut

There aren’t too many shoe designers whose work would look entirely at home interspersed between the paintings of 18th century Old Masters, but Manolo Blahnik is one such. This exhibition, co-curated by Blahnik himself, will feature some of the most extraordinary creations from his vast private archives juxtaposed with the collection’s artworks. Throughout his long career, the Spanish designer has openly drawn upon the high culture of Europe’s past, and each room will reflect a particular theme that has provided him

Marylebone’s stunning alfresco theatre will this year close its season with Tim Rice and Andrew Lloyd-Webber’s Evita. Here directed

by Jamie Lloyd, the iconic musical tells the tale of Eva Peron: born into poverty, Eva made her name as an actor in Buenos Aires, where she met her future husband—and later the president of Argentina—Juan Perón. She went on to become a champion for women’s and workers’ rights, dubbed “the spiritual leader of the nation”, but her high profile and outspoken views were not popular with the nation’s powerful generals.

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PACCHERI ALLA NORMA La Brasseria 42 Marylebone High Street London W1U 5HD labrasseria.com

There aren’t many shoe designers whose work would look entirely at home interspersed between Old Master paintings, but Manolo Blahnik is one such

with inspiration, from the spectacle of the commedia dell’arte theatre to the colour and drama of rococo art.

MUSIC THE REGENT’S PARK MUSIC FESTIVAL Until 8th September Regent’s Park London NW1 4NR regentsparkmusicfestival. org.uk Every Sunday afternoon and Bank Holiday Monday until 8th September, the Regent’s Park Bandstand will be playing host to a programme of free musical performances, including concert bands, jazz big bands, small groups and choirs. Highlights include the Fulham Brass Band on 21st July, the Duke Street Big Band on 4th August and Klezmer in the Park on 8th September.

All performances are free to attend, and deck chairs available to hire.

An Enquiring Mind: Manolo Blahnik at the Wallace Collection

Of Marylebone’s most enjoyable pasta dishes

Its name is said to have been inspired by the beauty of the Bellini opera of the same name, and when done well, as it is here, pasta alla Norma can certainly sing. A Sicilian classic, made with tomatoes, fried aubergine and dried ricotta cheese, at Marylebone’s La Brasseria, it is served with paccheri, fat tubes of pasta originating from Campania, rather than the more traditional macaroni, but they hold the rich sauce quite perfectly. Feel the heat of a Mediterranean summer even as it drizzles outside.

CALAMARATA SEAFOOD Fucina 26 Paddington Street London W1U 5QY fucina.co.uk Fucina, which sits at the more refined end of the Italian culinary firmament, serves up this dish of homemade calamarata (thick tubes of calamari-like pasta, hailing from Naples), swimming in a seabed’s worth of yellowtail, clams and mussels. Dotted with Italian tomatoes and small, Ligurian taggiasca olives and sprinkled with basil, while perhaps not traditional, this is a light, summery pasta dish that will brighten the greyest of days.

100 LAYERS LASAGNA The Cavendish 35 New Cavendish Street London W1G 9TR 35newcavendish.co.uk After it first made waves at acclaimed New York restaurant Del Posto in 2010, we’ve been hoping that a version of the monster dish that is 100-layers lasagna would turn up on this side of the pond. Enter The Cavendish, and its seemingly endless layers of silken

pasta sheets, interspersed with meat, parmesan and bechamel—now a firmly established staple on the menu of this elegant Marylebone eatery. Because more is always more, when it comes to pasta.

MANIATIKI Opso 10 Paddington Street London W1U 5QL opso.co.uk Most of us don’t immediately associate Greece with pasta (save, perhaps, orzo), but this is a dish that proves that Italy doesn’t have the monopoly on deeply moreish carbs. We’re not entirely sure what Opso’s ‘village pasta’, as they call it, is inspired by, but it looks a bit like chunky chips and, topped with fried duck egg, brown butter and smoked metsovone—a semi-hard, aged cow’s milk cheese from northern Greece—that only makes us want to eat it more. The result is a bit like a deconstructed Greek carbonara, sans pancetta.

BUTTERED SAVOY CABBAGE RIBBONS, TUSCAN BEEF AND PORK RAGU Caldesi Marylebone 118 Marylebone Lane London W1U 2QF caldesi.com Not strictly speaking a pasta dish, so we’re wary of describing it as such.

But given that Giancarlo and Katie Caldesi are some of the best in the Italian cookery business and have made it their mission to find gluten-free alternatives to pasta after Giancarlo was diagnosed with coeliac disease, we’re trusting them with this one. Besides, buttered ribbons of the freshest savoy cabbage, topped with a rich, slowcooked beef and pork ragu is bound to be delicious, despite the complete absence of dough.

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THE GUIDE

Station and the red telephone box. Dating from 1934, this two-storey house is far more low-key and compact than most of Scott’s architectural work, but no less distinctive.

With its modernism off-set by a classic, symmetrical simplicity, it proved less divisive than some other 20th century interventions, and is widely regarded as one of the area’s jewels.

28-29a Wimpole Street

A tour of some of Marylebone’s most notable houses

2 QUEEN ANNE STREET The word ‘important’ is sorely overused in architecture, but this is one building where the description is quite justified.

Chandos House is perhaps the crowning glory of the storied career of Robert and James Adam, the Georgian architects whose work in the early days of Marylebone’s development did so much to define the area’s aesthetic.

Built between 1769 and 771 as part of a speculative venture, Chandos House is that rare combination of subtlety and splendour: an austere façade of Craigleith stone hides a rich interior adorned with sumptuous plaster ceilings and marble fireplaces. Painstakingly restored in the early-2000s after decades of neglect, it is currently occupied by the Royal Society of Medicine.

28-29A WIMPOLE STREET In the 1890s and 1900s, many of Wimpole Street’s beautifully understated

Worley took every fussy adornment of the Victorian Renaissance— balconies, arches, gables, turrets, pinnacles—and flung them all at this extraordinary lobster-coloured corner plot

Georgian houses were supplanted by more ornate and flamboyant replacements. ‘Flamboyant’ doesn’t even begin to cover the most distinctive of these: the riot of pink terracotta at 28-29a Wimpole Street. Its designer, Charles H Worley, who also designed some marginally less characterful houses on Harley Street and Welbeck Street, was a magpie of an architect whose style seemed to shift rapidly from project to project. Here, he took just about every fussy adornment of the Victorian Renaissance— balconies, arches, gables, turrets, pinnacles—and flung them all at this extraordinary lobstercoloured corner plot.

22 WEYMOUTH STREET 22 Weymouth Street is a rare domestic design by Sir Giles Gilbert Scott, one of the true greats of British design, best known as the creator of Battersea Power

32 WELBECK STREET The run of terraced town houses at numbers 28-32 Welbeck Street, dating from around the 1770s, was built by John White as part of the Portland Estate development. This is classic Georgian architecture at its most beautifully understated: standard four-storey townhouses, slender and elegant, similar yet unique, most of them decorated with little more than a cast iron balcony and a shiny door. One of these houses—number 32—is most remarkable for what sits behind it: a beautiful hidden Russian Orthodox chapel, complete with RussoByzantine dome, built in the mid-19th century when the main house was home to the Russian embassy.

37 HARLEY STREET Harley Street is blessed with no shortage of architectural gems, including 18 Grade II* Listed buildings and dozens more with a Grade II ranking. The most significant buildings are the Georgian townhouses, but while charming, their individual significance can escape the untrained eye.

Amid such understated beauty, the Victorian and Edwardian infills stand out like the loud kids in a classroom of studious high achievers. 37 Harley Street, designed in 1899 by Arthur Beresford Pite, with its fancy slate roof and sandy-coloured stone is the true class clown, with its Baroque details and showy use of sculpture.

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