Prognosis issue 8

The periodical of the Harley Street Medical Area Issue 08 / 2021

The good, the bad and the ugly The factors that contributed to COVID running rampant, and the vaccine successes that should bring it under control The big interview Professor Roger Kirby, president of the Royal Society of Medicine Patient experience How Deep Brain Stimulation freed a patient from years of constant pain Second opinion Should the UK introduce an opt-out organ donation system?

One-stop heart and lung care for your patients.

Every day, private patients are referred to our hospitals for the exact same reason: to be seen by the world’s leading experts in heart and lung care.

Whether it’s to seek an expert opinion or arrange diagnostic testing, we work closely with health professionals to facilitate the best patient care quickly and easily.

Short-notice video appointments with our consultants are available so that your patients can access the care they need during this time.

If your patient prefers, in-person consultations are also available, and we offer a range of tests at 77 Wimpole Street which can be scheduled on the same day.

Tests available include: — CT (cardiac, lung and general) — Echocardiography (transthoracic, stress and contrast-enhanced) — Lung function (spirometry, gas transfer, lung volumes and end capillary blood gases) — MRI (cardiac and general assessment) — Non-invasive cardiology (exercise testing, ECG, pacing and holter monitoring) — PET-CT (including Rubidium cardiac imaging, oncology and neurology) — X-ray — Sleep studies

77 Wimpole Street | Royal Brompton Hospital | Harefield Hospital To find out more, or to refer a patient, please contact the customer services team on +44 (0)20 3131 0535 or email privatepatients@rbht.nhs.uk

Prognosis is owned by The Howard de Walden Estate 27 Baker Street London W1U 8EQ 020 7580 3163 hdwe.co.uk Estate contact Annette Shiel annette.shiel@hdwe.co.uk

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42 A healthy heart How the Harley Street Medical Area has become a global healthcare hub of sufficient reputation to draw one of the USA’s most influential clinics into its ranks

Publisher LSC Publishing 020 7401 2772 lscpublishing.com Editorial director Mark Riddaway mark@lscpublishing.com Editor Viel Richardson viel@lscpublishing.com Deputy editor Clare Finney clare@lscpublishing.com Managing editor Ellie Costigan ellie@lscpublishing.com Advertising sales Donna Earrey donna@lscpublishing.com Contributers Sasha Garwood, Orlando Gili, Julia Price, Christopher L Proctor, Kaite Welsh Design and art direction Em-Project Limited 01892 614 346 mike@em-project.com

Prognosis—1

4 HSMA update Julian Best, executive property director at The Howard de Walden Estate, on how the Harley Street Medical Area has responded to the challenges of the past year 6 Crystal ball How platelet-rich plasma therapy will evolve in the coming years 8 How does it work?

Optical coherence tomography 10 Thinking aloud The thoughts of Dr Dejan Dragisic of Wimpole Street Private Dental Clinic 12 Profile of a pathogen Marburg virus 14 Best of both worlds Shams Maladwala of The Royal Marsden Private Care, on the Trust’s integrated model of private and NHS care 16 Second opinion Should the UK introduce an opt-out organ donation system?

18 The big interview Professor Roger Kirby, president of the Royal Society of Medicine 24 The good, the bad and the ugly The factors that contributed to the COVID running rampant, and the vaccine successes that will hopefully bring it under control 34 Patient experience Sean Cannon on how Deep Brain Stimulation freed him from years of neuropathic pain 38 Stronger together A rehabilitation and treatment programme that bridges the gap between doctors and fitness specialists 42 A healthy heart How the HSMA has become a global healthcare hub

50 Harley Street hero Sophia Jex-Blake 52 A day in the life Dr Paul Ettlinger, founder and lead clinician at The London General Practice

This job is a combination of academic work and practical work. You are constantly learning, constantly developing.

You get to meet new people all the time, and we work in a team.

It’s a great job.

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Dr Dejan Dragisic of Wimpole Street Private Dental Clinic

2—Prognosis

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Prognosis—3

HSMA UPDATE

Julian Best, executive property director at The Howard de Walden Estate, on how the Harley Street Medical Area has responded to the challenges of the past year

Welcome to the latest issue of Prognosis, which, for reasons that hardly need explaining, is being distributed as a digital magazine only: just one small example of the adaptations demanded by the current circumstances.

As we all know, the past year has been incredibly difficult for people all around the world, and while the vaccine programme is providing some light at the end of the tunnel, it is clear that the months and years to come will also have their challenges. The Harley Street Medical Area (HSMA) is a global healthcare hub and as with our friends and colleagues across the globe, many of our practitioners were hit hard by the effects of the coronavirus pandemic.

The first lockdown was particularly difficult. This was especially the case for those practitioners such as GPs, dentists 4—Prognosis

and physiotherapists whose work, which requires close contact with their patients, meant that they reluctantly had to close their doors. The professional bodies which set and oversee the guidelines governing such fields needed time to design new workplace protocols to keep patients and clinicians safe. This meant that it was several months before the practices were allowed to re-open— a very tough period for patients and doctors alike.

By June and July, once new protocols had been established and supplies of PPE were less erratic, these practitioners began to welcome patients back in relatively high numbers. While the following lockdowns have been challenging, most clinicians have been able to continue serving their patients, which has been a real credit to their hard work and determination.

The situation has been very different for the hospitals in the HSMA, many of which ended up supporting the work of the NHS during the first lockdown.

With their international patients traveling here for treatment in far smaller numbers due to the travel restrictions, these institutions were able to place the spare capacity this created at the disposal of their NHS colleagues. They all found this to be a very rewarding experience, with the partnerships they developed with individual NHS hospitals working extremely well. Even after the initial contracts had run their course, institutions like The London Clinic, HCA and Schoen Clinic London—which relocated a significant amount of its technical equipment to the Nightingale Hospital at ExCeL in the Docklands— have continued to work with the NHS to help in any way they can. As well as treating non-COVID patients, there is a considerable job to be done to tackle the backlog of diagnostic and medical procedures that have had to be postponed during the crisis. These partnerships have revealed a real collegiate spirit between the public and private institutions, which it has been wonderful to witness.

The Howard de Walden Estate is at heart a property company, and one of the small ways in which we have tried to play our part is in the area of key worker accommodation, which was offered to some staff employed by HSMA hospitals.

It started with eight applications granted last year and another seven to be rolled out this year under quite strict criteria. We contact eligible institutions

letting them know that we have some residential apartments available to key workers at a substantial discount on the market rate. They go through an internal selection process to identify workers they think are eligible and then pass their details to us. A lot of frontline staff such as nurses and porters live a long way from where they work and are often working very long hours or finishing late at night. So, if we can provide some accommodation for them closer to their place of work, then it seemed like a worthy thing to do. It is an area we will continue to look at in the future.

Elsewhere, while some of our existing plans have been delayed—such as the arrival of Cleveland Clinic’s new consulting suite, which will now open in September this year—there have been some new additions to the area. For example, we have taken a listed building at 73-75 Harley Street and turned it into a multi-disciplinary consulting house with 25 consulting suites working in a variety of specialisms.

Something else we are looking very closely at is the area’s current lack of step-down medical facilities: dedicated rehabilitation facilities for post-operative patients who no longer need to be in hospital but still need a little extra help as they recover.

A residential facility that provides high quality clinical care and advice is something we know would be welcomed by both patients and their families to help with the transition back into normal life.

One very exciting project we are in the very early days of working on is the development of some space for a life sciences facility. This is an extremely interesting and dynamic field, which we believe would complement our primary healthcare services very well. A lot of our consultants teach and undertake research alongside their practices. There is still a lot of work to do but I think it would be wonderful to have life sciences as part of the HSMA offering.

Despite the challenging time we are all going through, The Howard de Walden Estate continues to look towards the future, thinking of ways to improve the HSMA’s healthcare offering. The success of the vaccine rollout has given us a route back to normal life and while that may look a bit different to the preCOVID world, there are some exciting projects in the pipeline to ensure that this continues to be one of the world’s leading diagnostic and treatment centres.

tbc

Prognosis—5

In years to come, we will be using blood-derived products in much more sophisticated ways. Better imaging technology combined with huge datasets will lead to a much better understanding of how to use biologic treatments like PRP

CRYSTAL BALL

Platelet-rich plasma therapy Mr Nima Heidari on the evolution of a treatment with huge untapped potential

State of play Platelet-rich plasma (PRP) is an incredibly useful substance that we get after separating blood into its different parts. It contains a huge number of different substances, mostly protein based, among which are small cells called platelets. When blood clots after a cut, these platelets play a key role in the formation of the clot, which does far more than simply stopping the bleeding. Parts of the healing process are initiated by clot formation, as it releases chemicals which trigger the formation of new muscle and skin.

With PRP, we harvest these platelets and inject them into areas where we want to either boost the healing process, or to re-initiate it when things have stalled. This can happen in areas where the blood supply is poor, such as tendons 6—Prognosis

and ligaments. We can also use this material to relieve the symptoms in parts of the body with degenerative conditions such as arthritis. In fact, we know that PRP treatment is very useful, particularly in the early stages of arthritis, to help to repair some of the damage that has occurred within the arthritic joint.

These are just a couple of the many different ways you can use plateletrich plasma at the moment.

On the horizon I think that changes in the area of diagnosis will have a huge effect on the use of PRP treatments. I specialise in the foot and ankle and since developing an interest in joint preservation, working with arthritic patients has really shown me what an incredibly varied disease it is. There are 22 bones in the foot alone, meaning that a large number of moving parts are anatomically very close to each other. Then there are the multiple forms of tissue, such as bone, cartilage and ligaments. Any one of these may be the cause of the patient’s pain. As we get better at identifying which one is affected, it may be that you treat different patients very differently, even though they all have the diagnosis of ‘arthritis’.

In some cases, PRP is the most effective treatment, while in others a different treatment modality is better.

For example, companies are developing products—some are already here— called ‘conditioned serums’. This is where you tailor the ratio of the substances within the plasma to achieve specific aims, such as relieving pain in arthritic joints.

In the distance In years to come, I think we will be using all blood-derived products in much more sophisticated ways.

Better imaging technology combined with better use of the huge datasets that clinicians are in the process of building will lead to a much better understanding of how to use biologic treatments like PRP. There are a huge number of substances contained in blood and for many of them, we don’t really understand their full functions or the potential they contain. The more research we do to find out about them, the greater the treatment possibilities will be.

Genetics also plays a role in this.

Twenty per cent of individuals are what we call ‘non responders’ for PRP and other biologic therapies, while another 20% are ‘super responders’.

We need to really understand what makes the super responders respond to these treatments so well. Is it something about individual genes, the nature of the disease being treated, or the biologics that we use? Can we learn things from these cases that we can use to help the non-responders?

At the core of all this will be an everincreasing understanding of the nature of platelet-rich plasma and other blood-based products—both in their constituent parts and the ways we as clinicians can use them to help our patients.

The Regenerative Clinic 18-22 Queen Anne Street, London W1G 8HU 033 0223 3332 theregenerativeclinic.co.uk

The Howard de Walden Estate are proud to support the UK Healthcare Pavilion. ukhealthcarepavilion.com A first of its kind virtual platform which acts as a front door to showcase the very best of UK Healthcare and Life Sciences.

Howard de Walden is the guardian of Harley Street Medial Area (HSMA). A collection of Marylebone-based hospitals, clinics and specialists, renowned for their outstanding patient care, pioneering treatments and use of cutting-edge technologies. hdwe.co.uk

harleystreetmedicalarea.com

HarleyStreetMedicalArea @HarleyStMedArea

Unlike sound waves, which can penetrate deeper into human tissue, light waves are really only transmissible when the structure is largely transparent. For example, there is a structure called the retinal pigment epithelium, a dense layer of cells that regulates the transport of nutrients and waste products to and from the retina.

While it is very reflective, we can still see some details behind it. But then we have a structure called the choroid. This is intensely infiltrated by blood vessels and represents a kind of barrier. Some devices using longer wavelengths and higher energy levels can get a bit below the choroid’s surface, but not very much.

HOW DOES IT WORK?

Optical coherence tomography Consultant ophthalmic surgeon Mr Shafiq Rehman on a technique that has revolutionised retinal medicine Interview: Viel Richardson

8—Prognosis

Optical coherence tomography (OTC) is a technology that allows us to image various parts of the eye using electromagnetic radiation—light—and to see its internal structures in exquisite detail. The eye is particularly well suited for this type of scan as the cornea, a natural lens, allows light to enter the eye in ways that are well understood.

The scanner first projects a beam of light into an optical splitter, which divides the beam into two streams.

One is a reference stream, allowing the scanner to precisely analyse the phase of the beam projected; the other stream is sent to the eye. These electromagnetic waves go through the cornea, hit the retina and bounce back.

The key to OTC is that each returning wave arrives back at the scanner modified in a slightly different way depending on the properties of the structure it encountered. This means the returning waves will have slightly different phases to the ones they had when projected. The scanner records and analyses these changes in phase, in relation to the reference beam, to create an initial map of the structures the light waves encountered in the eye.

These are then fed through very sophisticated computer algorithms which interpret the information and create an artificial image, which is a reflection of the real structure of the retina. This type of scanning can be incredibly detailed, highlighting features almost down to the cellular level. Some of the machines can see structures in the eye that are only 3-4 micrometres across. To give you a sense of what that means, a red blood cell is about 7-8 micrometres in diameter.

It is important to stress that OCT scans are not diagnostic in themselves, unlike those produced by some other scanning technologies. We still rely on clinical examination, talking to the patient and running other tests, but OCT is an absolutely core part of the evaluation of a patient.

If I see a patient in their seventies with deteriorating eyesight, such as blurring and distortion of images, there is a strong possibility that the patient is suffering from dry or wet macular degeneration. Dry macular degeneration is basically wear and tear.

Like with any other part of the body, tissue in the eye can atrophy as we get older and lose some of its effectiveness.

Wet macular degeneration is very different. Here, abnormal blood vessels grow through the retinal pigment epithelium behind the retina. These blood vessels then explode, causing bleeding and scarring which can lead to a very rapid deterioration of the patient’s vision. They can go from having normal eyesight to very poor eyesight within a matter of days. This type of macular degeneration clearly needs to be addressed as quickly as possible. OCT scans are extremely good at differentiating between those two types of macular degeneration, making it an absolutely essential tool.

Another condition this technology helps to diagnose well is a macular

Macular Part of the retina with a very high concentration of photoreceptor cells, responsible for the the fine vision required for reading.

Choroid A highly vascular, pigmented tissue which covers most of the eye behind the retina.

Diabetic retinopathy A complication of diabetes where high sugar levels damage blood vessels in the light-sensitive tissue at the back of the eye which make up the retina.

Optical coherence tomography

REFERENCE BEAM

REFERENCE BEAM

Reference mirror

Optical splitter

DIAGNOSTIC BEAM TO EYE

DIAGNOSTIC BEAM FROM EYE

Patient

Light source REFERENCE BEAM

DIAGNOSTIC BEAM FROM EYE

Detector

The key thing about optical coherence tomography is the way it is increasing our understanding of the pathophysiology—the physiological processes— associated with these conditions.

edoema, a very specific syndrome which is part of a complex disorder called diabetic retinopathy. With macular edoema, fluid accumulation in the retina leads to swelling of the macula, the central part of the retina. When a person looks at an object, the image falls onto the macular, so any changes in the macular structure will have a significant impact on the person’s visual acuity. OCT technology is not only good at highlighting this, but it can also measure the level of swelling, allowing us to quantify the syndrome’s progress. This allows us to develop age and genderbased normative reference databases, against which we can compare a patient’s condition. These images let us see the impact our treatment is having on those swellings and therefore how successful the treatment is being. This really helps

personalise the treatment we can offer.

One of the really exciting things about OCT is that it allows us to treat conditions we could not treat before. For many years a condition called vitreomacular traction syndrome (VMT) was extraordinarily hard, if not impossible, to spot. The vitreous gel is a sort of inert structure sitting in the space between the cornea and the retina. As we get older it can partially pull away from the retina. This is known as posterior vitreous detachment (PVD) and it is extraordinarily hard to visualise, and therefore diagnose, with the naked eye. In a patient with symptoms of mild vision disturbance you can spend three or four minutes examining the area in detail through a microscope and see little or nothing suggestive of PDV. On an OCT scan, it stands out very clearly, looking like a separate line that is pulling the retina forward. This means we can diagnose VMT quickly and accurately. Fifteen years ago we could only postulate a diagnosis. We could asses the symptoms and surmise that the patient may be suffering from VMT, but we could not be absolutely sure. Now we can even chart the effectiveness of any treatment in real time. It represents remarkable progress.

Another condition we can now diagnose and treat quickly is called a macular hole. Again, it can be quite hard to see a very small macular hole as it is starting to develop, but on OCT it’s immediately obvious. You can see the altered structure and decide how to manage it very early in the process.

Each one of these is a wonderful advancement, but the key thing about optical coherence tomography is the way it is increasing our understanding of the pathophysiology—the physiological processes—associated with these conditions. We now understand much more about the mechanisms by which these conditions develop and progress. This means we are better informed about how to manage and treat them.

It’s remarkable how much OCT has revolutionised the field of treating retinal disorders. Fifteen years ago, OTC scanners did not exist; now there isn’t a department in the country that would want to work without one.

Optegra 25 Queen Anne Street London W1G 9HT 020 7509 5400 optegra.com Prognosis—9

THINKING ALOUD

Dr Dejan Dragisic Oral surgeon at Wimpole Street Dental Clinic Interview: Ellie Costigan Portrait: Christopher L Proctor

The training to be an oral surgeon is long—it took me 11 years—so you need to like it, particularly as there’s not much else you can go into afterwards! I started in dental school, then did almost four years of medical school as well before going into specialist training. That was more than 20 years ago. I’ve never regretted it.

Medicine is in my blood: the wider family includes dentists, vets, a gynaecologist, a paediatrician, and my brother is an ophthalmologist.

I grew up with it.

I offer specific types of treatment that a lot of dentists don’t do. I’m lucky because I get these patients referred to me. We have several hundred practitioners in the Harley Street Medical Area, so there is a really nice exchange. If I have a patient who needs a filling or a crown, I know where to send them to get really good treatment.

Google can be dangerous. Patients form an opinion before they come in sometimes, which is quite often misleading, so I prefer when they don’t know much about the treatment we are going to provide. We can always point them in the right direction, give them links to good literature, to publications and peer-reviewed articles.

Treatments have changed a lot in the past 20 years, though not always for the better. It has become more financially driven. There’s much more cosmetic treatment, which is something I’m not involved in. I think the biggest advance has been in dental implantology, which has got better and safer. Knowledge and seminars are more accessible too, because of digitisation.

This job is a combination of academic work and practical work. You are constantly learning, constantly developing. You get to meet new people all the time, and we work in a team.

It’s a great job.

The mouth is an intimate area. Because of that, dental work or surgery can cause anxiety for a lot of patients.

Much of my work is invasive and can be unpleasant—extractions and cyst removals, implants—so you need to guide the patient psychologically. It can be intense: I talk a lot during treatment, to reassure patients.

It was always the plan to set up a practice in Marylebone. The buildings in Marylebone are beautiful. It’s also central, which is useful for patients as they come from both within and outside London, as well as abroad.

We were lucky; the practice that we acquired about six years ago was in a terrible state, so we could design it the way we wanted to.

Patients expect a high level of service and that begins with our reception and our nurses, how they talk to patients, how they explain things, how pleasant the waiting room is—even the smell of a surgery. Music is an important factor, as is making sure that you don’t make people wait. I like to get my patients in straight away.

We had to close in March last year until June, which was a disaster.

It has created a lot of problems because patients didn’t have any access to dental and medical treatment, so certain conditions we could’ve treated with simple intervention have become much more major. Since re-opening, it has been full-on.

10—Prognosis

Wimpole Street Dental Clinic 55 Wimpole Street London, W1G 8YL 020 3745 7455 wimpolestreetdental.clinic Prognosis—11

PROFILE OF A PATHOGEN Marburg virus

12—Prognosis

This is one of those viruses that keep people awake at night. The Marburg virus (MARV) causes Marburg haemorrhagic fever (Marburg HF).

Haemorrhagic fevers cause the patient to bleed profusely from the body’s orifices and Marburg HF is an extremely severe form. Though the first known crossing of the virus from animal to human was via monkeys, the host of this particular virus is the African fruit bat, Rousettus aegyptiacus, which show no obvious signs of illness when infected.

Marburg HF is a filovirus belonging to a group of viruses called Filoviridae, which cause severe haemorrhagic fever.

It is fatal in both humans and nonhuman primates. So far, three genera of this virus family have been identified: Ebola virus, Cueva virus and Marburg virus.

It was first encountered in Germany and

Haemorrhagic fever A general term for a severe illness, often associated with bleeding, that can be caused by a number of viruses.

Barrier nursing A set of stringent infection control techniques used to protect medical staff against infection by patients.

Blood clotting factors A group of proteins found in the blood that are essential to blood clot formation.

part of Yugoslavia, which is now Serbia, in August 1967. Thirty-one people were admitted to hospitals in Marburg, Frankfurt and Belgrade, suffering fever symptoms. The first patients were laboratory assistants who had been handling African green monkeys imported from Uganda but were soon followed by some of the medical personnel and family members who had cared for them.

The hospitals soon determined that they had a type of haemorrhagic fever, but every test for pathogens known to cause the disease returned negative.

Clinicians realised they were dealing with an unknown virus and after seven of the 31 died, the investigation was moved to more specialised laboratories.

One of two Marburg viruses, A and B, that cause illness in humans, was

isolated in November the same year.

The incubation period is between five to 10 days, with the first symptoms being a high fever, chills, headache and muscle pain. At around the fifth day, when most people would expect to start feeling better, another raft of symptoms begin to arrive. These include a maculopapular rash, which looks like red bumps on a flat red patch of skin, nausea, vomiting, abdominal pain, chest pain, a sore throat, and often diarrhoea. The symptoms become increasingly severe and can include jaundice, inflammation of the pancreas, severe weight loss, delirium, shock, liver failure, multi-organ dysfunction and the massive bleeding from various parts of the body that gives this kind of fever its name.

The main mode of transmission is through person-to-person contact, which can happen in several ways: direct contact to droplets of body fluids from infected people or through contact with equipment and other objects contaminated with infectious blood or tissues. Historically, the people at highest risk include family members and hospital staff who care for patients infected with Marburg virus, often without the proper barrier nursing techniques available to them. Particular occupations such as veterinarians and laboratory or quarantine facility workers who handle non-human primates from Africa may also be at increased risk of exposure to MARV. The nature of the disease means that the mortality rate is very dependent on where you are when contracting the disease. Modern medicine is very good at keeping very sick people alive and eventually returning them to health.

Even so, with the best care delivered in a timely fashion, the mortality of Marburg HF is 30%, which is high. However, in cases of poor care—or none at all— mortality rises to 90%.

The problem is that there is no specific treatment for Marburg haemorrhagic fever. All clinicians can do is support the body through the worst of the disease through processes like balancing the patient’s fluids and electrolytes, maintaining oxygen levels, keeping blood pressure stable, replacing lost blood and blood clotting factors, and treating any complicating infections.

Experimental treatments are showing some promise in non-human primate models, but as yet none have been tried in humans. Marburg haemorrhagic fever remains, for the foreseeable future, an extremely distressing and dangerous disease.

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ww A healthy heart Julian Best of The Howard de Walden Estate and Dr Brian Donley of Cleveland Clinic discuss how the Harley Street Medical Area has become a global healthcare hub of sufficient reputation to draw one of the USA’s most influential clinics into its ranks

Prognosis—13

BEST OF BOTH WORLDS Shams Maladwala, managing director of The Royal Marsden Private Care, on the Trust’s integrated model of private and NHS care and its new Cavendish Square facility Interview: Ellie Costigan

I have been with The Royal Marsden Private Carefor nearly seven years now.

As managing director of private care, I‘m responsible for the governance and management of private patients within the framework of the Trust, including operational, clinical and commercial aspects.

We have an integrated model; it’s the best of both worlds, private and NHS. In practical terms, it means we have distinct areas within the Trust—the NHS side and the private care side—but it is very much a symbiotic relationship. There are also areas that are shared between NHS and private patients, such as surgery and the ICU. It is much more efficient and a betterquality experience to have a shared resource for these clinically key areas.

The integrated model works on a number of levels. It works for patients, most importantly, because they get the safety assurance and governance that is so important in private healthcare. It works for sponsor groups, insurers and embassies, because they are assured that whatever pathway is taken, it will be evidence based. When drugs are prescribed, they are prescribed within the context of a multi-disciplinary team. It works for consultants, because they can carry out their private and NHS practice within the confines of one organisation, alongside the Trust teams they’re used to working with on a day-to-day basis. This leads to more time spent with patients and a better quality and continuity of care.

And, fundamentally, this integrated model also works for the Trust. All revenue generated via the private care division goes back into the Trust. This enables further investment into our teams, our kit, our staff, our research, and that benefits 14—Prognosis

all patients. I believe this model has been a contributor to the fact that the private care side has doubled in size in the past five years. We also have an outstanding CQC rating. These results are testament to the success of our integrated model. Other Trusts have similar arrangements, but The Royal Marsden is the largest of these private patient units in the country.

The fact that we are research-led is another very big differentiator of The Royal Marsden. It means patients can access the very latest and most innovative treatments in oncology. We have clinical trials happening all the time.

We work in partnership with the Institute for Cancer Research, so we really do offer cutting-edge treatments: whether it’s the latest genetic tests, CAR T-cell therapy, or the latest type of MR imaging. Having access to that, whether you’re a private or an NHS patient, is, I believe, the basis for outstanding care. Our new Cavendish Square site is an embodiment of that.

The new centre, due to open in the spring, is all about enabling us to diagnose cancers faster and earlier. We will have a full diagnostic imaging suite on hand, including MRI, CT, x-ray, mammography and ultrasound, plus nasoendoscopy and colposcopy. Chemotherapy will be available and there will be very clear pathways to and from The Royal Marsden.

There will be on-site pathology and pharmacy. Patients will have fast and direct access to The Royal Marsden’s world-leading diagnostic and researchactive consultants. It really gives patients and referrers assurance that The Royal Marsden, as Europe’s largest cancer centre, is providing a comprehensive set of services—and it’s all backed by research.

We are making a statement about our ability to deliver the kind of service we think is right. On the same day, they can have a consultation, diagnostics, bloods and get the results. That speed is key.

While COVID-19 has presented challenges, I’m pleased to say we have managed to create, in partnership with the independent sector and with the government’s support, a cancer hub to ensure that patients have access to lifesaving surgery and other treatments in a protected environment. There are also several things we’ve found through the pandemic that help drive efficiency and those are things that we’re going to look to retain. For example, virtual consultations are a great way to minimise the time patients spend in a hospital while also maximising consultants’ time. We are also developing our home-based services, such as at-home chemotherapy.

Over time, a greater number of international patients have sought to access The Royal Marsden’s treatments from all over the world, not just the traditional health markets. We’ve found through virtual technology—not just consultations, but the ability to provide training and education in those markets— that there are ways we can give those patients better access to treatment. With Cavendish Square, there is even greater opportunity to offer all our patients, both domestically and internationally, treatments and rapid diagnostics of the very highest quality.

The Royal Marsden Private Care 19a Cavendish Square London, W1G 0LP 020 7811 8111 royalmarsden.nhs.uk

Being research led means patients have access to the very latest and most innovative treatments happening in oncology.

Having access to that, whether you’re a private or an NHS patient, is, I believe, the basis for outstanding care.

Our new Cavendish Square site is an embodiment of that

Prognosis—15

1 The positive impact on families of such a system would be immeasurable

Dr Martin Saweirs It is the impact of a successful transplant not only on the patient but on the wider family that drives my support of this idea. I’ve been involved with patients who have had transplants, I’ve had patients who have died on transplant waiting lists, but with a recent patient, who had a chronic lung condition, it was the first time I had been through the entire process, from waiting list to transplant—and it really affected me. For his partner and their four children, daily life was based around managing four oxygen machines while he was confined to the upstairs part of the house, barely able to move from one room to another.

The kind of emotional burden they were forced to carry is very difficult to understand unless you witness it first-hand.

16—Prognosis

SECOND OPINION

Should the UK introduce an optout organ donation system?

The family would consistently go from being told “we have found a donor” to “sorry, it didn’t work out”. Once a viable donor organ has been found, there are various tests to go through to see if it is a suitable match. If the answer is no, it is a crushing blow for the whole family. It’s a situation that wreaks emotional havoc on everyone involved. Eventually, when the call came that they had a suitable set of lungs and the patient was going in, the hope was tempered with disbelief— the family found themselves unable to quite believe it was going to happen.

Even as an outsider you cannot help but get swept up in the emotion of the situation.

This is in no way a criticism of the people running the transplant services.

They are doing their best under extremely difficult circumstances. Issues with logistics and compatibility mean that the job will always be challenging, but it could be made so much easier if the supply of organs for transplant was not so far below the level we need.

Widening the picture, we have to consider the societal costs of people being on a waiting list for a long time— people being kept alive with oxygen or dialysis, for example. These lifesaving treatments can in the long run cause

problems of their own and are not nearly as efficient as a working organ. The very nature of the need for a transplant means that something has gone very wrong and the patient is not going to get better. In fact, things are only going to get worse over time. The quicker the patient has a successful transplant, not only do you prevent issues caused by the organ’s failure but also the potential complications caused by the machines keeping them alive.

If you think of the thousands of people on organ donor lists across the country, and add in their loved ones, a vast number of people are living their lives in a form of limbo—a limbo they could be released from if only we had a wider pool of donors. The key thing, of course, is to have robust safeguards in place and a clear and transparent system for people who don’t want their organs used after death to make their wishes known. With these in place, I believe moving to an opt-out system is a must. We just need to think of the decades of extra life experiences this would mean for entire families, not just the person whose life each successful transplant saves.

Dr Saweirs is a general practitioner at the 55 Harley Street practice

2 I have concerns about the nature of the debate surrounding the issue

Dr Nicola Stingelin-Giles If we look back at the history of personal rights, the doctors’ trial held in Nuremberg after the end of World War II formed a foundation of medical ethics by asserting the need for voluntary, informed consent prior to any intervention. This doctrine of consent is a central way to express and uphold the principle of respect for all persons, accepting each person’s right to autonomous decision making over matters regarding their personal healthcare—although we may not agree with or understand a particular decision.

This notion of personal autonomy has developed into one of society’s moral foundations. It is very difficult to argue against it, although the COVID-19 pandemic illustrates that there are situations when the public good ranks above personal wishes

We clearly have a need for more organs, the question is how do we approach the issue? If we are starting from a point of personal autonomy, this doesn’t really fit well with an opt-out situation. Such a system would involve us making an assumption about how people view their body after death, without that assumption ever being expressly stated.

If we can come to a genuine consensus that as soon as somebody is clinically dead, the body belongs to society, leading to a situation where organ donation is seen not as an obligation but an acknowledged duty, we would have a basis for opt-out.

But if we don’t have a real national debate, leading to a proper consensus, it would mean sliding away from that core principle of autonomy into a position where if we don’t express our opposition to an issue then our consent can be assumed, and the implications of that are quite worrying.

On the NHS website, it says: “We need a transformation in public attitudes.” To me, there is a sense of social engineering about this: you are setting out to shift society’s beliefs in a specific direction in order to support the solution you have already arrived at. No-one would disagree with the laudable intent, but the more I analyse the idea, the more disquieting I find it.

We need to really analyse the ethics

of the situation. Moral philosophers try to analytically tease out all the contradictions and problems, encouraging society to consider all aspects of a question. The shortage of organs in our society can be truly tragic; it can be regretted that not everyone expresses a wish to be a donor. Yet it is very important to recognise that our passions have a weight here as well as facts. Our moral intuitions have a huge role to play, intuitions that cannot be justified or explained, feelings that we struggle to put into words but which, nevertheless, cannot be ignored.

I suppose at the crux of my concerns is the fact that we have a huge body of highly developed, morally accepted laws and standards relating to informed consent when we are alive, but not much for when we die. I completely agree that we need to increase the amount of organs available for transplant, but I worry about the way we are coming to the decision. I don’t believe we have had the kind of societal debate necessary to arrive at a true consensus.

Dr Stingelin-Giles is an ethics advisor to the European Commission and a council member for Medicine & Society at the Royal Society of Medicine Prognosis—17

THE BIG INTERVIEW Emergency surgery Professor Roger Kirby, the new president of the Royal Society of Medicine, on the urgent need for reform, the drive for diversity, and tackling an existential threat Words: Viel Richardson Images: Christopher L Proctor

18—Prognosis

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“If I don’t succeed in turning this organisation around by the end of my tenure, I will have to commit seppuku in the RSM atrium,” says Professor Roger Kirby, staring out from the computer screen through which so much social intercourse currently takes place. The ritualised form of suicide to which he refers first emerged among the Japanese warrior class around the 12th century as a way of preserving or restoring a samurai’s compromised honour. It is a rather dramatic statement for the new president of the Royal Society of Medicine (RSM) to make, but then he has taken over in rather dramatic times.

Originally called the Medical and Chirurgical Society of London, the RSM was founded in 1805. It has faced plenty of challenges in its long and storied history, but the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has radically shifted the goalposts. For the first time, the society faces a genuine existential treat, hence its president’s consideration of ancient Japanese swordplay.

Prof Kirby had long felt there was a need for reform within the RSM; indeed, it was one of the reasons he wanted the job. His was always going to be a reforming tenure, but the speed and nature of that reform looks very different now from that which he first imagined. “This is a very precious institution which exists to provide health professionals with high-quality postgraduate education, and my main job now is to ensure that when this pandemic is consigned to the history books the RSM scholars will still be reading about it in our library.” The problem, as is so often the case, is one of money. “We have a wonderful building at 1 Wimpole Street with three beautiful lecture halls, an atrium area and conference facilities, all of which we rent out commercially,” he explains. “We have a 50-bed hotel, plus a restaurant and bar. That is three major sources of income that essentially disappeared overnight with the lockdown. It leaves us staring down the barrel of a £4 million deficit for 2020.” With such numbers involved, it is no surprise that a cloud flits briefly across Prof Kirby’s usually sunny brow. “This situation is unsustainable for the long or even medium term.”

The new president believes that institutions like the Royal Societies tend to be conservative and too resistant to necessary change, particularly if it affects some of their more cherished aspects. For example, the RSM HQ 20—Prognosis

houses the oldest and largest medical library in Europe. It is a wonderful place beloved by generations of researchers, clinicians and students, but it is not the bustling hub of activity it once was. Thousands of books and periodicals sit untouched for years as digitised facilities like MedSearch and PubMed give people remote access to papers and publications. “People do use it as a nice, quiet space to work, but they don’t look at the books. So reforming the library, making it more digital and turning that into a more engaging and interactive space will be a key priority,” Prof Kirby states. He views such changes to library services as one part of a fundamental change in the way the RSM meets its educational responsibilities, a central part of which will be the increased digitisation of its educational content.

“For historical reasons, we are far more relevant to people based in the southeast of England, and that needs to change,” he continues. “This is a multi-disciplinary organisation with access to deep expertise in all aspects of healthcare. Our committees are full of hugely qualified and experienced members with a great deal of knowledge. I believe there are many people who would be interested in sharing this knowledge, so we need to become much better at getting them heard.”

This last point is one of the foundation stones of the new president’s approach. Prof Kirby believes the RSM needs to raise its profile, that the society needs to extend its reach across all the healthcare professions in the UK and internationally. He makes the case that a wide variety of issues, not all of them medical, can impact on a community’s health and that the RSM really should be addressing them in some way. “For example, we have launched a series of webinars focused on the impact climate change is having on people’s health around the world,” he explains. “Global warming is going to affect us all. You can already see the changes it is causing, which are impacting on people’s health. We’re going to be talking about global health issues like TB, and how things like starvation and malaria link in with climate change. We are honoured that the Prince of Wales has agreed to open the series, which will involve top environmental scientists and experts on animal welfare and food production. SARS, MERS and most likely COVID

You cannot separate the health of the planet from the health of those of us who live on it. I want the RSM to be a leader in conversations about the links between planetary and human health

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all crossed over to humans via the food system.

You cannot separate the health of the planet from the health of those of us who live on it and I want the RSM to be a leader in conversations about the links between planetary and human health. I’m very excited about this series.”

On 25th May 2020 in Minneapolis, Minnesota, something happened that briefly forced even the pandemic off front pages across the world.

When a police officer took approximately nine minutes to choke the life out of George Floyd in broad daylight, surrounded by dozens of witnesses, the images horrified people across the world. It led to a rise in prominence for the Black Lives Matter (BLM) movement and caused minorities across the globe to reflect on and discuss their experiences of deep-rooted discrimination.

“I know that systemic racism has been deeply entrenched in our society and that very many people of colour have suffered greatly as a result.

Black Lives Matter has raised awareness,” says Prof Kirby. “It has meant that now we can begin to at least have a conversation, whereas before it was being swept under the carpet. Everybody knew there was discrimination, but nobody would mention it. Now you can be upfront about it, which I think is good. Uncomfortable, sometimes painful, but good.”

Such conversations are beginning to lead to actions. Prof Kirby reveals that the Royal College of Surgeons is in the process of an in-depth analysis of the experiences of Black, Asian and minority ethnic (BAME) surgeons, with the aim of highlighting the hurdles they face as they try to build a career. It will be interesting to see if any changes result from the finding of the report. Prof Kirby points out that at least half of newly appointed doctors in the NHS have trained abroad. Clinical staff from southeast Asia, Africa and India are common. “I bet the NHS is one of the most diverse organisations in the world, but it’s skewed because most of the top positions are held by essentially Anglo-Saxon men.” A wry smile shows that he is well aware of the fact that, as a white male himself, he has been a beneficiary of the system, but he is determined to do what he can to see it change.

“We need to widen the range of diversity in our field. When you go to a hospital ward you see this widely diverse workforce, but as you climb the 22—Prognosis

Royal Society of Medicine The Royal Society of Medicine (RSM) was established in 1805 with the aim of “uniting physicians and surgeons under one organisation to benefit from shared knowledge”. Originally called the Medical and Chirurgical Society of London, in 1907 it merged with 15 other specialist societies to create the RSM. Today the society’s role is to provide the highest quality education at postgraduate level and beyond to medical and healthcare professionals. It also provides a forum for discussing current medical issues in an atmosphere where innovative thinking thrives and the best ideas are disseminated. As a charity, the RSM receives no government support, thus ensuring its independence. It therefore relies primarily on membership subscriptions, support for its education programmes and philanthropy.

During the Covid crisis, the RSM has played a key role in providing an accessible platform for sharing clear, independent and trusted medical information. rsm.ac.uk

Communication has been the real issue throughout the COVID crisis, leading to confusion and a lessening of trust. I think we have proved to be a sorely needed source of information that people can trust

career ladder it lessens dramatically. The higher up the pyramid you get, the less diverse it is, and we have to develop ways of tackling that,” he says, with feeling. “There is this glass ceiling.

It halted generations of women, but they are now breaking through. It also exists for people of colour, but I’m hopeful that the BLM movement can be the springboard to help them start breaking through as well. The RSM needs to become a champion of all types of inclusion and diversity.”

One unforeseen effect of the pandemic has been the way in which both clinical and nonclinical communities have looked to the RSM to provide some clarity and perspective in this time of such uncertainty. “Our mission is to educate and inform—skills that have become even more important in the current situation,” Prof Kirby explains. “Something we have done which I am very proud of is our COVID-19 webinars. This weekly series has seen knowledgeable and talented people from diverse fields share their expertise on different aspects of the pandemic from national and international perspectives. Our audiences are growing, and they get amazing feedback—98% of people say they would recommend the webinars to a friend or watch them again.”

Prof Kirby is right to be proud: tens of thousands of people have participated in these webinars, and the information and insight they provide have regularly filtered through into the media. They are reaching a wide and increasingly influential audience and meeting a demand for authoritative information untainted by politics. “The pandemic has created enormous challenges for policymakers, health leaders and healthcare workers on the ground. Communication has been a real issue throughout the crisis, which has led to some confusion and a lessening of trust in the messages.

I think that our webinars have proved to be a sorely needed source of information that people can trust.”

Having spent years developing the skills necessary to provide the type of educational content suited to a physical presentation, the staff at the RSM have had to switch very quickly to providing digital learning of the same high academic standards, and it has been a real challenge. “We’ve had to become much more like

a TV company and less like a conference venue and that’s a pretty big change,” Prof Kirby says with a wry smile. “Different equipment, different skills and occasionally different personnel.

Health professionals have had to learn how to communicate online, they need to be articulate, clear and much briefer, which has been no bad thing! There’s an awful lot of re-training to do, and we still have things to learn, but I am incredibly proud of the way our staff have dealt with the challenges that faced them.”

Prof Kirby’s pride extends far beyond the walls of the Royal Society of Medicine. He is hugely impressed by the way the medical community as a whole has responded to COVID-19. “Health workers have had an extraordinarily difficult year, and they’re exhausted. Yet they still turn up every day to deal with large numbers of COVID patients while still being there for the non-COVID patients who need their care. I’m so proud of what’s been done. Even with the vaccine, it’s still going to be tough, but they’ll get through this. The NHS is a fantastic organisation, and it is beyond amazing what they’ve achieved.”

While the pandemic may have changed the nature of the job, it has thrown Prof Kirby’s belief in the need for reform into greater relief.

“My job is to modernise the RSM, to make it relevant to more people, to raise its profile and to make it much more financially viable,” the new president reiterates. “We have this wonderful tradition, this amazing building in a fantastic location. Marylebone and the Harley Street Medical Area were thriving before the pandemic.

They have taken some knocks but they will recover, as will the RSM. It will take hard work and imagination, but I’m looking forward to the challenge. Our response to the pandemic has shown that our people have an enormous amount of untapped talent and potential. I firmly believe that in them we have the ability to evolve into an RSM which is as relevant to the 21st century as it was for the 20th. But evolution will mean change, and it’s my job to be the leader of that change, to make sure that it is done in a way that allows us not only to survive but to thrive for another 215 years.”

Royal Society of Medicine 1 Wimpole Street London W1G 0AE 020 7290 2900 rsm.ac.uk Prognosis—23

THE GOOD, THE BAD AND THE UGLY 24—Prognosis

As the COVID-19 pandemic continues to dominate our daily lives, Prognosis talks to leading experts about some of the public health failings that contributed to the virus running rampant, and the vaccine development successes that will hopefully bring it under control Words: Viel Richardson

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For as long as humans have walked the earth, disease has appeared seemingly from nowhere to ravage communities, leaving fear and confusion in its wake. In times gone by, we might have called these outbreaks ‘pestilence’ or ‘contagion’.

In the 13th century, a common term was ‘plague’, a word that still retains nightmarish connotations, being forever linked with the Black Death, which swept away nearly a third of Europe’s population and brought the continent to its knees. Language matters, so it’s easy to see why authorities today prefer less emotionally charged nouns. Before 2020, the only people kept awake at night by the word ‘pandemic’ were epidemiologists.

The change of language is about more than a desire not to alarm the public: it represents the progress of science. The last 150 years have seen huge advances in our understanding of disease. Yet despite all our advances, severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), or COVID-19 as it is commonly called, has led to millions of deaths worldwide. It has been a global catastrophe. While dangerous viruses have always jumped species, the interconnectedness of modern life means that the danger has been hugely amplified. An epidemic can become a pandemic at a speed unmatched at any other time in human history. So, what can be done to combat this heightened risk?

During his long career, Professor John Ashton has been the north west regional director of public health and co-founder of the World Health Organisation (WHO) Healthy Cities Project. In early 2020, he was invited to Bahrain to oversee the kingdom’s public health response to the COVID-19 pandemic, which was rated among the best in the world by the WHO. Decades of working in public health have given Prof Ashton very strong views on the issue of disease response.

Central to these is the belief that the best way of protecting ourselves in the future is to embrace the wisdom of the past.

“We invented the concepts underpinning modern public health back in the 1840s. Based around town halls, medical offices of health and doctor’s surgeries, they were created in response to epidemics like tuberculosis and cholera,” he explains. “They did what I call ‘shoe leather epidemiology’, going out into communities to understand the conditions in which they lived and worked. It allowed health officials to quickly 26—Prognosis

identify outbreaks and create disease maps.

They could then start effective programmes of intervention and isolation. Environmental hygiene, refuse collection, access to fresh water, that kind of thing. And it worked.

With tuberculosis, for example, most of the reduction in deaths occurred before we discovered a treatment. Improvements in conditions in the home, sanitation and nutrition were among the key factors in taming these terrible diseases.”

Prof Ashton believes in the importance of having structures in place long before a disease rears its head. A pandemic is a public health issue, and the core belief underpinning all public health policy should be that prevention is better than cure—a message that takes on greater relevance when, as with COVID-19, no cure is immediately available. “We were woefully unprepared for this pandemic, despite warnings from the recent SARS-CoV (SARS 1), Middle East respiratory syndrome (MERS) and Ebola outbreaks,” the professor says. “This happened for both historical and contemporary reasons.”

In the UK, one of the drivers behind the postwar creation of the new National Health Service (NHS) was a series of pharmacological breakthroughs that allowed clinicians to cure previously untreatable conditions. Medical thinking was that those old 19th century public health systems, successful as they had been, were now redundant. “The belief was that the future of medicine was all about hospitals and pharmaceuticals. We had, or would develop, medicinal cures for all our ills. As a result, public health systems were allowed to run down.

The core message that prevention was better than cure was lost. What we are now discovering is that the baby had been thrown out with the bathwater,” Prof Ashton says with real feeling.

“What this belief failed to understand was that the crown jewels of the public health system were the networks it had developed within communities. They provided information on group characteristics and dynamics—the people who don’t visit the doctor as well as those who do. Local officials understood the local determinants of health and disease, the way people thought and acted. This is exactly the kind of information we have found it hard to understand, making it difficult to assess the true extent of COVID spread.”

In recent decades, the spiralling costs of healthcare have led to a renewed interest in public health systems designed to deal with non-communicable conditions such as heart disease, cancer and diabetes. In 1997, Tessa Jowell became the first Minister of Public Health, and Public Health England was created in 2013. But progress has been patchy at best.

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“The problem has been the level of commitment, and this is where we enter the realm of politics,” says Prof Ashton. “One of the pillars of the success of those early public health systems was the fact that control of municipal services was local. It meant that local health officials were in a position to direct policies pertaining to public health matters. Two major challenges they now face have been the privatisation of many local amenity services and the centralisation of policy control.

Local public health officials are now in the game of influencing rather than directing policy: a much less efficient system. This, coupled with low levels of funding, means that the present public health system is not nearly as effective as its predecessor.”

It is fair to say that Prof Ashton is not a fan of the present government’s approach. When he recalls the day in March 2020 that Boris Johnson cheerfully joked about shaking hands in a hospital with confirmed COVID patients, he gets visibly angry: “That showed extremely poor judgement. The situation was serious enough for him to launch the national lockdown only weeks later, yet his actions sent ‘a business as usual’ message to the entire nation. This at a time when his medical advisors, like the rest of the medical community, were becoming increasingly alarmed about the progress of the disease. There have been other mistakes, such as the delay of that first lockdown, but boasting about handshakes pointed to something far more serious and in my opinion completely unforgivable: not taking the situation as seriously as it should have been. It showed a complete misunderstanding of the importance of communication. In a public health crisis it is crucial that you have the public’s trust, and this is earned by good leadership and clear messaging.”

The professor points to what he believes was a crucial missed opportunity. When the government realised the situation was serious, local public health directors were barred by Public Health England from talking to the media.

This meant that a local perspective delivered by trusted regional voices was entirely missing at a crucial moment. “Public health officials have protocols and procedures for managing these situations. It is a difficult and sometimes unpopular process, but not following them leads to the mess we are now in where law enforcement is struggling to deal with the numbers of people breaking lockdown laws.”

The United Kingdom is at present struggling w Prognosis—27

THE MOST IMMEDIATE CONCERN WAS WHETHER SARS-COV-2 SHARED THE VERY HIGH MORTALITY RATE OF SARS 1, WHICH WAS SOMETHING IN EXCESS OF 10%. HOWEVER, WE’VE FOUND THAT WHILE SARS-COV-2 IS MUCH MORE INFECTIOUS, IT HAS A LOWER MORTALITY RATE

28—Prognosis

w Prognosis—29

with one of the highest death rates from COVID-19 in the world. So, the question is: where do we go from here? How do we navigate ourselves back to a place of social normality?

The global choice has been to develop a vaccine, and the level of international collaboration seen in the global push to do so has been one of the positives to come out of the pandemic. It has shown commitment to scientific advancement usually reserved for wartime, and to see it happen wholly in the service of saving lives has been the most glittering of silver linings.

Dr Ryan Thwaites is an immunologist working at Imperial College London. His main research interests are why, after exposure to a respiratory virus, some people become infected while others do not, and why, once infected, one person develops mild symptoms while another ends up in intensive care. The immune system plays a big role in these outcomes, so by trying to understand the nature of that involvement he hopes to help create new and effective interventions. With the arrival of the pandemic Dr Thwaites, switched his research to join the hunt for a vaccine and also became a member of a coronavirus taskforce run by the Academy of Medical Sciences and the British Society of Immunology.

SARS-CoV-2 is, as we have all heard, a novel virus—one that has not previously been in human circulation. It is significantly genetically distinct from other pathogens in circulation, even though it may be related to some. For example, about 15% of common colds are caused by other coronaviruses. SARS 1 and MERS are also coronaviruses. But SARS-CoV-2 is genetically distinct enough from these to be classed as a novel pathogen.

“You have to start investigations of a novel pathogen somewhere and immunologically a lot of our initial understanding of SARS-CoV-2 was based around what we had learned from the SARS 1 outbreak,” says Dr Thwaites.

“There were certain assumptions we could make about how the immune system would interact with the new virus. The most immediate concern was whether it shared the very high mortality rate of SARS 1, which was something in excess of 10%.

However, we’ve found that while SARS-CoV-2 is much more infectious, it has a lower mortality rate. It is still high for a respiratory virus, though: 30—Prognosis

much higher than influenza, for example.”

All those initial assumptions were rigorously checked, and while some will be discarded there were some very good educated guesses.

“One extremely good assumption was that the ‘spike’ protein would play a key role in the ability of the virus to infect cells. So, by producing immune responses targeted against that protein we could prevent the virus from causing disease,” Dr Thwaites explains. “Vaccine strategies targeted the spike protein because of that initial assumption and the results we are seeing shows that was a great call. It’s one of the reasons that the effectiveness of these vaccines is so high for a first-generation vaccine. It’s an incredible achievement.”

It is the historic success of vaccines against such diseases as polio, tetanus and smallpox that has led to such hope being placed in a coronavirus vaccine. Due to a truly heroic effort, we now have three licensed for use in Britain, with more coming through the pipeline. The Moderna and Pfizer vaccines are messenger RNA (mRNA) vaccines while the Oxford-AstraZeneca vaccine is what we call a ‘vectored’ virus. “These vaccines aim to expose the immune system to the spike protein as it is found on the surface of the coronavirus.

This trains the immune system to recognise and attack the virus,” Dr Thwaites explains. “We use different technologies to achieve that end. The mRNA vaccines give the body shortterm instructions for making the spike protein. Those cells that receive the vaccine start to produce it, and your immune system responds to what it thinks is a hostile virus. The OxfordAstraZeneca vaccine works by altering a harmless virus so it expresses the spike protein, without the rest of SARS-CoV-2 being present. These are different ways of achieving the same result, which is to get some spike protein into the body in a safe way, so your immune system learns to recognise and attack the real virus if it encounters it.”

There has been some misunderstanding and, to be frank,

Academy of Medical Sciences Dr Ryan Thwaites sits on the immunology and COVID-19 expert advisory group which was convened by The Academy of Medical Sciences and the British Society for Immunology.

The Academy, based on Portland Place, is an elected fellowship of medical researchers.

It has over 1,300 fellows, about half of whom are clinically qualified, the other half being laboratory scientists in a range of disciplines.

The Academy, which seeks to promote excellence in research,influence policy to improve health, promote careers in medical research, and foster links between academia, industry and government, is a registered charity that relies on philanthropic funding. To support its work and make a donation please visit: acmedsci.ac.uk/support Royal Society of Medicine Prof John Ashton sits on the advisory board of th e Journal of the Royal Society of Medicine.

To find out more about the RSM, see page22.

some deliberate misinformation about the nature of the mRNA vaccines and Dr Thwaites is keen to point out that these vaccines most definitely don’t re-write a person’s DNA. “The instructions about how to produce the spike protein are short lived,” he explained.

“The cells that start producing the spike protein do so for maybe a few days. This is enough time for your immune system to learn to recognise the protein and respond to it. Once the immune response identifies and kills these cells, they are replaced by cells without the instructions for producing the spike protein.”

All three vaccines differ from the traditional approach, which is to take the real virus, kill it and then inject it into people. However, while this is the first time these new approaches

Containment is key with a pandemic.

You need to identify cases and have the ability to isolate and support the communities involved. Most importantly, this needs to happen quickly

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have been widely used, both the mRNA and Oxford-AstraZeneca methodologies have been developed over several years and used in human trials before COVID-19, meaning scientists understand their characteristics.

Their advantage, which is of real pertinence in the current situation, is that they are much quicker to produce. With the mRNA approach, the first doses can be produced within a few weeks of knowing what a new virus looks like.

“Going through stages of producing large amounts of the actual virus and then killing it is very time consuming,” Dr Thwaites reveals.

“These new technologies were designed with speed in mind. That’s why they have come to the forefront now.”

One good assumption was that the ‘spike’ protein would play a key role in the ability of the virus to infect cells.

By producing immune responses targeted against that protein we could prevent the virus from causing disease

32—Prognosis

Which brings us back to preparedness.

The vaccines, in tandem with continued social distancing, have given us a route out of the SARS-CoV-2 pandemic. Some day soon, the world will breathe a collective sigh of relief.

While this pandemic will cast a long shadow, people’s interest will move on and the news will begin to be focused on other stories. There will be those, however, who will not be so quick to move on: epidemiologists and public health officials around the world will be studying all aspects of this pandemic for years.

Hard as it is to believe, we got lucky this time— we dodged a viral bullet. SARS-CoV-2 could very easily have proved as lethal as SARS-CoV, for example, making the past year unimaginably more traumatic than it already was. So how can we be better placed the next time (and there will be a next time)? As an old epidemiological axiom goes: “It’s not if, but when.”

“The answer is both simple and complex,” Prof Ashton explains. “Containment is key with a pandemic. You need to identify cases and have the ability to isolate and support the communities involved. Most importantly, this needs to happen quickly. The great thing is that we know how to do this. There needs to be a shift of emphasis back towards the precepts of good public health— systems where local authorities have the power and resources to build deep local networks and develop trusted conduits for getting health messages out to communities. As these networks are seen to improve local health outcomes, it raises confidence and builds trust. If we do this, not only will we have the structures in place to fight the arrival of the next novel virus, but the resultant rise in general population health would see our citizens better placed to fight off the illness itself.”

Whatever happens next, it is clear that we have to do something. Apart from the horrific societal cost, it is not clear that we could afford to repeat the kind of financial support seen during this pandemic. We need to be better prepared. Pestilence is the third horseman of the apocalypse. Somewhere out in the wilds of a plain or the depths of a jungle he stalks, waiting for the chance to charge over the horizon, trailing death, despair and destruction in his wake. We know he is coming; it is now up to us to determine what defences are in place when he arrives.

SHAPING THE HARLEY STREET AREA Synonymous with world-leading medical excellence, the Harley Street area is home to a wide variety of businesses from multiple sectors that have chosen to locate themselves in this globally recognised location.

The Harley Street Medical Area Partnership is a group of businesses and organisations with a shared goal: seeing this amazing area develop and grow.

Our aim is to bring key stakeholders together, so that we can help the Harley Street Medical Area to grow into a sustainable, secure and globally recognised business improvement district (BID).

HERE TO HELP Business Partnerships and BIDs give a voice to business communities, championing local priorities and ensuring the right people are at the decision table.We do this by focusing on four key themes: •

Public realm & wayfinding

•

International marketing

•

Business sustainability & connectivity

•

Safety and business resilience

WANT TO KNOW MORE? If you’d like to know more about the work we do, our journey to becoming a BID or to have your say on shaping the Harley Street area, please get in touch with our Partnership Director, Nicki Palmer.

34—Prognosis

Patient experience Sean Cannon on how Deep Brain Stimulation finally freed him from years of constant neuropathic pain Interview: Viel Richardson

I had been struggling with a condition called neuropathic pain for several years. The condition means that my nervous system is constantly generating pain signals, so even when there is no physical cause, I can suffer severe pain over large parts of my body. It is difficult to pinpoint the exact cause, but my partner Carole thinks it started when my car was hit from behind about eight years ago. There was damage to my spine which necessitated three discs being replaced and part of the spine being supported with titanium rods.

It was pioneering surgery at the time, and it seemed to go really well.

Quite naturally, I thought that was it.

Some time later, I started experiencing pins and needles in the fingertips of my left hand, which gradually moved up my arm and then moved across to the right arm. Then my legs started to be affected. I couldn’t feel the ground properly beneath my feet, it felt like walking on a trampoline and I started to stagger. My GP referred me to a neurologist who sent me for a brain investigation. After two MRI scans, they discovered a narrowing of part of the spinal cord and I was referred to a leading neurosurgeon, Mr Donncha

O’Brien. He immediately realised the seriousness of the situation and told me that without prompt intervention I could end up completely paralysed and needing mechanical assistance to breathe.

Mr O’Brien needed to perform two procedures to relieve all the pressure around the damaged area, but even so there were no guarantees of success.

I could still end up paralysed after the surgery, but without the procedures, paralysis was almost a certainty.

I felt I might as well go ahead.

Afterwards, I pretty much had to learn to walk again. Progress was initially good, then suddenly I started getting drop attacks, where I would suddenly fall for no reason. I would be conscious, know I was falling, but be unable to do anything to protect myself.

I couldn’t even put my hands out to break the fall. Once, I fell onto my face, breaking my nose and suffering from concussion for about two months.

I knew that part of the sleeve of my spinal cord was damaged and things were getting worse, so I started doing research into possible solutions.

I found Dr Declan O’Keefe, who specialises in spinal cord stimulators, and he agreed to take me on as a

patient. After prescribing ketamine infusions for the pain, he performed the nerve stimulation procedure.

This entailed inserting a probe to stimulate nerve activity in specific areas around the damage.

The operation solved my physical issues, but I still suffered severe pain and had to continue with the ketamine alongside other pain medication.

The problem was, it would have taken a second stimulator in the neck region to cure my pain as well, and there was simply not enough room. It was Dr O’Keefe who approached Prof Tipu Zahed Aziz about performing the deep brain stimulation (DBS) procedure to cure the pain. I came over to The London Clinic from Dublin for the operation. I was a bit nervous, but Prof Aziz told me I was in very good shape for someone with this condition, which improved the chances of a good outcome. This was very was heartening to hear.

After the operation, Prof Aziz told me that things had gone very well, so I was confident and excited about turning on the electrodes.

There wasn’t a ‘wow’ moment w when we finally switched them on.

Prognosis—35

WHAT IS DEEP BRAIN STIMULATION?

Professor Tipu Zahed Aziz, founder and head of Oxford Functional Neurosurgery, professor of neurosurgery at the University of Oxford and consultant neurosurgeon at The London Clinic It was more a case of slowly easing into the realisation that the ‘pain’ wasn’t bothering me as it had been. I realised I no longer felt any need to reach for the bottle of liquid ketamine I always kept nearby. I am now off all pain medication, which is wonderful.

I had been on a real cocktail of drugs to control the pain and was having to live with the side effects. Coming off them contributed a great deal to my improved quality of life.

In terms of the effect of the electrodes, it’s quite strange in as much as the pain hasn’t gone away.

Instead, it has been transformed to a different kind of sensation. The key thing is that this sensation doesn’t cause me discomfort or distress.

The electrodes trick my brain into experiencing the sensation in a way that is not ‘painful’.

Neuropathic pain Pain caused by damage or disease affecting the somatosensory nervous system.

Ketamine A medication primarily used for starting and maintaining anaesthesia. It induces a trance-like state, providing pain relief, sedation, and amnesia.

Anterior cingulate Part of the brain with connections to both the ‘emotional’ limbic system and the ‘cognitive’ prefrontal cortex.

Somatosensory Part of the sensory system concerned with the perception of touch.

36—Prognosis

Neuropathic pain is defined as pain resulting from injury to the brain or to the nerves that generate or transmit pain signals. What happens is that somewhere along the nerve pathways, nerves cells start firing out of control, which usually starts after some type of damage. It seems that because they have lost the type of signal input they normally receive, they become confused and just fire off signals at random, generating a sensation which the patient perceives as pain.

This type of pain has been described as a crushing or burning sensation.

The patient can suffer from extreme sensitivity, where a slight touch can send a huge burst of pain through the body. It is not like the pain most of us are familiar with; in fact, almost all patients say that someone who isn’t suffering from the condition would not recognise the feeling.

In Sean’s case, despite successful surgery, some damage to his spinal cord remained, which was the cause of his condition. Because the injury was located so high up the spine, Sean feels the pain throughout his body.

This meant that we could not target a specific region of the brain to reduce all of his symptoms. We needed something that would effectively treat his whole body.

The approach we took doesn’t stop the nerve signals from reaching the brain, thereby stopping the pain, but it does change the way in which the brain interprets the signals when they arrive.

When working well, it will transform the patient’s perception of the signals.

The ‘pain’ is being reduced to a neutral sensation, like touching a carpet. You

can still feel something, but there are no negative emotions attached to the incoming signals. In effect, we diminish the emotional importance of the signals, so the patient no longer perceives them as distressing.

During the operation, we implant electrodes very precisely into both sides of an area of the brain called the anterior cingulate. We then run wires under the skin from the electrodes to the programmable pacemaker which powers them.

We usually wait for six weeks for any post-operative swelling to calm down before turning on the electrodes, but Sean responded well enough to the procedure for us to turn them on after five weeks. The pacemaker sends a precisely calibrated electrical charge to the electrodes and the strength of the charge determines the effect the electrodes have.

So far, things have gone extremely well. The operation to implant the electrodes went smoothly and since switching them on I have been very pleased with the results. I will continue to be in regular contact with Sean so we can make the necessary adjustments to the settings to best manage his pain.

It will take a little time, but we will find the precise power settings that mitigate Sean’s pain as much as possible, allowing him to return to enjoying life to the full.

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

Electrodes

Extension

Lead wire

Neurostimulator

Prognosis—37

How a holistic rehabilitation and treatment programme designed to bridge the gap between doctors and fitness specialists is giving patients like Paul Mylrea, who felt some of the more extreme physical effects of COVID-19, a chance to fight back

STRONGER TOGETHER Words: Julia Price

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Social distancing might be our new normal, but over in the Harley Street Medical Area, two centres of expertise located just a few hundred metres apart have been showing why, at a time when safety is measured in distance (and isolation prescribed as a remedy), the working closely together is still important.

In the world of professional sport, open communication channels between trainers and medical professionals are a vital part of an athlete’s rehabilitation journey in the aftermath of injury.

It is a multidisciplinary approach that champions synergy—where physical therapy interventions are supplemented by medical expertise; physical recovery upheld by psychological readiness. Holism is the name of the game.

In recent months, Isokinetic, a sports medicine and rehabilitation clinic on Harley Street, has been working with AMP Athletic, a personal training gym located a short walk away, to offer patients like Paul Mylrea a model of rehabilitation and treatment usually reserved for elite-sport. The tailored programme has been designed to bridge what can often be a wide gap between the doctors, physiotherapists and fitness specialists involved in a patient’s recovery process. The dual approach was developed to ensure exercise is controlled and monitored by medical professionals in a safe way, mirroring the professional sport environment.

Mike Davison, who heads up Isokinetic’s Harley Street clinic, says: “For patients, our integrated approach 40—Prognosis

goes deeper than physiotherapy, with the objective of restoring optimal performance—and then maintaining it. It combines the latest technology and neuro-motor exercises to prevent the reoccurrence of injury, supported by clinical evaluation. Key to this is enlisting the support of specialist facilities to deliver to patients a complete care package tailored to their needs and to support their ongoing progression.”

This collaborative programme, which offers an evidence-based approach to rehabilitation, has been central to Paul’s impressive recovery. In April 2020, seriously ill with COVID-19, he was left hospitalised and fighting the more severe, physical effects of the illness. While in intensive care and receiving treatment, Paul suffered two massive strokes within a couple of days of each other—both caused by the coronavirus infection. Although typically considered a lung infection, COVID-19 has been found to cause blood clots that can deprive vital areas of the brain of blood supply and lead to severe stroke, including in patients as young as 30. The symptoms can leave patients with weakness or paralysis, lack of sensation, facial droop and speech impairment.

The condition left Paul unable to get out of bed when he awoke in hospital.

The second stroke he suffered was so big, in fact, that doctors thought it likely he would not survive, or would be left hugely disabled. With the pandemic seriously affecting stroke treatment and care, Paul was also unable to rely on standard rehabilitation therapy. “When I was in hospital I could only walk with

I have known Paul personally for a little while and his story just connected with me, not only because of his survival but also because of his willingness to live life, pursue activity and fight back

a walker and two people walking with me—that was in April,” he recounts.

“The NHS is great, but unfortunately they cannot always bring you back to the level of fitness you had before or help you enjoy every element of life.”

The 64-year-old, who is director of communications at Cambridge University, is now able-bodied. His physical recovery has been remarkable, which Paul credits to the holistic support he received from AMP Athletic and Isokinetic. Following his debilitating encounter with COVID, he underwent a tailored rehabilitation programme devised by Isokinetic to help with his strength and coordination and reduce the immobility-related complications of stroke. This was followed by ongoing maintenance and performance at AMP Athletic focused on therapeutic exercises, muscle strengthening and movement.

“Working with the trainers at AMP has been fantastic,” says Paul. “The trainers have noticed things that I wasn’t aware of and have helped me fix them.

One example of this is the stroke affected my right-hand side—I am naturally right-handed, and I thought things were going well, but in reality I had lost muscle mass and strength. These are the kind of things that if you don’t fix will affect you later on in life.”

When it comes to stroke, the main physical problem facing survivors is weakness in their limbs, according to the Stroke Association, and this can be improved with a combination of strengthening, stretching and endurance exercises. Meanwhile, studies indicate that prolonged immobility among patients can result

in significant functional decline. Key to combatting this is a multidisciplinary approach combining medical expertise with exercise and physiotherapy.

Rehabilitation success relies on creating a less disjointed experience for patients. Matt Curley, head coach at AMP Athletic, says: “With experience of working with sport injury clinics over the years, we understand there is a gap between physiotherapy and returning back to exercise. We pride ourselves on bridging that gap. It is important to get patients out of the clinical environment and get them back into a gym for their mental health. Ultimately the relationship between us and the medical professionals at Isokinetic has been really good for our clients, as in Paul’s case. We have open lines of communication where in the past I think people would have been intimidated to work with medical professionals.

In professional sport the channels of relationship and communication have always been open and that is what we have replicated.”

It isn’t just Paul’s physical condition that has seen a marked improvement.

“Medical evidence shows that keeping yourself fit doesn’t just have an impact on your body but also your mind and mental health,” says Paul. “I feel great now—not likely to do any marathons, but so much closer to my old self. It’s fantastic that AMP and Isokinetic work together in this way, as quite often there is a gap between the medical and the health side. It’s been great to benefit from an integrated approach with both organisations working together to get the best outcome for me.”

Doctors have attributed Paul’s extraordinary recovery to his previous very high level of fitness. While lockdown has no doubt had an impact on our daily routines in recent months, the benefits of exercise, both physically and mentally, are well-documented.

In fact, research shows that exercise can reduce the risk of major illnesses such as heart disease, stroke, type 2 diabetes and cancer by up to 50% and lower the risk of early death by up to 30%. All of these are conditions that can increase susceptibility to the worst rigours of COVID-19.

“I have known Paul personally for a little while and his story just connected with me, not only because of his survival but also because of his willingness to live life, pursue activity and fight back,” says Mike. “In essence, to use exercise to combat stress, be an inspiration to other people around you and to think proactively about your future. Exercise is a form of anti-ageing, but what you’re trying to do is live healthily for as long as possible.”

If there’s one thing we’ve learnt this past year it’s that the global pandemic can only be ended by a unified approach. And it is this collaborative spirit that Isokinetic and AMP Athletic are trying to embody. Located one street apart, the two facilities are combining their expertise in medicine and rehabilitation to help patients who have been physically affected

by COVID-19.

Mike concludes: “Isokinetic is part of the Harley Street Medical Area, an area that we like to think as being the world’s largest hospital. The area has world-class specialists but it’s important to ensure we have bridges of connectivity and communication, and also understand when we are not best placed for the patient experience. I’ve known AMP for two years and we have a great ongoing relationship. I think it’s an example of two groups within HSMA in health and wellbeing working together to give Paul and other patients like him the opportunity to live their lives as well as they can.”

Isokinetic 11 Harley Street London W1G 9PF 020 7486 5733 isokinetic.com AMP Athletic 14a Beaumont Mews London W1G 6EQ 020 7486 9127 amp.fit

Prognosis—41

Julian Best of The Howard de Walden Estate and Dr Brian Donley of Cleveland Clinic London discuss how the Harley Street Medical Area has become a global healthcare hub of sufficient reputation to draw one of the USA’s most influential clinics into its ranks Words: Clare Finney

A HEALTHY HEART 42—Prognosis

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There aren’t many streets in Britain as rich in cultural and historical references as Harley Street. Like Fleet Street or Abbey Road, the name alone conjures up a colourful array of associations, from the art of JMW Turner to the Oscar-winning film The King’s Speech.

Some of the great pioneers of modern medicine lived or worked on this street. Yet while this extraordinary heritage is as much a part of the fabric of the street as its beautiful buildings, in the past 10 to 15 years Harley Street has been quietly cultivating another reputation that could not be more forward-looking in its conception: being at heart of one of the most revered and respected private healthcare hubs in the world.

“This is now the largest concentration of medical premises in Europe,” says Julian Best, property director at The Howard de Walden Estate, which oversees the Harley Street Medical Area (HSMA).

“It may not have that sprawling sense of scale you see in the hubs of Boston, Massachusetts, for example, but the number and quality of medical providers is growing all the time.” The reasons are, for the most part, obvious. “As part of a triangle with Cambridge and Oxford, London is a global player now in the life sciences sector,” Best continues. “That, together with first-class university teaching hospitals, has really boosted London on the medical front. The presence of so much technological innovation and groundbreaking medical research has helped build up the area’s reputation.” Then there’s London’s status as a truly global city, with its transport links, international businesses and a dynamic, richly diverse population that has also given rise to some of the best cuisine and culture in the world. And then there’s the NHS. “The NHS is the bedrock of the experience and the skills that many of the consultants working on Harley Street have gained over the years, and it’s the place that many of them still consider home.”

This year, Harley Street will become home to yet another world-leading medical institution, Cleveland Clinic, which is opening its first medical outpatient centre at 24 Portland Place in advance of the arrival in 2022 of its London hospital in Belgravia. The American clinic’s London CEO, Brian Donley MD, believes “there is a lot for us to learn from a place like London, which has such a long and rich tradition of healthcare research and innovation”.

44—Prognosis

“For a long time, London has had outstanding research institutions, great medical training, and hospitals—and the NHS has done great things,” he says, recalling his experience with the health service 14 years ago. “I was an orthopaedic surgeon before I was running this project, and I was fortunate enough 14 years ago to spend six weeks touring NHS trusts around the country. Every three days we’d go to a different trust around the UK and it was a phenomenal experience, seeing the excellence of care, the passion of the staff—and the culture, which I felt at the time was very similar to the one we have here at Cleveland Clinic, where strong teamwork enables focus to be placed on the patient’s best interest.”

A key link between the HSMA and Cleveland Clinic is their historic status. “Cleveland Clinic is 100 years old. Harley Street has been famous

Cleveland Clinic is 100 years old.

Harley Street has been famous for medicine for even longer

for medicine for even longer. Both have heritage and both are about constant innovation,” says Dr Donley. “There is a great synergy between the two brands.” While it is hard to draw a direct comparison between UK private care sector and the US healthcare systems, Dr Donley continues, “the parallel between Harley Street and Cleveland Clinic is the focus on improving the experience and life of the patient. Enhancing the expression of empathy between the physician or the nurse and the patient—that is at the core of what we’re trying to do.”

Another key similarity between the HSMA and Cleveland Clinic, and one of the main reasons for their continued growth, is a constant striving toward innovation. “Harley Street cannot sit back and think about the last 100 years—any more than we can,” says Dr Donley. “We have to focus

on the next century: how we can continue to be great at giving care.” Harley Street’s venerable status might be well known in this country, “but it’s not really known internationally outside of certain medical circles,” says Best. Of course, the distinctive beauty of the period buildings will always give them an aesthetic appeal that goes beyond that of the more generically modernlooking healthcare centres—but one should not overestimate the extent to which Harley Street’s history influences the perception international patients and medical providers have of the area today.

Indeed, the historical component can occasionally work against the area. “There are still some people who associate Harley Street with less scientifically robust practices or the poorerend of cosmetic surgery, which were prominent

w

Prognosis—45

HARLEY STREET CANNOT SIT BACK AND THINK ABOUT THE LAST 100 YEARS—ANY MORE THAN CLEVELAND CLINIC CAN. WE HAVE TO FOCUS ON THE NEXT CENTURY: HOW WE CAN CONTINUE TO BE GREAT AT GIVING CARE

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in the area for parts of the 20th century,” says Best. Then there are the sheer logistics of trying to accommodate 21st century medicine into 18th and 19th century buildings. It is one thing to create, from scratch, a purpose-built oncology clinic and lab. It is quite another to adapt a former townhouse-come-GP surgery into an oncology unit that attracts some of the world’s best practitioners. “We need to ensure the buildings we have remain relevant and focused on improving and streamlining the medical pathway for patients,” he continues. “Harley Street is a conservation area, and over 30% of the buildings are listed. It is costly and time consuming—but we have become pretty adept over the years at planning buildings into new, interesting, exciting uses, that are best for medical occupiers.”

Part of the magic of Harley Street is that 48—Prognosis

its buildings are in a way a mirage; behind those pillar-clad Georgian facades is a wealth of research labs, stores, wards and medical apparatus of an intricacy and scale no one merely idling along towards Oxford Street could possibly fathom. “Most recently, we’ve converted two listed buildings and listed mews to create space for the first linear proton beam treatment unit, for Advanced Oncology therapy, with the support of Westminster City Council.

That is a great thing to have been part of.”

There is undeniably merit in having an area as beautiful as Harley Street, and Marylebone generally. “It gives us an edge,” says Best, but for him the real aim is to “continue to raise the bar in medical standards, and get the right balance of hospitals and clinicians. Oncology is well covered; cardiovascular is well covered; we have really

more pertinently, should be going forward. “It is the entire gamut of all that is needed: nurses, consultants, allied health professionals and so on. “It’s creating a market that continues to attract the best people to practice the best medicine,” Dr Donley continues, “and for that nucleus to be there and to keep going, you need continual innovation.” Welcoming an institution like Cleveland Clinic to join what Best describes as the area’s “anchor tenants: The London Clinic, HCA, Royal Brompton, Schoen Clinic, King Edward VII’s Hospital and Phoenix” means bringing together “people with a similar passion and top talents, but with unique perspectives and diversity of thought,” says Dr Donley— “and that is how innovation flourishes.”

We’d love to have lab space for life sciences, and we’ve always wanted a rehabilitation or ‘step down’ facility

good diagnostic capabilities—and by bringing in international operators like Cleveland, it keeps the domestic ones on their toes.”

Of course, one of the HSMA’s key assets for practitioners looking to move there permanently is that it does not exist in a vacuum, but in a village—one of the real few villages left in central London. “Marylebone is a village in its truest sense,” says Best, “because it can sustain itself.

You can, and many people do, work here, shop here, live here. There are 11 schools on the estate; good food and retail; and the medical is the jewel in the crown. It’s a community, within a large city environment,” he continues. “I think Marylebone as an entity plays an important role.”

There is a neat parallel between Marylebone as a complete entity, and Best and Dr Donley’s shared vision of what Harley Street is now and,

“I think what we can learn from London as well as help to develop is continued innovation around the model for healthcare—like our digital healthcare experience,” says Dr Donley, by way of example. “We have digital integrated patient medical records, which means that patients can access their records wherever they are, in real time; and the doctors can access them in real time. There’s complete transparency there, and transparency is critical to driving improvements in medical safety, efficiency and quality.”

Best’s plans for furthering the comprehensiveness of Harley Street’s offering include “complementary businesses: we’d love to have lab space for life sciences, and we’ve always wanted a rehabilitation or ‘step down’ facility, so that patients who have knee or hip replacements have an environment in which to recuperate.”

By creating this microcosm of complete, end-to-end healthcare within the beautiful environs of Harley Street, it is his hope—and that of Cleveland Clinic’s—that “we will do things that will inspire and push others, beyond Cleveland Clinic and Harley Street and around the country,” says Dr Donley. “That is good for society, for London, and for all 70 million people in the UK.” Cleveland Clinic London clevelandcliniclondon.uk The Harley Street Medical Area harleystreetmedicalarea.com

Prognosis—49

HARLEY STREET HERO

Sophia Jex-Blake 1840-1912 Physician and campaigner Words: Kaite Welsh

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In 2020, despite her contributions to medicine, English Heritage rejected a request to commemorate Sophia Jex-Blake with a blue plaque on Harley Street. The request was made by Queen’s College, the Marylebone school where Jex-Blake had both studied and taught mathematics prior to beginning her medical education. She enrolled at the school in 1858 and the next year, while still a student, was offered a role as maths tutor. Since her parents refused to allow her to be paid for teaching—a job would be far too unladylike—she worked for free while living in the Finchley home of fellow Queen’s student (and future social reformer) Octavia Hill and her family.

This rejection by English Heritage wasn’t the first time Jex-Blake’s achievements had been overlooked. It wasn’t until 2019 that she was awarded

her medical degree from the University of Edinburgh—over 150 years after she successfully campaigned for women to be admitted to the institution. If her inclusion on the list of Edinburgh graduates was overdue, it wasn’t from lack of persistence. She had first applied in the spring of 1869, shortly after her essay advocating for female participation in medicine appeared in the early feminist campaigner Josephine Butler’s book, Women’s Work and Women’s Culture. Jex-Blake may have captured the zeitgeist, but Edinburgh turned her down nonetheless, stating that its centurieslong tradition of male-only education couldn’t possibly be overturned for one solitary woman.

So Jex-Blake did what any enterprising woman would do: took out an advert in the Scotsman newspaper calling for

When the women were due to sit their anatomy examination, they were met with a crowd of several hundred protestors who managed to stop traffic for a full hour. A group of drunken male students hurled abuse and rubbish at them, blocking their way into the building

other similarly-minded women to join her, and together they successfully petitioned the university to allow them to sit the entrance exam, before matriculating in March 1870. They took separate classes to the male students for the sake of propriety, and the ‘Edinburgh seven’ as they were known spent the next few years cloistered in a small room in 15 Buccleuch Place, soaking up all the knowledge they could get.

Not everyone was happy, though.

When the women sat their November exams, the male student body made their feelings known. When the women were due to sit their anatomy examination at Surgeon’s Hall, they were met with a crowd of several hundred protestors who managed to stop traffic on South Bridge for a full hour. A group of drunken male students hurled abuse and rubbish

at them, blocking their way into the building. When they did finally enter the exam room, one waggish student sent in the Royal College pet sheep as well, clad in a mortarboard and gown, on the grounds that it was as competent to practise medicine as the women. Only three of the male students were fined— £1 each—and when Jex-Blake argued that they had been encouraged in their ‘protest’ by a teaching assistant at the medical school, he sued her and won. In contrast, she had to pay £915.

In 1872, still determined to make the case for female doctors, Jex-Blake published Medical Women: A Thesis and History. But progress came to a disappointing halt when, in 1873, the University of Edinburgh refused to award the women their degrees.

If the traditional institutions weren’t going to train female doctors, the women would have to do it themselves.

In 1874, after returning to London, JexBlake joined forces with several other equally passionate women, including Elizabeth Garrett Anderson, to found the London School of Medicine for Women in Bloomsbury. Two years later, the UK Medical Act removed the previous restrictions and allowed both sexes to qualify as doctors. Jex-Blake was finally awarded her MD in Berne and then the Licentiate of the King’s and Queen’s College of Physicians of Ireland, meaning she could at last be registered with the General Medical Council, becoming the third registered woman doctor in the UK. Spurred on by this victory, Jex-Blake returned to Edinburgh to open an outpatient clinic and finally practice medicine as a fully qualified doctor. By 1885, the clinic moved to larger premises and became the Edinburgh Hospital and Dispensary for Women, the first hospital in Scotland to be entirely staffed by women. But Jex-Blake’s ambitions didn’t stop there, and her support for women’s medical education hadn’t dimmed. With women still not permitted to study medicine at Edinburgh, she opened the Edinburgh Medical School for Women—and this is where she hit her next set of obstacles, this time ones which had nothing to do with her sex but everything to do with her temperament.

Although her trailblazing opened the door for other women, her acerbic, uncompromising nature won her few friends, and she spent the mid-point of her career embroiled in disagreements, controversies and legal battles. In 1888, Grace Cadell, one of Jex-Blake’s first cohort of students, stayed past her allotted

time at the Leith Hospital where clinical teaching took place, to stay with a patient who had suffered a head injury. When Jex-Blake, who had set an immovable finishing time of 5pm for the women, found out, her immediate response was to expel Cadell and her sister Ina, who had been with her: a harsh punishment for a seemingly trivial offence. They responded by suing her, supported by another student, Elsie Inglis. The court ruled in the sisters’ favour, with JexBlake asked to pay £100 damages to the women. The bad publicity affected the school’s reputation, and when Inglis left it was to set up a rival establishment, The Edinburgh College of Medicine for Women, which would go on to gain the kind of legitimacy that Jex-Blake had been fighting for.

When, in 1892, the University of Edinburgh officially opened its doors to female students, it was the culmination of decades of campaigning by Jex-Blake, but one of the consequences of this success was to render her own school increasingly irrelevant, forcing it to close soon after. Jex-Blake continued practising medicine at her home in Bruntsfield Lodge, which would eventually become the Bruntsfield Hospital. After JexBlake retired, Elsie Inglis became senior consultant there despite her old adversary’s firm but ultimately fruitless objections.

Jex-Blake died in 1912. She had never married, although she spent the majority of her adult life with Margaret Todd, a fellow doctor 19 years her junior. They were clearly partners in almost every sense of the word, although there is no concrete evidence of a romantic or sexual aspect to their relationship. Much of her life was recorded by Todd—also a novelist, who took seven years to complete her own medical degree because she was writing Mona Maclean, Medical Student, a roman-a-clef about her time as a student. The Life of Sophia Jex-Blake, published in 1918, has been dismissed as a hagiography, and certainly none of Jex-Blake’s flaws were outlined, making it a slightly insipid read, but it is a valuable starting point for exploring its subject’s extraordinary career.

There is a plaque dedicated to JexBlake in the archway of the old medical buildings at the University of Edinburgh, and it seems fitting that the institution that was so reluctant to admit her has finally embraced her contributions to medicine and the world. It is a shame that similar recognition could not be afforded her on Harley Street.

Prognosis—51

24 A DAY IN THE LIFE

Dr Paul Ettlinger, founder and lead clinician at The London General Practice Interview: Jean-Paul Aubin-Parvu Images: Orlando Gili

I am a great believer in the importance of personal care during this modern technological age. This means guiding and helping patients through the avenues of private medicine with a real human touch, but with all the available up-to-date facilities, technologies and clinical guidelines, ensuring that they get the very best medical care.

We will look after absolutely anyone who wants to have private medical care, from people who live locally through to patients flying in from all over the world.

We look after various companies and do a lot of executive health screenings. We also look after several embassies and many of the five-star hotels in London.

Claridge’s and The Connaught, for example—we are their doctors.

As founder and lead clinician, I look after and supervise the medical 52—Prognosis

management of the practice to make sure we’re maintaining excellent standards, but I also see patients on a daily basis. I am also one of the lead medical officers for the entertainment insurance industry and as such I’m often asked to review cases—for example, to assess the risk for medical underwriting for performers and film actors.

I tend to get up between 6.30am and 6.45am. I am someone who gets up instantly rather than lying there hitting the snooze button. I must have a very strong internal body clock because I often wake up just one minute before the alarm is due to go off.

Depending on the weather I will either cycle to work on a hire bike or arrange for a cab to pick me up. Sitting in the back of the car gives me a great

Prognosis—53

I had COVID-19 at the very beginning and was extremely ill with it.

But I pulled through.

I think that gave me a greater understanding of the disease and an empathy towards those patients who have unfortunately suffered with it

opportunity to catch up with emails and review any results that may have come in overnight.

I arrive at the practice by around 7.30am, but I won’t usually see my first patient until nine o’clock. I always tell my patients that this is a good time to phone me if there’s an issue. I might tell them to pop in and see me at 8.30am. I can even do a visit on my way into the office if the patient isn’t well enough to travel.

We tend to finish the clinical work at about 7.30, 8pm. We have a number of doctors consulting at the practice each day and so we also have clinical meetings together. Then there are our practice meetings and clinical governance meetings. We are very strong on our clinical governance structure.

For us, it’s all about striving to give each patient the very best personal care—that’s the philosophy throughout our practice. We also provide a 24-hour visiting service. Our phones are always answered, and if it’s out of hours then the call is automatically transferred to the on-call doctor, who can assess whether the patient requires a visit.

The beauty of working in Harley Street is if a patient needs a scan, for example, you can ask them to sit in the waiting room while you arrange the investigation and then get that patient to come back to you straightaway with the report, so you can make a diagnosis instantly. You can get laboratory tests really quickly. You can walk round to the laboratory and have the results back within the hour. I don’t think you can do that anywhere else in the UK, actually.

This is what the Harley Street Medical Area offers.

54—Prognosis

There have been many, many challenges of practising as a GP during the COVID pandemic, one of them being that I actually had the disease myself at the very beginning and was extremely ill with it. This was back in mid-March 2020. But I pulled through. I think that gave me a greater understanding of the disease and an empathy towards those patients who have unfortunately suffered with it. It also gave me a yearning to be at the forefront of providing services to patients during this pandemic.

We had to shut our premises during the first lockdown, but we kept the phone lines open. We had to ensure that our staff were able to work from home and could answer calls. We introduced video and telephone consultations to allow us to continue offering care to all our patients, and we could also offer a visiting service provided the patient wasn’t suffering any COVID symptoms.

Having already been fairly computer literate and technology savvy we had to instantly educate ourselves and learn even more about the digital sphere.

Obviously, we had to ensure that all the government guidelines and protocols were fulfilled. It was a difficult period, but we continued to offer the best care we possibly could.

We introduced our COVID-19 Safety Net service for patients concerned or affected by coronavirus. After an initial video consultation with one of our doctors, the patient receives a home support pack which includes an oxygen saturation meter with pulse monitor and, if required, a thermometer and blood pressure monitor. Then each day for the next seven days one of

our doctors will contact the patient by telephone or video consultation to check on their symptoms, discuss the measurements they have taken—sent via a digital app created in partnership with Careology—and provide general support. Our patients have found this service very reassuring, knowing that someone is actually looking after them and, if need be, can advise them to seek further specialist help.

We have introduced other services in direct response to the pandemic including coronavirus testing—we were very fortunate that our laboratories were able to offer us a very prompt service from the beginning—and Fit to Fly coronavirus test certificates. When people are able to start leaving the country again, I think there will be a further increase in patients wishing to take advantage of that service.

This has obviously been a very worrying time, particularly for the most vulnerable patients. I still have some patients who haven’t left their house since last February. I think there has been a large amount of fear engendered in the population and, of course, there has been an increase in mental health issues, which we’ve seen from all spheres actually. The anxiety that COVID has developed in patients is within all populations of society, and really isn’t related to which socio-economic group you might fall in. We will be dealing with it for many years to come.

The London General Practice 114a Harley Street London W1G 7JL 020 7935 1000 thelondongeneralpractice.com

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