The Physician - BAPIO Medical Journal 2014 by The Physician

Vol 3 Issue 1 • November 2014

www.bapio.co.uk

Physician The

Journal of The British Association of Physicians of Indian Origin

In this edition... Placebo Response and Culture Recent Advances In Shoulder Surgery Dementia In South Asians Toolkit - Improving Quality and Efficiency Why We Need the Model for Improvement? 1

The Physician • Vol 3 Issue 1 • November 2014

Physician The

Journal of The British Association of Physicians of Indian Origin

CORPORATE & EDITORIAL Editor In Chief Dr Ramesh Mehta

In this edition... Message from Editors ��4 Placebo Response and Culture ��5

Editor Dr Parag Singhal Guest Editor Mr Vipin Zamvar Managing Director Buddhdev Pandya MBE Editorial Support: ProofScience www.proofscience.com Design & Printing: Decipher Graphic Design Ltd www.deciphergraphicdesign.co.uk Sponsorship Buddhdev Pandya MBE Director of Policy and Promotion Nimish Bhatt Commercial Director Published by BAPIO Publications Ltd 281-287 Bedford Road Kempston Bedford MK42 8QB Buddhdev.pandya@bapio.co.uk

Motivation and its Relevance for Doctors and the Learning Society ��8 Dementia in South Asians in the United Kingdom: An overview ��11 Recent Advances in Shoulder Surgery ��16 Increasing Sarcoma Awareness ��21 Are Ethnic Minorities More Likely to Develop Triple Negative Breast Cancer? : A systematic review ��22 Is the Technical Quality of Screening Mammograms Lower in Asian Women who Cannot Understand the English Language? ��23 Geriatrician-led Comprehensive Hip Fracture Programme in a New Acute Collaborative Hip Unit in a UK Hospital ��24 Are Oxygen Alert Cards Recommended by the British Thoracic Society Serving their Intended Purpose? : Our experience in a district general hospital ��25 Research in learning difficulties ��27 ‘When things get on top of me...’ Deliberate Self-Harm in Children and Young People: Implications for medical professionals ��27 The MaZon toolkit: Improving quality and efficiency in mental health services in a financially challenged NHS ��28

What I Wish I’d Known: Can We Improve Preparedness Amongst Junior Doctors? ��30 Physical Health Initial Objective and Subjective Assessments by Medical and Nursing Staff: A comparison ��31 An evaluation of waiting times after the introduction of electronic requests in East London Forensic Services ��32 The Cultural Humility Model of Cross-Cultural Communication Skills Training ��33 Children who Sexually Abuse other Children: A survey of young and teenage sexual offenders ��34 Breast Cancer Risk Factors in South Asian Women Presenting with Breast Cancer at the Nightingale Centre, Manchester ��35 An Integrated Approach to Health Service Delivery ��35 From Zero to Comprehensive Fracture Liasion Service within Existing Resources ��36 Comparison of Prognostic Indices in Symptomatic and Screen-detected Invasive Breast Cancer in Asian and Caucasian Women ��38 Do Disparities Exist in Surgical Treatment and PostMastectomy Reconstruction between Asian and Caucasian Patients Diagnosed with Breast Carcinoma? ��39 Why We Need the Model for Improvement? ��40

Editorial Advisory Board Professor Rajan Madhok

Mr Vipin Zamvar

- Chairman BAPIO

- Consultant Cardiothoracic Surgeon, Edinburgh and Editor in Chief,

Professor Davinder Sandhu

Journal of Cardio Thoracic Surgery

- Professor of Medical Education, University of Bristol

Dr Arun Baksi

Professor Dinesh Bhugra

- Honorary Consultant Diabetologist, and Founder Editor Practical Diabetes

- Professor of Institute of Psychiatry and President World Psychiatric Association

Professor Aneez Esmail

Professor Raman Bedi

- Professor of General Practice, Associate Vice-President,

- Head, International Centre for Child Oral Health

Social Responsibility & Equality and Diversity

Dr Zulf Mughal - Consultant in Bone Disorders & Honorary Senior Lecturer in Child Health

Mr Keshav Singhal

Professor Terence Stephenson

- Consultant Orthopaedic Surgeon, Princess of Wales Hospital, Bridgend

- Professor of Child Health, Institute of Child Health and Chair,

Professor Mala Rao

Academy of Medical Royal Colleges Professor Elisabeth Paice OBE

- Professor of International Health, University of East London, Head of Public Health Workforce and Capacity, Department of Health in England

- Chair NWL Integrated Care Management Board,

Professor Bhupinder Sandhu

Past Dean Director London Deanery

- Professor of Paediatric Gastroenterology and Nutrition, Bristol Children’s Hospital

AcknowledgEments: The Publishers wish to thank the sponsors for their support: • Mead Johnson Nutrition • Weston Area Health NHS Trust • Medical Defence Shield • Fortis Healthcare • Priory Hospital The Physician - ISSN - 1987 - 6329 is published quarterly by BAPIO Publications Ltd. Published on behalf of British Association of Physicians of Indian Origin. Disclaimer: The opinions and views expressed by the author in his magazine are not necessarily those of the editor or the publishers. Although, care is taken in preparation of this publication, the editors and the publishers are not responsible for any inaccuracies in the articles. Great care is taken with the regards to artwork supplied, the publishers cannot be held responsible for any loss or damage incurred. The Physician • Vol 3 Issue 1 • November 2014

Messages

Message from Guest Editor Inequality and Diversity When I was growing up in India, I often heard about how “Unity in Diversity” was one of the pillars of the Indian nation. Diverse ethnic populations thrived in the melting pots of Bombay, Delhi and other metros. However, there was always an undercurrent of inequality behind the facades of these slogans, and beyond

Mr Vipin Zamvar Guest Editor

the major cities.

This issue of the Physician also highlights some of the various quality improvement projects in the NHS. Dr Abhaya Gupta describes how a geriatrician-led system for the care of elderly patients with hip fracture improves outcomes. Many may consider this a no-brainer (quality improves if you shift responsibility for care of elderly patients with multiple comorbidities from orthopaedic surgeons to any other group of physicians) (apologies to my many orthopod friends).

Inequality thrives at various levels even in the UK. Social scientists and politicians debate a lot about our unequal society, and have at times diametrically opposite ideas for dealing with it. However, there is another kind of inequality that affects mainly

Prof. Bhugra explores how cultural influences play an important role in the patient-physician relationship. It behoves physicians to be aware of the cultural beliefs of the patients they serve.

the minority groups in the UK. As you skim through this issue

Prof. Sandhu explores the various factors that motivate doctors.

of the Physician, you will come across many articles that explore

Very poignant is his quotation of Muhammad Iqbal’s epic poem

why South Asians lag behind in many of the health indicators in

“Khudi ko kar buland itna ke har taqder se pehle khuda bande

areas as diverse as mental health, and breast cancer.

se khud pooche, bata teri raza kya hai”. “Rise to such heights

Mammographic technical quality appears much lower for Asian

that God himself asks you, what do you wish your fate to be”

women who cannot understand English (page 23); Significant

With this meeting in Manchester (Towards excellence in patient

disparities exist in post-mastectomy breast reconstruction

care), and with this issue of the Physician, if young BAPIO

between Asian and Caucasian women in Manchester (page

members can feel motivated to dream on and look beyond the

39); Breast screening uptake rates remain low in ethnic minority

immediate horizons, BAPIO would have partly served its mission.

women (page 38). “Sitaron se aage jahan aur bhi hai, aur bhi hai”. Inequality is suffered not only by the recipients of healthcare, but by the providers as well. A recent GMC report concluded

Vipin Zamvar

that Black and Ethnic Minority doctors from the UK are twice as

Consultant Cardiothoracic Surgeon,

likely to face sanctions from the GMC compared to White UK

Royal Infirmary of Edinburgh, Edinburgh

medical graduates.

zamvarv@hotmail.com

Message from Editors A peer reviewed medical journal was conceived by British

‘The Physician’ provides a perfect opportunity for doctors to

Association of Physicians of Indian Origin (BAPIO) as part of

showcase their contribution to Education and Research. We

its continuous education platform and an evidence of BAPIO’s

urge all, especially young doctors to use this vehicle to enhance

commitment to enhance Good Medical Practice. ‘The Physician’

their career.

was launched in 2012 at the Wembley Stadium by Lord Ajay We would like to thank all the members of Advisory Editorial

Kakkar.

Board and the colleagues who have given time to contribute

Dr Ramesh Mehta

We are pleased to publish this special edition to coincide with

to this special edition of ‘The Physician’. We acknowledge the

Editor-In-Chief

the BAPIO Annual Conference which has attracted a high

support provided by Mr Vipin Zamvar who so kindly agreed to

caliber of presentations on innovation and academic excellence.

be our Guest Editor. We also thank Mr Buddhdev Pandya MBE,

The Editorial team has thus decided to include the abstracts

the Managing Director for coordinating the publication process.

of both oral and poster presentations at the conference. We were pleased to see the overwhelming response and the high quality of the work. Due to space constraints we could not

Dr Ramesh Mehta

accommodate all the abstracts.

President of BAPIO and

Readers will be pleased to see in this edition, the diversity of

Consultant Paediatrician

the academic subjects from motivation and leadership to future care of elderly and dementia. There is discussion on ‘Model for

Dr Parag Singhal Editor

Improvement’ to Health Care and clinical topics like diagnosis

Dr Parag Singhal

of breast cancer and solid tumours. We are committed to

Hon Secretary of BAPIO and

promoting academic excellence through ‘The Physician’. Your feedback will be much appreciated.

Consultant Endocrinology and Diabetes Mellitus,

The Physician • Vol 3 Issue 1 • November 2014

Placebo Response and Culture Dinesh Bhugra FRCP, FRCPE, FRCPsych, FFPH, MPhil, PhD* Professor of Mental Health & Cultural Diversity Institute of Psychiatry, King’s College London PO 25, Health Service & Population Research Department, London, UK Email: dinesh.bhugra@kcl.ac.uk Dr Antonio Ventriglio Department of Clinical and Experimental Medicine, University of Foggia, Italy Via G. Marconi, 3; 71041, Carapelle (FG), Italy; email: a.ventriglio@libero.it

Introduction Cultures define who we are, how we are brought up, how we describe distress and how we seek help as well as the sources of help we choose. Medicine as a discipline has its own cultural values which at times may conflict with broader cultural values. Understanding the culture of medicine may help the patient engage better with physicians and may make right therapeutic intervention readily acceptable. Cultures encourage individuals, their carers and families to accept what is acceptable in treatment at all levels. Cultures can influence whether individuals see tablets, capsules, injections or syrups as more potent as well as readily acceptable. In addition, cultural factors embedded in individuals and their families play a major role in the therapeutic alliance, even though often these are ignored.

emphasising that in spite of common experiences of what may be deviant or abnormal, the experience of illness is far broader than disease and they do not map clearly on to each other, while their respective trajectories and outcomes may well be distinct.2 A key aspect of therapeutic alliance is the commonality of explanatory models which is often rare, as physicians may well have medical explanations whereas patients and their families may believe in natural, supernatural, social or mixed causes; this would add to a disjunction between the patients and their doctors.

Cultural variations in treatment responses have been studied, but not widely, while the role and type of medication have not been explored at length. In this essay we explore the role of placebos and their acceptance for treatment, as well as the roles the placebo can play and the cultural understanding of various factors. Disease and illness: The practice of medicine focuses on disease, and physicians are trained to explore and diagnose diseases which are seen as abnormal structures or the functioning of body or organs related to medical understanding of pathology and abnormal physiology. These are thus medically constructed and physicians are trained to identify these and deal with them. On the other hand patients and their carers and families are often interested in the altered state of being and functioning which interferes with their daily living. This experience is defined as illness and is socially and culturally constructed.1 Thus, these differences are not only constructed differently according to patient and physician perspectives, they will have different models explaining these experiences, the resulting distress and where and how help is sought to deal with these experiences. Cultures and societies define what is seen as abnormal or deviant, and how health resources are allocated. It is worth

In addition, both patients and doctors have certain expectations from the therapeutic encounter. Kleinman3 observed that in Taiwan, patients expected their Western doctors to provide injections and not to spend time on answering questions or giving explanations, whereas Chinese medicine practitioners were expected to provide herbal treatments, to remark on symptoms and diet and to answer questions. This clearly indicates patient expectations which may well have changed of late due to increased and easy access to information about symptoms. When seeking help, patients and their families also expect certain levels of healing which have been described as being of three types: natural, inter-personal and technological.4

Placebo: The word placebo is derived originally from Latin, and its literal meaning is ‘I please’. Placebos in medicine have been used for centuries.5 It is fairly well established that even inert substances

The Physician • Vol 3 Issue 1 • November 2014

As mentioned above, expectations drive the placebo effect.18 In cultures where the patient has different expectations from their doctors and would want their doctor to make the decisions for them, it will be interesting to explore the effect of the placebo. The placebo effect has been compared to that of the healing effect shown by shamans.19

can and do produce significant effects on individuals, even though sometimes it is not entirely clear how these effects occur.6 Often their effect is seen as a negative one.7 Placebo response: It has been argued that the response to a placebo is very strongly affected by a number of factors including colour, name, origin, appearance and route of administration of the substance.8 It is inevitable that individual personality traits of patients will also play a role in the placebo response.9 Cultures influence cognitive schema through child rearing patterns which can be very culture-specific, and thus directly and indirectly affect personality development. Interestingly, it has been argued that the placebo effect occurs as a result of classical conditioning.10 There is no doubt that information processing plays a major role in the placebo effect.11 Cultural patterns of information processing will influence the processing of information. Miller et al3 suggest that the placebo effect primarily influences illness and affects disease only minimally, if at all. Colour of medication: Not surprisingly, patient compliance with medication has been shown to be strongly associated with how the medicine is perceived to be and what its actions are likely to be.12 The actual size and colour of tablets play a major role in giving a clear message to the patient. It has been shown that tablets which are blue are seen as more depressant-sedative, while yellow capsules are seen as stimulant-antidepressant.13 Blue preparations are generally seen as more soothing, whereas red, yellow or pink are seen as stimulating.14 In a systematic review, De Craen et al15 confirmed that red, yellow and orange drugs were associated with a perceived stimulating effect, whereas blue and green tablets were seen as calming. These authors15 note that stimulant medication was marketed in ‘hot’ colours – red, yellow or orange tablets – whereas antidepressants tended to be marketed in ‘cool’ colours such as blue, green or purple. Schapira et al16 observed that symptoms of anxiety were most likely to respond to green tablets, while those with depressive symptoms appeared to respond to yellow tablets. Among student volunteers, red tablets tended to act as stimulants, whereas blue ones acted as depressants; two tablets were seen as having more effect than one.17 6

Cultural variations: As cultures determine the cognitive schema and the interpretation of symbols, their impact on individuals needs further exploration. Buckalew and Coffield13 reported that white capsules were seen as analgesics by Caucasians, but as stimulants by African-Americans; whereas black capsules were seen as stimulants by Caucasians and as analgesics by African-Americans. These studies need to be replicated to ascertain whether these effects are still in existence. Sedating agents produced more sedation in individuals who were passive and intellectually-oriented, whereas those who experienced paradoxical reactions (i.e. agitation and anxiety) were more likely to be action-oriented and athletically inclined; thus personality traits may influence the pharmacodynamics and pharmacokinetics.9 As mentioned above, cultures influence personality development, which requires further exploration. In many cultures explanations of their illness and perceptions about their faith affect responses to illness and treatments. Faith in the medical system and in the prescribing doctor will affect engagement, as well as the therapeutic alliance. Often in clinical trials these aspects are not explored at all, where in some cultures they may well play a major role in producing a therapeutic effect. This observation therefore, raises significant questions about what individual perceptions and causations of illness and expectations from the treatment in general and medication in particular are. It is possible that any strong expectations of efficacy or expectancy (defined as experienced likelihood of an outcome or an expected outcome) may well give rise to the experience of benefit, thereby becoming a self-fulfilling prophecy. As noted above, as classical conditioning plays a role in the placebo response, so do the verbal suggestions and behaviours of health professionals,10 which vary across cultures and thus require further study. Cognitive modulation: Cultural symbols and their meanings determine therapeutic adherence and alliances. In traditional (technologically less advanced) societies, patients and their carers seek explanations in natural or supranatural causes, but expect the healer to identify the cause and propose appropriate rituals for its negation. On introduction of Western medicine into these cultures, in the early stages both systems may well be used simultaneously, simply to complement each other.

The Physician • Vol 3 Issue 1 • November 2014

Review

Psychiatric Treatment 2013; 19: 162–170.

The Way Forward: Researchers need to explore cultural factors in acceptance of medication and the role that plays in the therapeutic alliance and adherence. It is crucial that the symbolism of physical treatment options available to patients, their carers and families, and the therapeutic interaction are explored in both qualitative and quantitative manners.

6. Ross S, Buckalew LW. On the agenting of placebo. American

How cultural and ethnic groups see the form of medication and associated factors, and whether that determines engagement and also perceived and real outcomes must be explored. Perceived potency of the pills or capsules needs to be incorporated in the therapeutic encounter so that adherence and alliance can be improved.

with a placebo test. Comprehensive Psychiatry 1968; 9: 118–137.

Understanding patients’ explanatory models and their pathways into care must form the basis of the start of the therapeutic interaction. Physician communication affects the therapeutic alliance, and that in turn influences a response which may be attributable to the placebo effect.20 Evaluating the efficacy of any therapeutic interaction has to take into account the placebo effect and cultural variations and expectations, as the placebo effects are mediated through symbolism as well as the perception of the healer by the patients and those who care for them. As most clinical trials are now being conducted in China, the Indian subcontinent and Eastern Europe, it is an opportune time to explore relationships between psychological mediators in the placebo response and their cultural and biological substrates. Dietary habits, smoking patterns, pharmacodynamic and pharmacokinetic differences in the metabolism of drugs vary according to ethnicity and affect drug absorption, metabolism and excretion. These need careful exploration and assessment in drug trials as well as clinical practice. Mind–body relationships can be better explored in the context of the placebo response, and health care professionals need to be aware of the impact which placebos can have on psychiatric as well as on physical conditions.

Psychologist 1979; 34: 277–278. 7. Huculak S. Attempting to define placebos and their effects: a keywords approach. BioSocieties 2013; 8: 164–180. 8. Shapiro AK, Wilensky H, Struening EL. Study of the placebo effect

9. Janke W. Response variability to psychotropic drugs: overview. In W Janke (Ed.) Response Variability to Drugs. New York: Pergamon, 1983, pp 217–260. 10. Foot D, Ridge D. Constructing the placebo effect in the placebo wars: what is the way ahead? Sociology Review 2012; 21: 355– 368. 11. Colloca L, Miller FG. How placebo responses are formed: a learning perspective. Philosophical Transactions of the Royal Society B 2011; 366,doi:10.1098/rstb.2010.0398 accessed June 19, 2014. 12. Buckalew LW, Sallis RE. Patient compliance and medication perception. Journal of Clinical Psychology 1986; 42: 49–53. 13. Buckalew LW, Coffield KE. An investigation of drug expectancy as a function of capsule color and size and preparation form. Journal of Clinical Psychopharmacology 1982; 2: 245–248. 14. Buckalew LW, Ross S. Relationship of perceptual characteristics to efficacy of placebos. Psychological Reports 1981; 49: 955– 961. 15. De Craen AJM, Ross PJ, de Vries AL, Kleijnen J. Effect of colour of drugs: systematic review of perceived effect of drugs and of their effectiveness. British Medical Journal 1996; 313: 1624–1626. 16. Schapira K, McClelland H, Griffiths NR, Newell DJ. Study on the effects of tablet colour in the treatment of anxiety states. British

References

Medical Journal 1970; 2: 446–449.

1. Eisenberg L. Disease and illness. Culture Medicine and Psychiatry 1977; 1: 9–23. 2. Stoeckle J, Zola IK, Davidson G. The quantity and significance of psychological distress in medical patients. Journal of Chronic Disease 1964; 17: 959–970. 3. Kleinman A. Medical and psychiatric anthropology and the study of traditional medicine in modern Chinese culture. Journal of Institute of Ethnology. Acad Sinica 1975; 39: 107–123. 4. Miller FG, Colloca J, Kaputchnik T. The placebo effect: illness and interpersonal healing. Perspectives in Biology and Medicine 2009; 52: 518–539. 5. McQueen D, Cohen S, St John-Smith P, Rampes H. Rethinking placebo in psychiatry: the range of placebo effects. Advances in

17. Blackwell B, Bloomfield SS, Buncher CR. Demonstration to medical students of placebo responses and non-drug factors. The Lancet 1972 (June 10); 1279–1282. 18. Justman S. Placebo: the lie that comes true. Journal of Medical Ethics 2013; 39: 243–248. 19. Kaptchuk TJ. Placebo studies and ritual theory: a comparative analysis of Navajo, acupuncture and biomedical healing. Philosophical Transactions of the Royal Society B 2011; doi: 10.1098/rstb.2010.0385 accessed 19/06/2014. 20. Verhulst J, Kramer D, Swann AC, Hale-Richlen B, Beahrs J. The medical alliance: from placebo response to alliance effect. Journal of Nervous and Mental Disease, 2013, 201(7), 546–552.

The Physician • Vol 3 Issue 1 • November 2014

Opinion

Motivation and its Relevance for Doctors and the Learning Society Professor Davinder P S Sandhu MD, FRCS (Ed.Urol), FRCS (Eng & Glas), Cert.Med.Ed, FRCPE, FDSRCS(Eng), FRCGP(Hons). Prof of Medical Education University of Bristol Senate House, Tyndall Avenue, Bristol, BS8 1TH. UK Email: davinder.sandhu@bristol.ac.uk

“Khudi ko kar buland itna ke har taqder se pehle Khuda bande se khud pooche bata teri raza kya hai.” “Tu agar mera nahi banta, na ban, apna toh ban, Tu jhuka jab ghair key aagey, na tan tera na mann, Apney mann main dub kay pa ja suragh – e – zindagi,

Some patriotic and powerful poetic lines from Allama Iqbal. Do they still apply to us and in what context? For some the above lines will be motivating. However they cannot do this unless they

(secrets of a great life) Tu agar mera nahi banta, na ban, apna toh ban.”

move us, unless we identify with the message and can make sense of it.

Muhammad Iqbal 1877 – 1938

The main reason why we have the capacity to be moved is that biologically we are endowed with a natural desire to develop ourselves. This is one of the reasons why evolution works because this intrinsic progression is part of the natural kingdom of all animal and plant cells. This article explores the intrinsic motivation of human beings, and the fact that doctors hold a special place in society of having the trust of patients, and thus they have a natural role of being a leader, making motivation even more relevant. The credit for developing these ideas belong to the German neurologist and psychiatrist Kurt Goldstein (1878 – 1965) who introduced in his book “The organism: a holistic approach to biology derived from pathological data in man” in 1934, the term self-actualization. Sadly Goldstein faced much turmoil in his life having being dismissed from his professorial post in Berlin by the Nazis in 1933.

Brooklyn College NY, he was influenced by many European intellectuals that were immigrating to the US, and Brooklyn in particular, people like Adler, Fromm, Horney, as well as several Gestalt and Freudian psychologists. Later when he held the position of Chair in Psychology at Brandeis University Massachusetts he met Goldstein and no doubt the latter inspired Maslow to continue to develop his theory of ‘Hierarchy of Needs’ (Figure 1). Maslow takes us from our basic needs such as food, water and sleep to the highest level of development where we can use our imagination, come up with creative ideas and embed them if they have value into innovation. As doctors we have a duty to

The other tragedy was the title of the book which nobody understood and so failed to attract an audience. Goldstein eventually moved to the United States where he met Abraham Maslow (1908 – 1970) who further developed Goldstein’s theory in his book, “A theory of motivation”. Maslow’s path of development is interesting as he first studied law in New York and then switched to study Psychology at the University of Wisconsin. While he was teaching Psychology at

The Physician • Vol 3 Issue 1 • November 2014

our patients and Maslow has placed the ethical aspect morality right at the top. Morality is something that defines a medical professional – ‘a doctor is a professional who does the right thing for his patients even if no one is watching’. And to achieve this we need the principles of “common sense, good manners and morality”. More recently Daniel Pink in his book “Drive” endorses that there are three characteristics of professionals. They like a degree of autonomy, have a natural motivation to achieve mastery and finally they wish to be recognised for their achievements. For all professionals in senior leadership role in their organisation who desire to improve productivity and quality of outcomes, whether it is patient care or reduction in waste the above is critical. This is because it is related to behaviour.

develop themselves, they need to bring their competence in the real world of ‘culture’ where we all exist. We treat and work with people who are different to us and they change all the time. They look, sound and dress differently. They eat different food and their rituals and festivals are strange. Certain customs such as bereavement has different connotations. Thus as leaders we need to be sensitive to the needs of our patients and colleagues. Amongst many similar and overlapping leadership theories is Daniel Goleman’s ‘emotional intelligence’. We are all human and thus emotional. Emotions are the sine qua non of being human. Emotional intelligence is our capacity to read and respond appropriately to people. This is important for achieving capability in the role of being a doctor especially in independent practice. The commonest cause of complaints against doctors, whether by patients or the increasing number from other doctors is related to attitude. Recently culture has gained a higher profile through the Ebola virus crisis realising that we live in a global world which is increasingly becoming smaller by air travel and 24/7 media. Our students do electives all over the world and equally our patients can come from any part of the globe. In medical education we try and embed the principles of emotional intelligence by understanding ‘adaptive learning’. What this means is an appreciation that every learner is unique. We learn at different paces, we bring different experiences into our sphere and we absorb different things. We also leave with different information.

As leaders we are entrusted to develop our organisation and the people who work in them. People won’t judge you by what you say but much more by how you act. There is therefore a natural progression to behaviour determinants rather than knowledge. George Miller’s (1919 – 1998) triangle captures this well for medical training (Figure 2). Miller’s original triangle has been adapted to take in cognition and behaviour. At the very bottom is knowledge. Knowing comes from knowledge. The more you know the more knowledge you have. This was how medicine was taught. Knowing is no longer good enough. It is how the knowledge is applied, under “knows how” that matters. This implies a degree of sophistication as judgement is required as well as prioritisation ability. The next two domains which relate to behaviour are directly related to patients. It is one thing to become competent but how is this competence demonstrated when faced with a real patient. And finally – does - how skilled are we in independent practice. There is also a subtle difference between being competent and being capable. Competence defines what we know in terms of knowledge, skills and attitude. Capability is more comprehensive and at a higher plane in that this relates to the ability to change, generate new knowledge, and improve performance. Doctors deal with people who are mostly strangers, and to

Our learning is trust based and this includes an appreciation of our diversity. Howard Gardner’s multiple intelligences’ theory demonstrates our diversity as some are musical, others strong in languages and others still in spatial or mathematical or interpersonal or intrapersonal skills. We may think we know ourselves but this is not true. We are blind to some aspects of ourselves that others can see. Tragically for us there is the unknown box of Johari’s window that neither we nor others are aware of our full potential. Maslow‘s famous quote “the story of the human race is the story of men and women selling themselves short” comes to mind. All this questions what is education and how can it lead to selfactualisation? Part of the answer lies in the self-determination theory which distinguishes between two types of motivating conditions: controlled and autonomous. Controlled motivators are all accompanied by either explicit or implicit rewards or punishment. People thus act with a sense of pressure and anxiety. This can in education take the form of rote learning which is short lived and poorly integrated into the students long term values and becomes de-motivating. Autonomous motivators are those personally endorsed by the learner and reflect what the individual finds interesting and important. This leads to greater

The Physician • Vol 3 Issue 1 • November 2014

Opinion

conceptual understanding and deep learning through powerful internal motivation.

Fig 1. Maslow’s Hierarchy of Needs

The key here is reflection which serves many functions and occurs naturally in response to complex and new problems. It is also demonstrated in anticipation of challenging situations. Reflective practitioners are able to assess a situation both from the theoretical background and practical experience. Feedback is essential for reflection and the highest form of feedback is self-feedback. We know when something does not go well or we excelled. Donald Schon (1930 – 1997) and the great American philosopher John Dewey (1859 – 1952) would say that education is the re-organisation of experience. Change is the default position and we are in a continuous process of transformation. We must learn to guide, influence and manage these transformations. We must make the capacity for undertaking them integral to ourselves and to our institutions. Thus reflection as the natural vehicle of education is a key part of learning processes in general, and conceptual and perceptual change in particular. Therefore education should not be thought of as a segregated activity, conducted for certain hours, in certain places, at a certain time of life. It is an everyday occurrence and intrinsic to us as we seek to develop mastery. We are indeed part of the learning society. It is the aim of society to fit in with our own development of understanding our environment. This has relevance to our own intrinsic motivation coping with change. We struggle to understand or are surprised by the results of change which can be unexpected, and therefore are forced to think creatively in order to resume control of our shifting environment.

PROFESSIONAL PRACTICE

Fig 2. Miller’s Triangle

To develop this further within the role of medical education and to quote like Iqbal, John Dewey’s inspirational message, “we need to cease conceiving of education as mere preparation for later life, and make it the full meaning of the present”. This is how we connect with the world.

The assessment of clinical skills / competence / performance

Does CSA

CSA

Shows How Knows How

BEHAVIOUR Performance

Competence

COGNITION AKT

Knows

Knowledge

Adapted from Miller GE.

Action

WPBA

The Physician • Vol 3 Issue 1 • November 2014

Dementia in South Asians in the United Kingdom: An overview Mansoor Shawl1, Iracema Leroi2,3, J S Bamrah2 North West Deanery, Greater Manchester

Manchester Mental Health and Social Care Trust

Manchester Academic Health Sciences Centre

Address for correspondence: Dr Mansoor Ahmed Shawl ST5 Trainee, Department of Old Age Psychiatry, Rawnsley Building, Manchester Royal Infirmary Manchester M13 9WL (UK) email: mansoorshawl@yahoo.com

Abstract Dementia is now a major public health concern in the United Kingdom (UK), with rates of dementia increasing steadily. Amongst elderly migrants and Britons of South Asian origin rates of dementia are significantly higher compared to white British elders. However, the rate of help seeking and receiving a formal diagnosis of dementia within these communities is significantly lower than in white communities. The South Asians who arrived in UK in the middle of the last century are entering old age. Their health needs are increasing and since age is the main risk factor for developing dementia, the prevalence of dementia in this community will also rise significantly. This escalation will have implications for memory services and as well as for local communities and the resources needed to support elderly people. This article will provide an overview of various aspects of dementia within the South Asian community in the UK. We will highlight the marked discrepancy in rates of diagnosis and access to care services in South Asians elders as compared to their white British counterparts. We will outline the progress that has been made thus far in making services more accessible to the specific needs of the South Asian community.

Introduction Dementia is a clinical syndrome characterised by global cognitive impairment, which represents a decline from previous levels of functioning and is associated with impairment in functional abilities and, in many cases, behavioural and psychiatric disturbances.

this is expected to double every 20 years with a resulting upsurge in the already significant negative economic and societal impact. Currently the total estimated cost of dementia worldwide is US$604 billion (£380 billion). Detection of dementia in its early stages is infrequent and as many as 28 million people living with dementia worldwide do not have a diagnosis and access to care. The prevalence of dementia in the United Kingdom (UK) is 1.3% and it is estimated that over 800,000 people are currently living with some form of dementia. Of these, nearly 25,000 are from ethnic minority groups. The UK, like India, has an aging population however in the UK, the population of people aged 65 and over is expected to rise to 23% by 2035 and considering that age is the most important risk factor for the development of dementia, it is expected that the current prevalence of dementia in the UK will rise to over one million by 2025 and to over two million by 2051 (All-party Parliamentary Group on Dementia, 2013). In contrast, in India, there will be less than 10% of people aged 65 by 2035 .This discrepancy is due to India having a low percentage of the population currently over the age of 65, as compared to the UK (Matheson, 2010).

The most common form of dementia is Alzheimer’s disease (AD), representing three quarters of all cases of dementia (Ot et al., 1995).

The number of people from ethnic minority communities with dementia, particularly those of South Asian origin, which is the largest non-European community in the UK, is projected to increase to 170,000 by 2051.

There are currently nearly 36 million people with dementia in the world and

This is a seven fold increase, which is considerably greater that the projected two fold increase in the UK population in general (Alzheimer Society, 2013). This rise in dementia prevalence may

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in part be explained by the high rates of vascular risk factors which are associated with the emergence of dementia. For example, the prevalence of adult-onset type 2 diabetes is three to five times higher in the South Asian community as compared to the white population (Oldroyd et al, 2005). Moreover, there is a high prevalence of hypertension and stroke in this community (Cappuccio et al, 2003). In this article we will focus on the challenges around the diagnosis of dementia in South Asian communities in the UK, the role of the caregivers in supporting people with dementia, and the specific obstacles that people from ethnic minorities have to face when they access local health services.

Low rates of diagnosis of dementia in South Asian communities One of the key challenges in the diagnosis and management of dementia in the South Asian community in the UK is the marked

discrimination along with a perception of living in a discriminatory society add to the ethnic inequalities in health (Nazroo, 2003; Rait et al, 1997). Finally, within South Asian communities, physical health has tended to be the focus of attention rather than mental health, including dementia, resulting in a marked disparity in the rate of consultations for physical health as opposed to mental health issues (Nazroo, 2003). In some cases, help seeking for mental health issues may be actively discouraged by the community or family members. The reasons of under-utilisation of memory service by the South Asian community in the UK are complex and compounded by a lack of knowledge of the services that are available locally as well as reluctance to approach services due to the belief that they are culturally inappropriate and would not meet the needs of the help seekers. The relative dearth of South Asian workers within the services is also a contributing factor. At a primary care level, general practitioners (GPs) find it hard to detect memory impairment in South Asian patients as there is often a reluctance on part of the patient and their family to have a diagnosis, which may stem from an incomplete understanding of the concept of dementia (Seabrooke et al, 2004).

Experiences of South Asians within memory services

variation in the rate of diagnosis compared to white British elderly. Overall, less than 50% of those in the UK in general with dementia receive a formal diagnosis and therefore may not have access to care and support. Notably, the ethnic minority community is substantially overrepresented in the proportion of those without a formal diagnosis (World Health Organization, 2010). There are several reasons for this. Firstly, there is often a lack of awareness and knowledge about the dementia syndrome within ethnic minority communities in the UK and cognitive decline is often regarded as an aspect of ‘normal ageing’ (Moriarty et al, 2011). This attitude may lead to a sense of therapeutic nihilism on the part of family and caregivers, and help seeking may only take place at a point of crisis or at a stage when symptoms are severe and families can no longer cope on their own. Secondly, among ethnic minority communities in the UK, there appears to be a pattern of under-utilisation of health care services in general (Purandare et al, 2007), which is even more pronounced for memory assessment services. Thirdly, there is a clear link between health inequality and socioeconomic inequality. Experiences of racism and

Memory services in England, and generally in the UK, are overwhelming situated within secondary care departments of later life psychiatry, which are part of mental health trusts in the National Health Service (NHS). This contrasts with most other health systems worldwide where dementia care and memory services are often situated in departments of geriatric medicine or neurology. The NHS was founded in 1948 and is one of four publically funded healthcare systems in the UK primarily funded through central taxation. This means that a full range of health services, including memory or dementia services are free at the point of use, catering to the needs of the population from ‘cradle to grave’. Since dementia care is multi-faceted and involves several agencies and disciplines, it also reaches beyond the NHS and is offered by social services, usually under the jurisdiction of the local authority or city council. This ‘social care’ is variably funded and often means tested, implying that below a certain income threshold, users of the service are not required to pay for services. These will include personal care at home, day care services and residential care homes. As for the medical assessment and health care of people with dementia within later life psychiatry, there is often a ‘Memory Assessment Service’ that accepts referrals from GPs in primary care. Most often, a psychiatric nurse will conduct an initial screening assessment at a domiciliary visit followed by a consultation by an old age psychiatrist in order to obtain a

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specific diagnosis and treatment plan. Allied health services such as occupational therapy and psychology will then get involved if appropriate and referrals to social services for consideration of a ‘care package’ or caregiver support will be made. This system described above has until very recently been planned and delivered in England through the Department of Health (DH) by means of a range of regional strategic health authorities (SHA) and primary care trusts (PCTs). However, in April 2013, a new system was established through the Health and Social Care Act 2012 and all NHS Trusts are now expected to be commissioned through newly established ‘Clinical Commissioning Groups’ (CCGs) which are being clinically led by local GPs in each area. The aim is to give GPs and other clinicians the power to influence commissioning decisions for their patients and ensure that the local health services offered by the NHS are appropriate to the needs of the surrounding community. Thus, it has become extremely important for memory services in England to understand fully the specific demands and needs of their patients to ensure that the correct services are being commissioned. Within the North of England particularly, where South Asian communities are well established, culturally

assessment tools which are culture-, education- and language‘neutral’ and suitable for the clinical setting (Rait et al, 1996). Furthermore, if translators are available, which is usually at a significant cost to the NHS, aspects of subjective emotional states are often rendered lost in translation. Available assessment tools, particularly neuropsychological test batteries, may overestimate the severity of cognitive impairment in people with lower levels of education or those who are not proficient in English (Moriarty et al, 2011). Additionally, if a patient reaches the point of a diagnosis of dementia, their care is often further complicated by a high rates of comorbid medical problems. Specifically, ,the South Asian population has a higher rate of vascular risk factors such as type two diabetes and hypertension than Caucasians (Khunti et al, 2009; Knight et al,1993). This means that South Asians have a higher risk of developing vascular dementia or cerebrovascular disease that worsens the course of all forms of dementia.

Impact of dementia on caregivers

appropriate services have to be better developed. Furthermore, health inequalities across England are marked and cities in the North, particularly within immigrant and ethnic minority communities, have the highest rates of morbidity and lowest rates of life expectancy in the country. This also impacts of the rates of both undiagnosed and diagnosed dementia. For example, Manchester is ranked last out of 150 local authorities in terms of the ‘worst health’ indices, life expectancy. In 2012, northern cities such as Manchester had amongst the highest rates in England of cardiac disease, stroke and diabetes, conditions which are particularly common in South Asian communities and are clear risk factors for developing dementia. If people from ethnic minorities do manage to present to local services with memory problems, they often face significant hurdles. There are no easily accessible and valid dementia

In the UK over 670,000 people act as primary unpaid caregivers for people with dementia. This saves the NHS estimated £11 billion every year (Knapp et al, 2007). Being cared for at home can be cost effective (Lance M et al, 1998) and it may also reduce the risk of dying (Lankers D et al, 2010); however it often leads to significant strain on caregivers and may lead to burnout. Ethnic minorities generally live in close knit communities and take pride in looking after their loved ones. Thus, the needs of caregivers within these communities need to be carefully considered. The caregivers are generally women who are invariably daughters or daughters-in-law, and they may face significant social isolation and high levels of caregiver burden. In some cases, female family members are brought over from the home country to act as full time caregivers for the dementia sufferer. Such caregivers may be at even more at risk of segregation from the mainstream community and face loneliness and impaired quality of life since they have little opportunity to integrate into the new community, learn the

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language and develop an identity beyond the caregiving role. Furthermore, they may not seek help as they may not regard themselves as formal ‘caregivers’ but instead consider only their obligations to the family . Often there is the perception that only close family care is acceptable to meet the needs of the affected person and professional care services are ‘second best’ and only for those lacking in family support and belonging. Importantly, a fear of being criticised by their own community for seeking help and not coping with their own family issues is another barrier to seeking help (Moriarty et al, 2011).

The ones that do manage to seek help find that the dementia services are not culturally sensitive. There are different hurdles including difficulty in communicating with other people because of language barriers. (Alzheimer Society, 2013). In South Asian communities there is a greater stigma associated with dementia. The carers can also feel stigmatised because of their association with a person having dementia. This leads to reluctance in accepting service as there is a fear that it may result in the person’s dementia becoming public (Moriarty J et al, 2011). Looking after a patient with dementia can put considerable strain on the carers. It can affect carers’ mental as well as physical health. Women caregivers and those who come from a lower socioeconomic group are the most vulnerable. They experience higher levels of anxiety and depression (Sorensen and Conwell, 2011). Most caregivers provide 24 hour care for their relative without any respite. This results in burnout and frustration (Seabrooke et al, 2004). Policy issues affecting South Asian Elders with Dementia The medical targets for dementia care are as follows:

•

Early and more rapid diagnosis

•

Good quality care in the early stage

•

Attempt to delay progression

•

Good ongoing monitoring

A report published by the social services inspectorate found that older people from Black and Ethnic Minority (BME) communities suffer great disadvantage in accessing community care services. Another finding was that the services were not appropriate to meet the specific needs of this community. The recommendation was that professionals must be aware of the issues of race and culture and keep them at the forefront when setting up services rather than marginalising the needs of elders belonging to BME community (DH, 1998). The issue of ethnicity is addressed in the national dementia strategy (NDS). It emphasises that the needs of BME people may be different from the majority white population. Services need to take this into account. Professionals should be trained in a way that enables them to identify and understand the variable needs of people from BME groups (DH, 2009). Prime Minister David Cameron gave a new life to the National Dementia Strategy (2009) by setting up “Prime Ministers Challenge on Dementia” which states that ‘We must ensure that every person gets the treatment and support which meets their needs and their life’ (DH, 2012). As part of this strategy, an All-Party Parliamentary Group (APPG) on Dementia was established. It examined the experiences of people from BME groups living with dementia and the added challenges they face. A report making recommendations was published in 2013. It highlighted the importance of raising awareness about dementia, tackling modifiable risk factors, making services respond to the specific needs of the BME communities and sharing good practice (APPG, 2013).

Progress in memory services for ethnic minority communities In spite of the increasingly acknowledged obstacles to obtaining parity of dementia assessment and care for elders from BME groups, some progress is being made towards a wider recognition of the challenges faced in the diagnosis and management of dementia in South Asian community in the UK. In some places there are specialist ethnic minority dementia services. These include the Meri Yaadain dementia team (My Memories; see Box 1 below) in Bradford Alzheimer’s Society’s ‘Connecting Community’ project which works closely with community leaders to make sure that the informative material regarding dementia is meaningful and appropriate for diverse communities and LMCP Care link (Box 2) which works with the South Asian communities in Manchester and Trafford, and tackles issues of poor engagement, physical and mental health problems. These non-statutory services have played a role in reducing stigma, raising awareness of major health concerns such as dementia thus helping in early diagnosis and treatment (APPG, 2013). There are Asian elders’ resource centers that cater to the social, cultural, emotional and spiritual needs of the south Asian elderly population (Asian Elders Resource Centre, 2014).

Conclusions The Physician • Vol 3 Issue 1 • November 2014

In summary, the BME community in the UK faces many challenges with regards to accessing dementia services. There are cultural, social and medical barriers to them accessing health services and obtaining appropriate treatment. While nationally there are initiatives in this regard at the level of the government, it is too early to speculate that the drive to improve diagnostic rates will mirror in this community compared with Caucasians. There is an urgent need to target the BME community in the current programme by NHS England to break barriers of stigma, and offering culturally specific assessments, otherwise the NHS will continue to propagate a two-tier system in the assessment and treatment of dementia. Initiatives by some communities show pockets of success and could be replicated in other areas with a high BME population. Failure to do this will seriously undermine the ambition to fulfill the PM’s dementia challenge.

References

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Oldroyd J, Banerjee M, Heald A, Cruickshank K (2005) Diabetes and ethnic minorities. Postgrad Med J 81: 486–90 Ott A, Breteler M, et al, (1995) Prevalence of Alzheimer’s disease and vascular dementia: association with education: the Rotterdam Study. BMJ 310: 970-973. Purandare N, Luthra V, Swarbick C, Burns A (2007) Knowledge of dementia among South Asian (Indian) older people in Manchester, UK, Int. J. Geriat. Psychiatry 22(8): 777-81. Rait, G., Burns, A., & Chew, C (1996) Age, ethnicity and mental illness: a triple whammy. BMJ, 313, 1347-1348.

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Recent Advances in Shoulder Surgery

Vishal Sahni MB BS, MS Orth FRCS Surgery Glasgow, MCh Orth., Liverpool, FRCS Orth, London, MFSEM, Sports Injuries, Ireland Ashish Narang MB BS, MS Orth., MRCS Surgery, UK VS - Consultant Orthopaedics Surgeon with Special Interest in Shoulder and Elbow Surgery: Southport & Ormskirk Hospital NHS Trust and Renacres Hall Private Hospital; Honorary Senior Lecturer, University of Liverpool, Liverpool, UK AN - Clinical Fellow in Orthopaedics, Southport & Ormskirk Hospital NHS Trust

Introduction

has been successful in reducing pain and improving function

Being the most complex and mobile joint in the body, the shoulder joint is vulnerable to injuries and disorders. Shoulder surgery, especially arthroscopic, has evolved enormously over the last ten years, while newer techniques and instrumentation have facilitated the remarkable expansion of ambulatory or “day case” surgery.

in patients with an intact rotator cuff. But the results of Total Shoulder Arthroplasty in large or massive cuff tears are unsatisfactory due to sub-optimal function, eccentric glenoid loading and early loosening. These limitations were overcome in 1987 when Professor Paul Grammont described a new reverse prosthesis with improved biomechanics.4 The principles

History of Shoulder Surgery

of this design were inherent implant stability, convex glenoid

Almost a hundred years ago E.A. Codman published his first two known cases of rotator cuff repair, but they were not well received by the surgical community at that time. He in fact had to resign from the chair of the district surgical society. But this did not deter him, and in 1934 he authored the first book on shoulder surgery, The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa, a book that is still pertinent today and should be studied by any practising shoulder surgeon.1 The book was decades ahead of its time, as it described the pathology of rotator cuff disease, shoulder anatomy and biomechanics, shoulder rehabilitation, a classification of proximal humeral fractures, neurologic disorders about the shoulder, and tumours about the shoulder. Codman believed that critical avascular zones in the distal portion of the tendon predisposed it to calcification and degeneration, a theory which was never validated, but lately in vivo studies by Rudzki et al (2008) found a significant decrease in the vascularity of the rotator cuff after the age of 40, which correlates with the higher incidence of cuff tears in this age group.2

medialised and distalised centre of rotation.

component with centre at or within the glenoid neck, and

The next major contribution in the field of shoulder surgery was made by Dr Charles Neer, who described the classification of proximal shoulder fractures which is used to date.3 He explained the pathogenesis and the treatment of impingement syndrome and most importantly, he designed an implant for hemiathroplasty of the shoulder for comminuted fractures of the proximal humerus, which still derives its name from him. This was followed by the need for treatment of arthritis with massive cuff tears. The aim of shoulder surgery is to restore or replicate the anatomy of the glenohumoral joint and function of the rotator cuff. The conventional Total Shoulder replacement The Physician • Vol 3 Issue 1 • November 2014

Review

In the 1950s, Masaki Watanabe ¬– often called the “founder of modern arthroscopy” – developed the first practical arthroscope.5 Initially, use of arthroscope was limited to the knee, but many surgeons saw its use in the shoulder and began to apply it in the 1980s. The use of the arthroscope in shoulder surgery was a major milestone which led to the development of many new instruments and techniques. During the 1990s, the improvements in implants, fluid pressure pumps, shavers, radiofrequency devices and instruments improved, leading to almost every shoulder surgery being performed arthroscopically.

Knotless double row repairs: The use of fully threaded anchors and forming a knotless construct using two anchors medially and two lateral locks can provide a low profile secure fixation with increased tendon-to-bone contact.

Recent Advances in Shoulder Arthroscopes Shoulder arthroscopy has seen many advances in recent years which include both better technology and instruments, and use of newer techniques. Starting first with the most important instrument, the arthroscope, the use of magnifying lenses with fibre-optic technology and digital monitoring has tremendously improved the visualisation of the shoulder joint. These new scopes have smaller diameters with better fields of vision, better optics and better flow of fluid through the sheath. In addition to the commonly used 30 degrees scope, the new 70 degrees scope is useful in those difficult corners.

Suture anchors Suture anchors have undergone remarkable changes over time, and the newer designs have focused on greater load-to-failure strength, ease of insertion and ability to accommodate multiple sutures. The most recent innovations address the issue of potential revision surgery. Bioabsorbable suture anchors: Suture anchors basically function to attach soft tissues to bone; they were initially made of metal but lately have been replaced by bioabsorbable suture anchors. Bioabsorbable fully threaded suture anchors provide higher pull-out strength in poor quality bone. The fully threaded design also prevents anchor pull back, as seen in the countersunk design. Bioabsorbable materials: Composed of PLLA and ß-TCP, these have better osteoconductive and bioreabsorbable qualities leading to early bone formation.

All suture anchors have recently exploded on the market with a view to eliminating concerns of bone loss and hardware prominence. Made of high-strength polyethylene MaxBraid suture material with a polyester-sleeve anchoring element, the anchor is placed in a prepared hole. Then, when tension is applied to the sutures, the anchor sets by bunching up to a size larger than the prepared hole.7 Bioabsorable sutures with a titanium tip allow the direct push-in technique of suture insertion, minimising the need to prepare a bone channel for the lateral row, where soft tissue can sometimes obscure the view.

PEEK is another thermoplastic material used in suture anchors with excellent stability and biocompatibility.

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Shoulder Arthroscopy under Regional Block

Neer’s Prosthesis

The use of regional blocks after shoulder surgery was described as early as forty years ago by Winnie, who advocated giving a single injection after shoulder surgery.8 Two decades later Tuominen recommended continuous infusion of anaesthetic by an indwelling catheter. Initially regional blocks were used to supplement a general anaesthetic (the gold standard now is the ultrasound guided Inter-scalene Nerve Block), but recently many units (including my own) have started performing arthroscopic surgery under the nerve block alone and without a general anaesthetic in appropriate cases.

Copeland’s Shoulder Replacement: The aim of this design was to mimic anatomy as closely as possible and to replace the damaged surface with minimal interference. The use of a cementless technique and minimal bone loss were the mains advantages of this design.

The advantages of regional anaesthesia are decreased postoperative pain, as well as nausea and vomiting and a lower complication rate. There are further advantages of decreased time spent in anaesthesia rooms, decreased time spent in the post-anaesthesia unit and reduced total costs.

Shoulder Replacement The history of shoulder arthroplasty dates back to 1893, when a French surgeon Jules Emile Pean replaced a shoulder due to tuberculosis of the joint, where a humeral stem made of platinum and leather was used to articulate with a head made of rubber coated with paraffin. This was followed by Charles Neer in 1955 reporting the first simple, humeral prosthesis in a case of fracture of the humeral head. Neer emphasised that the soft tissue components of the procedure were the most important for stability and function, with the hemiarthroplasty providing a scaffold upon which to rebuild the shoulder. By the early to mid-1970s, several Total Shoulder Arthroplasty systems using a polyethylene glenoid component had been introduced. The first complete system was the Neer II, created by Neer and Robert Averill and introduced in 1973.9 Similar designs at that time included the DANA, St George, Monospherical, Cofield and Mazas, which had both unconstrained and semi-constrained options.

Newer stemless designs based on the same principles include the Simplicity and Eclipse from Arthrex, which by resecting a part of the head lead to lesser stretching of the rotator cuff and associated pain. These designs still preserve a lot of bone stock required for any revision.

Total shoulder arthroplasty or anatomical total shoulder arthroplasty has come a long way since its advent in the 1970s. The latest designs allow for accurate reconstruction of the proximal humeral head, taking into account variations in inclination angle, version and head offset. All these adjustments can be made with the humeral stem in situ using modular components. With anatomical reconstruction of the head and glenoid there is accurate balancing of the rotator cuff, leading to better functional outcomes.

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Arthroscopic Arthroplasty Treatment of bipolar osteochondral lesions in the shoulder of young patients is a challenge for the shoulder surgeon. Treatment by conventional shoulder arthroplasty carries the risks of glenoid loosening, osteolysis and polyethylene wear. One of the novel techniques used in this situation is the use of all arthroscopic biological shoulder resurfacing. This technique uses cadaveric osteochondral grafts from the humeral head, medial tibial condyle and tibial plafond performed through the rotator interval. Short term follow-up of patients with this technique shows promising results in terms of pain relief, regained motion and accelerated rehabilitation. The potential advantages proposed are preservation of bone stock and lesser damage to surrounding structures, allowing early rehabilitation.11

Reverse Shoulder Arthroplasty

Arthroscopic Latarjet Procedure

The latest design Delta Xtend is a modification of the Delta I from Grammont in 1985. It consists of a cementless titanium modular hydroxyapatite (HA)-coated or monobloc cobalt–chromium alloy (Co–Cr) cemented stem, variable thickness polyethylene (PE) cup and a glenoid component with a central peg and cannulated screws. Zimmer produced the Trabecular Metal Reverse Shoulder System (TMRS). Instead of Hydroxy Apatite coating, the implant integrates porous tantalum on the base plate, its central peg and on the proximal side of the humeral stem. In order to prevent scapular notching, the humeral stem has a low profile with no metal above the humeral osteotomy.

The Latarjet procedure was developed over 50 years ago by French surgeons to treat shoulder instability. It involves using a bone graft from the coracoid and attaching it to the anteroinferior glenoid with the help of screws. A modified method for the arthroscopic procedure was developed to facilitate the procedure and minimise the risk of injury to the brachial plexus. The arthroscopic placement of the sleeves is a safe and reliable technique, which avoids extensive exposure. Secondly, the use of arthroscopically positioned sleeves permits an even more precise placement of the coracoid graft by drilling the inferior hole once the graft is already partially fixed by the superior screw. The arthroscopic preparation of the glenoid rim and the capsulo-labral reconstruction can be achieved more precisely by arthroscopy.12

Lima LTO (Italy) has produced the SMR (Systema Multiplana Randelli) prosthesis and recently the SMR HP design. The main difference between the two designs is that the HP has a PE glenosphere, instead of the standard metal design and the PE insert; this has been advocated by the company in order to reduce scapular notching. Equinoxe of Exactech Inc. (Gainesville, Florida) combines a medialised centre of rotation (COR) along with a curved glenoid metal plate, which has a unique cylindrical hollow peg with holes in order to augment bone ingrowth and graft insertion. The humeral stem can be used for primary standard and for reverse arthroplasties, and has less angle than the Grammont design in order for the humerus to be lateralised, without lateralising the COR.10

Arthroscopic-assisted Latissimus Dorsi Transfer Latissimus dorsi muscle-tendon transfer is performed to replace the irreversibly lost contractile elements in patients with irreparable tears of the postero-superior aspect of the rotator cuff. Jean Grimberg et al described a new arthroscopic assisted LD transfer with tendon tubularisation and fixation in a bone tunnel in the humeral head. A mean follow up of 29 months showed results similar to open procedure with significant improvements in constant score, active ante-flexion, external rotation and strength. Some surgeons have extended the indication of LD transfer in reverse total shoulder arthroplasty to improve external rotation.13

Future Shoulder surgery has evolved considerably in the last few decades, especially with the introduction of arthroscopic surgery. Advances in surgical technique have been supported with advances in instruments, implants and technology. Also, the training curve for arthroscopic surgery has shortened by the increase in experienced arthroscopists, training simulators and models, and a new generation of keen trainees brought up on computer games.14 These advances lead us to question: what is in store in the future? 19

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With ever evolving technology and the inventive minds of surgeons, nothing seems impossible. CT navigations systems in shoulder arthroplasty have already been introduced. The use of navigation in both anatomic and reverse shoulder arthroplasty holds promise for the future.15

Arthroplasty: Current Concepts, Results, and Component Wear Analysis. J Bone Joint Surg Am. 2010;92:23–35. 5. Hans HP, Yuping Yang. The Past and the Future of Arthroscopy. Sports Injuries. Prevention, Diagnosis, Treatment and Rehabilitation. 2012, XXVIII, 1247. 6. Lavery KP, Rasmussen JF, Dhawan A. Arthroscopic transosseous-equivalent rotator cuff repair. Arthrosc Tech. 2013 May 18;2(2):e183-5. 7. http://www.qmed.com/mpmn/article/suture-anchor-system-flingssoft-tissue-injuries-under-juggerknot. 8. Phillips P, Cagle H, Herrera H. The Use of Interscalene Block Prior to Shoulder Arthroscopy; Implications for Postoperative Pain Management. The Internet Journal of Anesthesiology 1997 1(1).

Senior author, Vishal Sahni, who performed and reported the world’s first Robot Assisted Arthroscopic Shoulder Surgery, using the Prosurgics Freehand© robotic camera, controlled by a headband mounted infra-red device. The use of robotic arthroscopic surgery may enable the surgeon to perform more complex and precise tasks in restricted spaces. Arthroscopic polymer resurfacing joint replacement and office needle arthroscopy are currently being trialled. The possibility of a genetically engineered rotator cuff inserted via the arthroscope is also being explored.16 Another exciting field is the use of ‘Signature Shoulders’. These are custom made for each patient for most accurate anatomical reconstruction. First a CT scan with 3D reconstruction is done to accurately note the anatomical parameters. The images are then sent to the company to design a computer-generated preoperative plan for custom shoulder replacement. This guide helps ensure accurate anatomy and placement of the prosthesis. After the preoperative plan is approved by the surgeon it is sent to the company where a 3D printer is used to make custom shoulder blocks.17

References 1. William J. Mallon. E. Amory Codman, American Academy of Orthopaedic Surgeons. (Internet) Available from: http://www. aaos.org/news/bulletin/janfeb07/research1.asp [Last accessed on August 12 2014]. 2. Rudzki JR, Shaffer B. New approaches to diagnosis and arthroscopic management of partial-thickness cuff tears. Clin Sports Med 2008;27:691¬–717. 3.

Neer CS., 2nd Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54:41–50.

4. Nam D, Kepler CK, Neviaser AS, et al. Reverse Total Shoulder

9. David M. Dines, Cato T. Laurencin, Gerald R. Williams Jr. Ch 3: The Evolution of Shoulder Arthroplasty. Arthritis and Arthroplasty: The Shoulder. Elsevier Publications, 2009. 10. Sachinis NP, Athanasiadou P. Current designs and trends in reverse shoulder arthroplasty. OA Orthopaedics 2013 Nov 01;1(3):24. 11. Gobezie R, Lenarz CJ, Wanne JP et al. All Arthroscopic Biological Total Shoulder Resurfacing. (Internet) Available from: http://www. clevelandshoulder.com/pdf/arthroscopy-manuscript.pdf [Last accessed on Aug 15 2014]. 12. Taverna E, Ufenast H, Broffoni L, Garavaglia G. Arthroscopically assisted Latarjet procedure: A new surgical approach for accurate coracoid graft placement and compression. Int J Shoulder Surg 2013;7:120–3. 13. Grimberg J, Kany J. Latissimus dorsi tendon transfer for irreparable postero-superior cuff tears: current concepts, indications, and recent advances. Curr Rev Musculoskelet Med. 2014 March;7(1):22–32. 14. Funk L. Advances in Arthroscopic Shoulder Surgery. Asia Pacific Orthopaedic Association, Kuala Lumpur, 2004. (Internet) Available from: http://www.shoulderdoc.co.uk/article.asp?article=110. 15. Kircher J, Wiedemann M, Magosch P, Lichtenberg S, Habermeyer P. Improved accuracy of glenoid positioning in total shoulder arthroplasty with intraoperative navigation: A prospective randomized clinical study. J Shoulder Elbow Surg. 2009;18:515– 20. 16. Lawrence VG, Scott AR. Emerging Ideas: Evaluation of Stem Cells Genetically Modified with Scleraxis to Improve Rotator Cuff Healing. Clin Orthop Relat Res. Oct 2011;469(10):2977–2980. 17. Exciting new technology....among the first in the U.S.- ‘Custom’ Total and Reverse Shoulder Replacement. (Internet) Available from: http://www.bone-joint.net/newsletter.php?nid=18 [Last accessed on Aug 15 2014].

The Physician • Vol 3 Issue 1 • November 2014

Abstracts

Increasing Sarcoma Awareness CR Chandrasekar Consultant Orthopaedic Surgeon, Liverpool

Lumps and bumps are common. Often, most lumps are presumed to be harmless if they are not painful. Sarcomas are malignant tumours of the connective tissue which forms the bulk of the human body. However, sarcomas are rare, constituting about 1% of all cancers. Sarcomas can occur anywhere in the body, and in any age group. Sarcomas form 14% of all childhood malignancies. The three subgroups of sarcomas are primary bone sarcomas, soft tissue sarcomas and gastrointestinal stromal tumours (GISTs). Red Flags for bone sarcomas Bone pain Bony swelling

In a UK survey of a group of teenagers and young adults with cancer, 42% of those with soft tissue sarcomas said they had visited their family doctor more than five times before they were referred to hospital. The mean number of physician visits before referral to a specialist unit for bone or soft tissue sarcoma was 4.85 in an American study. Between 19% and 53% of new patients with soft tissue sarcomas referred to sarcoma centres follow inadequate initial excisions,1 and 59% have residual sarcoma on re-excision. It would be useful to have sarcoma education in the undergraduate curriculum, but the reality is a lack of priority and awareness. There is the option of having an e-learning module provided by reputed medical journals and accessible to all interested medical professionals, with the ability to learn in their own time and space (BMJ learning module).2 Voluntary incentive-based education is also another option to increase sarcoma awareness (prizes and funded fellowships3).

Night pain Analgesia resistance Red Flags for soft tissue sarcomas Swelling more than 5 cm in size Painful swelling

Increasing public awareness

Increase in size Deep to deep fascia Recurrence after previous operation Sarcomas are best managed by a multi-disciplinary team (MDT) in a specialist centre. It is important to identify red flag features for a sarcoma, and to refer early to a specialist centre for comprehensive multimodality treatment. Early diagnosis and appropriate treatment can save lives. Delays in diagnosis, incorrect diagnosis, unplanned excisions and inappropriate treatments are not uncommon due to lack of public and professional awareness of sarcomas. 89% of United Kingdom (UK) litigation claims for sarcoma were due to delays in diagnosis, and the average litigation cost was £84,000.

centres treating sarcoma patients. Even in the designated sarcoma centres, only a few students get the opportunity to see sarcoma patients and work with experienced sarcoma clinicians. This results in many medical students graduating with little or no knowledge of sarcomas, and even after graduation, the opportunities, time and desire to learn more about sarcomas are scarce. This often results in delayed and even incorrect diagnoses of sarcomas, inappropriate interventions and poor outcomes, as ‘what the mind does not know, the eyes cannot see’.

Another part of the conundrum is the difficulty in raising public awareness of sarcomas. Obviously, benign lumps and bumps are far more common and it is important not to overemphasise sarcomas with public awareness campaigns. Patients do, however, have to take some responsibility for their own health – leaving tumours to reach a large size is common. Often sarcomas are painless, and many patients feel that there is no need for intervention unless there is physical or functional impairment. This notion is compounded by false assurances from well-intentioned peers and professionals that the swelling may be benign. Therefore, it is important for the public and professionals to be aware of red flags.

Increasing sarcoma awareness among medical professionals

With a mysterious lump often comes the fear of a possible cancer diagnosis, resulting in reluctance to seek treatment. Hence, it is important to emphasise that sarcomas are treatable, especially when they are diagnosed early, and that there are a number of people who have been cured.

Even in developed countries like the UK, there are currently no designated modules on the undergraduate medical curriculum that cover sarcomas, and there are fewer than 20 designated

Even so, a simple message like ‘lumps could be dangerous – have them checked’,4 is a useful option to promote public awareness. Local media can be helpful in raising sarcoma awareness. Local

The Physician • Vol 3 Issue 1 • November 2014

public awareness initiatives such as the patient’s story5 and a local football star promoting awareness6 may also be helpful. In conclusion, a comprehensive approach to raise public and professional awareness may result in early diagnosis, avoid inappropriate treatment and improve outcomes and survival rates for sarcoma patients. We hope to encourage sarcoma awareness among BAPIO members, GPs, GP trainees and surgical trainees. If you are interested in learning more about lumps, bumps and sarcomas, please complete the following BMJ learning module: http:// learning.bmj.com/learning/module-intro/lumps--bumps--andsarcomas--a-guide-.html?moduleId=10050381&locale=en_GB

References/News articles 1) Unplanned excision of sarcomas: The effect of an unplanned excision of a soft-tissue sarcoma on prognosis. Chandrasekar CR, Wafa H, Grimer RJ, Carter SR, Tillman RM, Abudu A. J Bone Joint Surg Br. 2008 Feb;90(2):203–8. doi: 10.1302/0301-620X.90B2.19760

2) BMJ learning module on lumps, bumps and sarcomas: http:// learning.bmj.com/learning/module-intro/lumps--bumps--andsarcomas--a-guide-.html?moduleId=10050381&locale=en_GB 3) Sarcoma awareness week funded fellowships: http://www. icsmsu.com/exec/wp-content/uploads/Sarcoma-awarenessposter.pdf 4) BBC News (24/6/14) – ‘Scrotum tumour ignored by pensioner Bob Day for a year’: http://www.bbc.co.uk/news/uk-englandmerseyside-28003999 5) Chester Chronicle (1/8/13) – ‘“Don’t suffer illness in silence like I did” says ex-soldier’: http://www.chesterchronicle.co.uk/ news/chester-cheshire-news/ex-chester-soldier-warns-peopledangers-5390332 6) Liverpool Echo (23/7/2013) – ‘Tony Hibbert supports Sarcoma health awareness campaign’: http://www.liverpoolecho.co.uk/ news/local-news/efc-in-the-community-5268500

Are Ethnic Minorities More Likely to Develop Triple Negative Breast Cancer? : A systematic review Limbada R,1 Slater A,1 Jain AK2

PubMed from 2005 up to 2013, with studies specifically aimed at TNBC.

De Montfort University, Leicester, UK

The Nightingale Centre and Genesis Prevention Centre, Wythenshawe Hospital,

Manchester, UK

In the UK, receptor data have not been consistently recorded and involve smaller sample sizes. Hence, the relevant articles include ethnic groups from the Asia-Pacific region and the US. Keywords used were: triple negative, TNBC, ethnicity, incidence, prevalence. The data from all relevant articles were combined to give a sufficiently large sample size.

Results:

Background: Triple negative breast cancer (TNBC) accounts for 10–15% of diagnosed breast cancers worldwide. TNBC is negative for oestrogen receptor (ER), progesterone receptor (PR) and the human epidermal growth factor receptor 2 (HER-2) expression, and is associated with a poor prognosis. Our study aims to systematically review the possible link between various minority ethnic groups and the development of TNBC.

Methods: A systematic review of carefully selected studies was carried out with searches of relevant articles in Medline, Science Direct and

Complete receptor data were available for 72,763 cases, which constitutes the sample group. On the available ethnicity data these were divided into five groups: Caucasian (50,797), Black (4,969), Asian (6,909), Hispanic (9,898) and other (190). Overall there were 9,887 TNBC cases in the sample group comprising of Caucasian (5,956), Black (1,341), Asian (842), Hispanic (1,732) and other (16). Hence, overall, 13.59% of all diagnosed breast cancers were TNBC, with 11.73% in Caucasian, 26.99% in Black, 12.19% in Asian, 17.5% in Hispanic and 8.42% in other women.

Conclusions: Overall, minority ethnic women have a higher incidence of TNBC than Caucasian women, with resultant poor prognosis. With a rising minority ethnic population in the UK, the overall number of TNBC cases will rise. Further research is required to explore the reasons for this.

The Physician • Vol 3 Issue 1 • November 2014

Abstracts

Is the Technical Quality of Screening Mammograms Lower in Asian Women who Cannot Understand the English Language? Jain A K,* Iram S,2 Reece V,2 Griffiths M,2 Morris J,1 Steele A,1 * Corresponding author: Professor Anil Jain, Consultant Radiologist; anil.jain@manchester.ac.uk

University of Manchester, Manchester Academic Health Sciences Centre

The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester,

Introduction: Good patient and radiographer communication is vital for good quality mammograms. Many Asian women aged 47 to 73 years cannot understand English. The Radiographers QA Guidelines categorise mammographic images as Perfect (P), Good (G), Moderate (M) and Inadequate (I). The standards required are 75% P–G, 97% P–G–M and <3% I .

Methods: One hundred women with digital screening mammograms were randomly selected retrospectively, and divided into two groups: Group A featured 50 Asian women who could not understand English (confirmed from the radiographer notes on the screening forms); Group B featured 50 Caucasian women. Any patients with a disability, learning difficulties or previous breast surgery were excluded. Two folders were created on PACS and the images were anonymised. The films readers were not aware of the classification of the two groups. All mammograms were independently assessed by two experienced film-reader advanced practitioners using the PGMI scoring system. The final score for each case was reached by consensus with a consultant breast radiologist.

Results: The PGMI mammographic scores for the Asian women were P (0), G (16), M (26) and I (8), while the scores for the Caucasian women were P (0), G (31), M (18) and I (1). The mammographic scores of 32% (P–G), 84% (P–G–M) and 16% (I) for the Asian women were significantly lower than the scores of 62% (P–G), 98% (P–G–M) and 2% (I) for the Caucasian women (linear trend test p = 0.001).

Conclusion: The mammographic technical quality appears much lower in Asian women who cannot understand English, highlighting a need for improved communication. Further studies are also required to see whether other factors play any role in the poor technical quality in this group.

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Geriatrician-led Comprehensive Hip Fracture Programme in a New Acute Collaborative Hip Unit in a UK Hospital

Dr Abhaya Gupta Consultant Elderly Care, Glangwili Hospital,

two departments, with improved training opportunities. Nurses are specialised and provide skilled care, while the therapists feel highly supported by the geriatrician.

Conclusion

Carmarthen SA31 2AF Email: guptaabhaya@hotmail.com

Title: The increasing incidence of hip fractures in elderly patients, their multidisciplinary complex needs and poor outcomes have led to the development of several orthogeriatric models of care. A new orthogeriatricianled Acute Hip Unit was established at Glangwili Hospital, Carmarthen, UK, in July 2011.

Methods

The orthogeriatrician-led collaborative interdisciplinary Acute Hip Fracture Unit is a new innovative service model of care for frail elderly hip fracture patients during their acute hospital stay. This Unit is the first in Wales, winner of the Chief Executive Award in 2011, and was established within existing resources. It provides high quality seamless evidence-based uniform care. A combination of geriatrician led pre- and post-operative care; close working with orthopaedic surgeons; multidisciplinary team working; implementation of systematic protocols; early identification and management of medical issues; enthusiasm and leadership of the geriatrician are the likely reasons for these improved outcomes.

Until 2011, complex and challenging frail, elderly hip fracture patients were managed in orthopaedic wards under any one of the ten orthopaedic surgeons with once weekly orthogeriatric liaison consultations. National audits showed poor quality of care, delays and inconsistent management approaches. With stakeholder agreements, a radical alternative to traditional care was established with a new Acute Hip Fracture 15 bed unit. Now patients are directly admitted from the Emergency Department to the new Acute Hip Unit, providing joint patient care between orthopaedic surgeons and one orthogeriatrician. A new operational policy written by the author describes flow pathways, treatment algorithms, care protocols, new clerking pro forma, fast track admission, preoperative geriatric assessment, daily geriatrician-led clinical care on weekdays, implementation of standardised protocols, weekly geriatricianled multidisciplinary meetings, emphasis on early mobilisation and early discharge planning. The results from a prospective observational study with retrospective historical control are published. Patients above 50 years of age were included – 235 in preintervention and 259 in postintervention groups. The mean age was 82 years, and 75% were female. Postintervention, there was improvement in time from A&E to ward (3.28 vs 5.5 h); time to surgery (68.4% vs 61.7%); preoperative geriatrician assessment (76.1% vs 0.5%); falls’ assessment (73.9% vs 5.1%); shorter acute hospital length of stay (15.1 vs 19.3 days); reduced reoperation rate (4% vs 14%); reduced ITU rate (3% vs 4%); reduced readmission rate (31% vs 41%); and reduced hospital mortality (4% vs 12%). Therefore, tremendous improvements in the quality of patient care have been achieved – also acknowledged by the patients. There is also new collaborative working of junior doctors across

Relevant Publications: 1. Gupta A. Commentary: Hip fracture: then and now. Geriatric Medicine. 2010;40(10):567. 2. Gupta A, Thurston A. Osteoporosis: new opportunities. Geriatric Medicine. June 2012.pp.37–43. 3. Gupta A. Medical management of hip fractures and the role of orthogeriatrician. Reviews in Clinical Gerontology. Nov 2012;22(4):261–73. 4. Gupta A. The effectiveness of geriatrician led comprehensive hip fracture care in UK. J R Coll Physicians Edin ;2014.44:20–6. 5. Gupta A, Havelock W. A new future for hip fracture care – Orthogeriatrician led and in ‘Acute’ Hip Unit’ accepted for publication in Clinical Medicine 2014.

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Abstracts

Poster presentations-

6. Frankland S, Gupta A. Prevalence of anaemia in

1. Gupta A et al. Orthogeriatric input in secondary prevention of fragility fractures. Poster at IOF AsiaPacific meeting, Singapore. Dec 2010. Abstract in Osteoporosis International. 21(5):Dec2010.

hip fracture patients. Poster at World Osteoporosis Conference, Seville, April 2014. Abstract in Osteoporosis International 2014;25.suppl2. 7. Siddarth KV, Rehmat Karim & Abhaya Gupta. Prevalence

2. Gupta A. Efficacy of a geriatrician led hip fracture program. Poster at IOF-ESCEO conference Rome, Italy April 2013. Abstract in Osteoporosis International. 2013;24suppl1.S131. 3. Marshall K, R.S, S.C, Gupta A. Assessment of renal functions & associated metabolic abnormalities in hip fractures. Poster + Oral presentation at World Congress on BMJD. Brussels Nov 2013. 4. Eeranti R, M.S, S.C, Gupta A. Bisphosphonate prescribing in patients with hip fracture. Poster at World Congress on BMJD, Brussels. Nov 2013. 5. Frankland S, Gupta A. An observational study of S Creatinine levels in hip fractures. Poster at World Osteoporosis Conference, Seville, April 2014. Abstract in Osteoporosis International 2014;25.suppl2.

of co-morbid conditions among fracture neck of femur patients in an acute hip unit. Poster at ECTS Prague May 2014. Bone Abstracts (2014) 3 pp.245 | doi:10.1530/ boneabs.3.pp245 8. Rehmat Karim, K V Siddarth & Abhaya Gupta. Prevalence of post-operative medical and surgical complications among fracture neck of femur patients in an acute hip unit. Poster at ECTS Prague May 2014. Bone Abstracts (2014) 3 pp.249 | doi:10.1530/boneabs.3.pp249

Disclosures No financial gain; no conflict of interest. Figure: Dr Abhaya Gupta receiving highest Chief Executive Award by Chief Executive of Hywel Dda UHB in November 2011 for starting first Acute Hip Unit in Wales.

Are Oxygen Alert Cards Recommended by the British Thoracic Society Serving their Intended Purpose? : Our experience in a district general hospital Hughes A, Leeman S, Sinha, RK, – Yeovil District Hospital, Yeovil, UK

oxygen saturation is within the target range and if alert cards have any impact.

Abstract

Methods:

Background:

Patients who were issued alert cards from November 2011 to November 2012 were identified from the respiratory nurse’s register. Data were collected from the available medical notes using a locally designed pro forma.

Some patients are at risk of developing hypercapnea and/or acidosis with excessive oxygen. The British Thoracic Society (BTS) recommends providing an “oxygen alert card” and 24%/28% Venturi mask for such patients to alert health professionals and to ensure administration of oxygen in a controlled manner to achieve the recommended target saturations.

Aim: The aim of this study was to determine if oxygen alert cards are being issued appropriately, patients use them as instructed,

Results: 79 patients were issued alert cards during the study period and all patients had a documented episode of hypercapnea and/ or acidosis. 63 notes were available for review. 19 patients were readmitted over 38 episodes and all passed through the emergency department (ED), but there was no record to confirm

The Physician • Vol 3 Issue 1 • November 2014

Review

1. Dr Adam Hughes: Foundation Year 1 doctor, Yeovil District Hospital, Yeovil, BA21 4AT

that cards were shown. In 27 of 38 episodes (71%) in the ED, oxygen saturation was outside the recommended range. 33 cases were brought in by ambulance. Only 2 (6%) of patients showed an alert card to the ambulance crew. Oxygen saturation was outside the recommended range in 25 episodes (75.7%).

2. Sister Sheila Leeman: Respiratory Nurse Specialist, Yeovil District Hospital, Yeovil, BA21 4AT

Conclusion and discussion: All alert cards were issued appropriately. The majority of patients at risk of coming to harm from uncontrolled oxygen therapy had high oxygen saturation. It is difficult to conclude if oxygen alert cards would have influenced this as very few patients showed their card to healthcare professionals. We postulate that this can be improved by educating patients and their carers, encouraging them to present their cards to healthcare professionals and educating healthcare professionals to ask for oxygen alert cards in a manner similar to asking for allergies. We also propose changing the name of the oxygen alert card to another which would imply serious danger from inappropriate usage of oxygen for a higher impact. An electronic register of such patients, accessible to ambulance services and the ED, would also be helpful.

Email: adam.hughes@hotmail.com

Email: sheila.leeman@ydh.nhs.uk

3. Dr R.K. Sinha: Consultant Respiratory Physician, Yeovil District Hospital, Yeovil, BA21 4AT

Primary email: rajan.sinha@tinyworld.co.uk

Secondary email: rajendra.sinha@ydh.nhs.uk

Tel: 01935 384747

Please send all correspondence to: 1. Dr R.K. Sinha: Consultant Respiratory Physician, Yeovil District Hospital, Yeovil, BA21 4AT

References:

Primary email: rajan.sinha@tinyworld.co.uk

The British Thoracic Society Guidelines for emergency oxygen use in adult patients (Thorax 2008;63(Suppl VI)

Secondary email: rajendra.sinha@ydh.nhs.uk

Conflict of interest: none Authors’ Details: (All authors have consented to the submission of the results of this study for a poster presentation in the forthcoming BAPIO conference in November 2014)

Additional Information: The authors have communicated the result of this study in the form of an e-letter to the “Emergency Medicine Journal” and have obtained their permission for submission of the results of this study for consideration for a poster presentation in the forthcoming BAPIO conference in November 2014, and if accepted, then also for subsequent publication in the journal “The Physician”.

The Black and Minority Ethnic (BAME) population represents 27% of those on the waiting list to receive a life-saving transplant, but only 5% of organ donors are from the BAME communities. The NHS’s Blood and Transplant Strategy “Taking Organ Transplantation to 2020” details the commitment from the organisation to increase the number of transplants carried out in the United Kingdom and improve the outcomes of these by putting in place a number of measures. These include increasing awareness in the BAME communities of the need for donation, to benefit their own communities and provide better support for people in these communities to donate. It is difficult to access certain communities, which means they are unable to obtain the information and make their own informed choices. I have been working with the local public health department to gain access to the South Asian communities in Lancashire in order to educate and inform them of the benefits to donation. Initially I was met with negative, disapproving views and felt that I would not be able to change opinions. However, after 15 months I have seen a great shift in attitude. I have been able to access all ages within the community and attend many local events. I have not addressed the question of religion intentionally, as I want people to be educated around the benefits of organ donation to their communities, for them to ask questions regarding religion and make their own informed choice. The project is set to continue for several years to come, and I have the assistance of the local council and NHS Trust in which I work, to thus allow me to push the boundaries and continue engaging with these communities in order to change attitudes and improve health outcomes.

Angela Ditchfield Specialist Nurse Organ Donation, East Lancashire Hospitals NHS Trust

The Physician • Vol 3 Issue 1 • November 2014

Abstracts

Research in learning difficulties Dr Ezhil Anand MBBS (India),

The access to research participation depends on the perception of the participant’s ability to consent, and potential harm to them. The main consideration is the Mental Capacity Act. There are practical difficulties due to problems with communication, involvement of carers and advocacy.

M.Med.Sci (Nottingham), MRCPsych Consultant Psychiatrist in Learning Disability Psychiatry Highfield Unit, Lynfield Mount Hospital, Bradford BD9 6DP Mobile: 07795176879 Email: Ezhil.Anand@bdct.nhs.uk

Research in people with learning disabilities has potential benefits, although recruitment is a big challenge. Generally they are underrepresented as participants. Poor participation leads to poor validity, with generalisation also not possible due to this. The issues include conflict between autonomy and protection.

Research has shown that participation is dependent on participants being contacted directly, the method of seeking consent and invasiveness. There are ethical issues about capacity/consent, best interests, accountability and surrogate decision making. My experience is based on studies done as a Principal Investigator in the Learning Disability Psychiatry Department at Bradford.

‘When things get on top of me...’ Deliberate Self-Harm in Children and Young People: Implications for medical professionals Dr Vidya Rao,

Professional practice implications

Consultant Community Paediatrician, Walsall Manor Hospital Trust

Need to respect confidentiality – requires sensitive handling. The professional has to balance between reporting against the young person’s wishes and well-being.

Dr Indu Anand

Consultant Childr Psychiatrist, Dudley and Walsall Mental Health Partnership

Setting the right priorities

Introduction: Deliberate self-harm (DSH) is a major public health issue affecting 1 in 10 young people in the UK. Madge et al (2008) reported that over 70% of 15–16 year olds admitted to DSH at some stage in their lives. The incidence is rising as a result of cyber bullying, sometimes resulting in suicide.

Aim: Briefly to outline:

A ‘harm minimisation’ approach is sometimes called for in the best interests of the young person.

Training and supervision of professionals Changes in attitudes should be achieved in the professionals. Training that explains the reasons for self-harm and suggestions on how to respond should be part of level 3 child protection training.

Early prevention

•

Epidemiology of self-harm in young people

•

Reasons for self-harming

•

Risk factors and vulnerable groups

•

Methods of deliberate self-harm

•

Prognosis

A public health approach aiming to promote emotional wellbeing, security and resilience from an early age. Children will need to learn coping mechanisms rather than to self-harm.

Promoting mental health in schools

The talk will draw on professional guidelines and national strategy documents to highlight the following:

Social and Emotional Aspects of Learning (SEAL) programme, anti-bullying guidance including strategies to combat homophobic and cyber bullying.

Accident and Emergency services Have a role in early recognition and referral to specialist agencies.

The Physician • Vol 3 Issue 1 • November 2014

Innovation

The MaZon toolkit: Improving quality and efficiency in mental health services in a financially challenged NHS Arokia Antonysamy, 2Naomi Chambers, 3Anita Ghosh, 4Tarun Khanna, 5Vinod Rao, 6 JS Bamrah, 7Burt Burton 1

Lancashire Care NHS Foundation Trust, 2Manchester Business School

1, 4, 5

Cheshire and Wirral Partnership NHS Foundation Trust, 6, 7Manchester Mental Health and Social Care NHS Trust

Correspondence: Arokia Antonysamy, Parkwood, East Park Drive, Blackpool, FY3 8PW Email: Arokia.Antonysamy@lancashirecare.nhs.uk

Introduction In the United Kingdom, the 1930 Mental Treatment Act revolutionised the care of psychiatric patients emphasising the role of community care. During this period, outpatient treatment was initiated and asylums developed into mental hospitals (Gordon, 1930), with these transformational changes coming into fruition in the 1950s. Community care for psychiatric patients represented the biggest political change in mental healthcare in the history of the NHS. Most of the mental health policies since the 1970s focused on the closure of long-stay psychiatric hospitals and their replacement by community-based services (Carrier & Kendall, 1997). Community mental health teams (CMHTs) were established in the early 1980s, with each team being clinically led by a consultant psychiatrist covering a local geographical population aligned to a group of GP practices. The caseloads of consultant psychiatrists working in CMHTs are variable, averaging about 350 patients (Tyrer, 2001). Reviewing patients in the community can be particularly challenging as some of them may remain stable, whilst others are more prone to frequent relapses and require regular reviews. In addition to this, the consultant will also need to prioritise those discharged from hospital and new referrals from GPs. Traditional service-based definitions of recovery have required significant symptom remission, plus a return to employment and independent living (Lieberman et al, 2002), that is, a return to pre-morbid states of health. Service user definitions of recovery are in general broader and more pragmatic. These definitions tend to focus on resuming active control over one’s life (Davidson et al, 2005b), and establishing a meaningful and satisfying life with a positive sense of identity founded on hope and self-determination (Andresen et al, 2003). Importantly, user definitions do not insist on symptom remission, instead placing importance on the personal discovery of how to live with enduring symptoms and vulnerabilities (Roberts & Wolfson, 2004). This occurs through a process of changing one’s attitudes, goals, skills and roles (Anthony, 1993) in order to assist social inclusion. 28

The 2005 Department of Health document New Ways of Working outlined some of the difficulties facing psychiatry. In particular, it highlighted flaws with the present system in which consultants maintained high personal caseloads of outpatients who did not meet the criteria for input from the CMHT. Outpatient clinics are often booked to capacity weeks in advance due to heavy case loads. It is not unreasonable to suppose that this must affect the ability of the service to respond to emergencies in a timely fashion, which in turn could affect admission rates and patient outcomes. There is limited understanding in the CMHT regarding patients’ eligibility for discharge from secondary care due to a lack of criteria and guidelines facilitating discharge.

Aim The aim of this project was to create a tool that would help to promptly identify patients nearing the recovery stage and facilitate discharge from secondary care mental health services, thereby empowering them to function independently.

Objectives Our main objectives were to design a set of criteria that can be used to categorise patients according to their clinical, psychological and social needs and risks. The criteria should also facilitate timely transfer from secondary care services into primary care by applying user-based definitions of recovery.

Method A process of consultation with stakeholders including general practitioners, consultant psychiatrists, CMHT staff (including managers, nurses, psychologists, occupational therapists, social workers, support workers, service users and carers) was carried out. We conducted workshops and direct discussions with stakeholders, and through this process developed a preliminary set of criteria that could be used to categorise patients according to the clinical need to inform resource allocation. The discussions also included critical analysis of the literature evidence available on tools and guidelines focused towards patient recovery in mental health. The criteria developed were modified in line with the stakeholders’ suggestions and criticisms, until a set of

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generally agreed criteria called the MaZon (Manchester Zoning) toolkit was developed.

Strengths •

The MaZon tool is simple, user friendly and can be interpreted by managers and clinicians, thereby encouraging communication between different professional groups. The tool is flexible and can be adapted to other settings in secondary mental health services, including inpatient teams and crisis teams irrespective of the age group.

•

Support from the executive and operational management teams is essential and was provided in this project.

•

The pilot was very successful in identifying potential problems and possible solutions, and demonstrated benefits in terms of cost and quality.

•

Facilitates a team approach to risk management (Best Practice in Managing Risk, DoH, 2007).

•

Allows better training and supervision of junior doctors, nurses and other staff.

•

Increased capacity to respond to emergencies (e.g. surge capacity planning during a pandemic flu) efficiently and effectively.

•

Creates opportunities for the MaZon tool to be linked to the Mental Health Clustering Tool.

Results Using the MaZon toolkit, patients were zoned and transferred to primary care if appropriate. This process was carried out by doctors in conjunction with the CMHT. As a result, overall caseload was reduced by 30%. This resulted in a number of improvements as detailed below. Improvement Measures

Actual Changes Made After The Zoning Exercise

Prompt identification of patients in the recovery stage and transfer to primary care

Transfer of 33% of patient caseload (117 cases) to primary care in 7 months, with only 6 of these patients being re-referred within the next 5 months, all of whom were managed successfully in the community without requiring inpatient admission

Reduction in waiting times

Patients referred from GPs and primary care mental health teams were seen within 2 weeks of being referred, whilst previously they had to wait 15 to 18 weeks

Increased responsiveness to emergencies

Creation of an emergency slot in the consultant’s clinic enabled team members to discuss patients at risk of relapse or arrange for a face-to-face review; this prevented those patients from attending A&E and they reported better satisfaction as they were treated promptly by their own team

Increased continuity of care

Direct consultant supervision available on clinic days, consultant overseeing the care of all patients

Discussion Effects of Change: did this lead to improvement for patients? Improvements for patients included a reduction in waiting times and a decrease in clinic caseload, meaning increased time for patient consultations. There were also reductions in the number of clinics being cancelled by the provider. This is because the whole medical team was present on clinic days, allowing cover for unexpected absences. The introduction of emergency slots resulted in the CMHT and doctors responding to emergency situations in a more timely fashion, while the increased multidisciplinary work and access to supervision improved staff confidence in managing complex patients. The emergency slots helped to maintain continuity of patients care within the team, preventing unnecessary visits to the emergency department, and also enhanced joint working with the crisis teams. The zoning exercise has encouraged the CMHT and clinicians to focus on promoting the recovery and rehabilitation of our patients, and to ensure that our resources are targeted towards patients with the greatest needs. It also facilitated the transfer of stable patients back to primary care, where they can be managed in a less stigmatising environment, with the knowledge that should their circumstances deteriorate, the secondary services will be able to respond promptly. This has in part been achieved through collaboration with primary care, with these new lines of communication between the secondary and primary services significantly contributing to improved patient care.

Limitations •

This is a new tool, and hence information on its reliability and validity may take a considerable period as it needs to be tested in different teams and settings.

To overcome the above limitation, the same exercise was conducted in 2 other teams in a comparable location, but a different county. The results were fairly similar, indicating that about 20% of the patients in the CMHT can be safely stepped down to primary care or recovery teams in the short term, while this exercise also identified another 10% that can be stepped down in the medium term.

Conclusion The MaZon toolkit offers exciting opportunities for mental health services to prioritise and allocate resources efficiently in order to deliver high standards of care to patients, whilst facilitating recovery and empowering patients to function independently in the community. The tool enables business continuity in the face of economic difficulties and other circumstances which lead to staff shortages. The involvement of staff and patients in the development of the tool was key to its success, and also fostered feelings of empowerment and responsibility. The diverse views of the team were used as a source of possibility and adaptation, and we were able to tap into staff experience and talents that were previously under-utilised. The

The Physician • Vol 3 Issue 1 • November 2014

Innovation

tool provided objective evidence of the patients’ progress and set a clear direction for the team in terms of moving towards a recovery-focussed service. Research into the use of payment by results in mental health services is ongoing, and is a contentious topic. The Department of Health is investigating the use of rating scales such as the Health of the Nation Outcome Scale (HoNOS-PbR) and the Clustering Tool (DH, 2010) in mental health commissioning. We have developed a tool which can be linked to these, but has the primary aim of identifying patients in the recovery stage, and then discharging them back to general practice, while ensuring that resources in community mental health services are utilised appropriately.

References 1.

Andresen R, Oades L, & Caputi P. (2003). The experience of recovery from schizophrenia: towards an empirically validated stage model. Australian and New Zealand Journal of Psychiatry, 37: 586–594.

Anthony W. (1993). Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16: 11¬–23.

Boardman J, Henshaw C, & Willott S. (2004). Needs for mental health treatment among GP attendees. British Journal of Psychiatry, 185: 318¬– 327.

Carrier J, & Kendall I. (1997). The rise and fall of the psychiatric hospital. Evolution of policy. In: J. Leff, (Ed.), Care in the Community: Illusion or reality. Chichester: Wiley.

Davidson L, O’Connell M. J, Tondora J, et al. (2005b). Recovery in serious mental illness: a new wine or just a new bottle? Professional Psychology: Research and Practice, 36: 480–487.

Department of Health. (2005). New ways of working for psychiatrists: Enhancing effective, person-centred services through new ways of working in multidisciplinary and multi-agency contexts.

Gordon R. G. (1930). Mental Treatment Act 1930, British Medical Journal 6, 2(3648): 978.

Kennedy P, & Griffiths H. (2001). General psychiatrists discovering new roles for a new era and removing work stress. British Journal of Psychiatry, 179: 283–285.

Lieberman R. P, Kopelowicz A, Ventury J, et al. (2002). Operational criteria and factors related to recovery from schizophrenia. International Review of Psychiatry, 14: 256-72.

10. Roberts G, & Wolfson P. (2004). The rediscovery of recovery: open to all. Advances in Psychiatric Treatment, 10: 37–48. 11. Tyrer P, Al Moderis O, & Gulbrandsen D. (2001). Distribution of caseload in community mental health teams. Psychiatric Bulletin, 25:10-12. 12. Department of Health. (2010). (Internet) Available at: www.dh.gov.uk/en/ Managingyourorganisation/Financeandplanning/NHSFinancialReforms/ DH_4137762.

What I Wish I’d Known: Can We Improve Preparedness Amongst Junior Doctors? Background

Methods

The changeover of UK doctors in August is associated with increased patient mortality. However, changing rotation within the same academic year is more common, equally disorientating, and less discussed in comparison to both this and other medical staff transition points.

We produced a short information leaflet of shift-specific information to benefit our junior successors in the Emergency Department. Before and after publication of the leaflet, a questionnaire was distributed to assess (i) FY1/2s’ orientation levels, (ii) their knowledge of important hospital- and shiftspecific procedures, (iii) their subjective ability to work efficiently as part of the team, and (iv) their ideas for further quality improvement.

The transfer of shift-specific information between doctors changing rotation is patchy, research is scarce, and efforts to formalise these ‘orientation processes’ are insufficient. During our year as FY1 doctors at Addenbrooke’s Hospital in Cambridge, using information from clinicians, managers and allied healthcare professionals, we undertook a novel multi-disciplinary grassroots quality improvement project with widespread implications. We assessed our colleagues’ level of orientation when changing rotation, evaluated the success of an information leaflet in orientating doctors and implemented a comprehensive, evidence-based, multi-disciplinary and multimedia package of both remote and face-to-face orientation materials to help our junior colleagues be more prepared when starting their rotations. We have also extensively reviewed the relevant literature and have novel ideas for project improvements, further work and local and national policy change.

Results 50/91 surveys were returned in respect to assessing the leaflet, where it was found that those doctors without access to the resource felt unanimously disorientated, and all felt they would benefit from a bespoke, remote orientation resource. Doctors using the information leaflet were significantly more confident that they knew what to expect and the role of themselves and others within the team. They were more aware of the selection of important local protocols that we assessed, and the qualitative feedback was positive.

Conclusion The quality improvement project is evidence-based, comprehensive and extensive. Our multimedia orientation

The Physician • Vol 3 Issue 1 • November 2014

package for orientation, feedback and iterative quality improvement includes face-to-face and remote formats: the leaflet (disseminated in print, online and via email), an induction video (funded by a £978 ‘Innovation in Medicine’ grant; http:// player.vimeo.com/video/100090960), the ‘WikiFY’ (a selfsustaining, crowd-sourced, intranet-based orientation website allowing outgoing doctors to record shift-specific information for their successors to read and update; http://fyguide.campgmc.ac.uk) and an FY2-led induction meeting for doctors. All are now compulsory for doctors new to Addenbrooke’s Hospital.

rotation in any UK hospital to use (e.g. on the NHS ePortfolio),

Our ideas for ongoing improvement are to (i) influence national policy (neither the GMC or Foundation Programme advocate peer-to-peer transfer of rotation-specific housekeeping tips), (ii) translate our WikiFY prototype into a searchable national database of shift-specific information for any doctor starting any

1 Foundation Year One House Officer, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK

and (iii) establish a culture of peer-to-peer orientation by sharing our ideas of best practice. Our simple interventions have reduced doctors’ disorientation levels and improved their performance, with our package of materials undoubtedly improving local services and patient care as a whole. Shah P,1 Rakhimov Y,1 Osimo EF,1 Fry AC,2 Collins GB1

2 Consultant in Acute Medicine & Nephrology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK Correspondence: parth.a.shah88@gmail.com

Physical Health Initial Objective and Subjective Assessments by Medical and Nursing Staff: A comparison Mind, Body, Spirit: Psychiatry in context Presentation Type: Poster Staff: A comparison

SANJIB GHOSH Academic Clinical Fellow and ST5 in Forensic Psychiatry North London Forensic Services and Queen Mary University London

Abstract:

B (for all) and C (IV drug users) were at 16.3%, 0% and 0%, respectively.

Aim This is a Quality Improvement Project of physical health assessment and monitoring at East London Forensic Services. It is a combination of 2 audits: (1) medical, and (2) nursing responsibilities at admission.

Around 80% of the patients had their blood pressure, pulse and temperature recorded. There were no records taken for peak flow, urine output or girth.

Discussion

Method We sampled approximately 49 patients’ notes (20% of the total number of patients). We sampled the admission, established treatment, female, learning disability, intensive care, personality disorder and rehabilitation wards.

The results are significantly lower than the 100% standard. This was partly due to the new introduction of an electronic system, and only the partial use of it. Clinical culture favours measuring some parameters far less than others.

Recommendations

Results 51% of the formal physical assessments were done. 49% had no formal assessment. In only 34% had the GP’s address been noted. The standard systems’ examinations – neurological, cardiovascular, respiratory and abdominal in descending order – were next highest in proportion (53%–45%). Peripheral symptoms of anaemia, oedema, cyanosis and clubbing in descending order ranged at only 27%–20%. GP reconciliation of medicines and offering injections for Hepatitis

• Physical assessment (examination) to be the formal responsibility of the medical team, and physical monitoring (observations) of the nursing team. • Reiterate that the documentation should be placed in the set pro formas of the physical documentation section. • New pro forma (enclosed). Continuous follow-up and review of any patients without an assessment. • Peak flow meter and urine volume measurement kits on each ward.

The Physician • Vol 3 Issue 1 • November 2014

Abstracts

• Education of standards via induction, supervision and emails. • Providing checklists of the standards to staff and patients to record. The patients can keep diaries and gain control over their healthcare.

An evaluation of waiting times after the introduction of electronic requests in East London Forensic Services Abstract:

Recommendations:

Aim

1. Induction educational package on filling out SOAD requests started and reviewed by the audit and innovation committees, including representatives of each member of an MDT and service users.

This Quality Improvement Project evaluates whether SOAD request time-keeping standards are being maintained since the electronic request system was introduced. It will highlight any area of potential improvement, suggest an informed standard and is the first of its kind following the new e-system.

Method

2. The Mental Health Act Office team should closely record the data. 3. Follow-up missing data or delays with the CQC.

We retrospectively sampled all 34 patients for whom a SOAD had been requested within the Medium Secure Unit of the forensic directorate since October 2012, when the electronic request system was initiated, until July 2013. Data were collected through the clinical notes, and electronic notes.

Results

4. Consider asking the SOAD to electronically fill in a T3 form and forward this to the Mental Health Act Office.

References: Care Quality Commission http://www.cqc.org.uk/organisations-we-regulate/mental-health-services/mentalhealth-act-guidance/second-opinion-appointed

Missing data accounted for 15% of the cases. 9% of these were cases where it was known that a SOAD request had been made from discussions and/or other documentation, but there was no available record of the exact dates of request and visit. For the completed data, the mean number of days from SOAD request to visit was 25.1.

Discussion This is almost twice that of our team’s targeted 14 day standard. There are 2 major causative issues: 1. the recording of the data, 2. the actual time taken for the SOAD to arrive.

The Physician • Vol 3 Issue 1 • November 2014

The Cultural Humility Model of Cross-Cultural Communication Skills Training Anil Jain,1,2 Gill Reddick,1 Lester Barr,1 Valerie Reece,1 Cathy Hill,1

professional acting as an interviewer and another health

Professor Anil Jain, Consultant Radiologist;

and other general scenarios have been rehearsed in five courses

anil.jain@manchester.ac.uk

thus far.

The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK

The University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK

Background:

professional acting as an observer. Various breast cancer care

Conclusions: Self-reflection, observer ratings and facilitators’ feedback have enabled participants to develop their skills of using cultural humility in communicating with patients from diverse communities in their day-to-day practice. The programme has encouraged groups to explore and overcome the barriers to communication.

Breast screening uptake rates remain consistently low in ethnic minority women. Poor communication plays a significant part in this. To a large extent, it relies on improving health professionals’ ‘Cultural Competence’. The ‘Cultural Humility’ model, however, is a dynamic approach that reaches beyond cultural competence, and is a lifelong process of self-reflection and self-critique.

Objectives: i)

Inculcate a shared breast team understanding of the cultural humility model

ii) Encouragement to become an active participant iii) Use trainees’ feedback to develop future learning processes

Methods: The cultural humility model relies on actively engaging in an ongoing process of communication besides actively following the patient. A range of non-verbal and verbal skills have been modelled and rehearsed in situations of increasing complexity with opportunities to reflect and develop greater self-awareness using role play, video playback and Interpersonal Process Recall.

The five study days so far have attracted very high ratings from participants. Further developments are planned, such as conducting a questionnaire survey of all the participants on the long-term impact on their day-to-day practice, and providing them with on-going opportunities for reflection and increased

Design and Delivery:

awareness of their patients’ needs.

One hundred health care professionals from the North of England have now participated in ‘Enhanced Cross-Cultural Communication Skills Training’ study days.

References:

The morning consists of a mix of didactic lectures and interactive group work, encouraging engagement throughout. Besides the ‘micro-skills’ of active listening, they are taken through guidelines for interviewing across cultural boundaries (Fontes, 2008). The afternoon involves videotaped role-plays between patients/ carers/lay people from diverse communities, with a health

Fontes, LA (2008) Interviewing Clients across Cultures: A Practitioners Guide. New York: Guilford Press.

Kagan, N (1980) Influencing human interaction- Eighteen years with IPR. In A.K. Hess (Ed.) Psychotherapy supervision: Theory, research and practice. New York: Wiley.

Tervalon, M & Murray-Garcia, J (1998) Cultural Humility versus Cultural Competence: a critical distinction. Journal of Health Care for the Poor and Underserved. Vol.9, No.2, 117–125.

The Physician • Vol 3 Issue 1 • November 2014

Abstracts

Children who Sexually Abuse other Children: A survey of young and teenage sexual offenders over a 10 year period Author: Dr Vidya Rao, Consultant Paediatrician, Walsall Manor Hospital NHS Trust

Victim Gender Abuser age group (years)

Male

Aim:

4–12

To study the profile of child and teenage alleged child sex offenders and their relation to their victim.

13–15

16–19

Total

Female

Total

Background: Child sexual abuse (CSA) can leave a negative experience on victims. In one study, 1 in 3 girls and 1 in 10 boys reported sexual abuse at least once in their lifetime. 6% of girls and 1% of boys report penetration in the most severe form of CSA. About one-third of abusers were adolescents and were in the victims’ peer group.

Method: A retrospective review of consultants’ medical reports over a 10 year period. Results: In a study of 172 cases of CSA over a 10 year period, in 42 cases (25% of the total) the alleged perpetrator was aged 19 or under (median age 14). The table on the opposite page shows the relationship between the age of the perpetrator and the gender of the victim. The victims in these 42 cases were predominantly white (35/42), although there were also 4 dual heritage, 2 black and 1 Asian child. There was a clear pattern in the relationship between the ages of the perpetrators and their victims.

Abuser age group (years)

Age range of victim

4 – 12

2 – 12

13 – 15

4 – 12

16 – 19

11 – 16

Relationship of abuser to victim Brother/half- /step- brother

20 (48%)

Uncle/cousin

4 (9.5%)

Unrelated but known to child and family

17 (40%)

Unknown stranger

1 (2.4%)

Type of abuse with overlap

Number

Penetrative incl. anal, vaginal

Oral

Touching

Other

Conclusion: This small study showed that a quarter of the alleged abusers in cases of CSA are themselves children or adolescents. More than half were related, and the others were known to the child and/or family.

Recommendations: Keep-safe messages should emphasise the risk of peer and abuse from family members, as well as from those known to the child. Child and adolescent molesters need to receive appropriate counselling to reduce reoffending and to prevent them from graduating into adults posing risk to children.

The Physician • Vol 3 Issue 1 • November 2014

Abstracts

Breast Cancer Risk Factors in South Asian Women Presenting with Breast Cancer at the Nightingale Centre, Manchester Levy, Lior,1 Jain, A K1,2 *Corresponding author: Professor Anil Jain, Consultant Radiologist; anil.jain@ manchester.ac.uk

University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK

The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK

Abstract:

were 11 years of age or younger at menarche. 9% of the screening and symptomatic cases were 30 years old at their first pregnancy. Both groups had had 3.5 average live pregnancies. 17% of the screening and 24% of the symptomatic cases did not breastfeed. 10% of the symptomatic, but 25% of the screening cases had a positive family history. Only 4% of the screening, but 29% of the symptomatic cases had had previous breast disease. The average tumour size was 16.6 mm (range 3–50 mm) for the screening and 36 mm (range 13–120 mm) for the symptomatic cases. 13% of the screening, but 37% of the symptomatic invasive cancers had poor prognosis Nottingham Prognostic Index scores.

Conclusion:

Aim: To study breast cancer risk factors in South Asian breast cancer patients.

Methods:

There is no significant difference in breast cancer risk factors between symptomatic and screening patients. However, symptomatic cancers present earlier and are more aggressive.

References:

We retrospectively studied breast cancer risk factors in South Asian breast cancer patients diagnosed at the Nightingale Centre, Manchester. The Nottingham Prognostic Index was calculated for all invasive cancers.

Results:

V A McCormack, P Mangtani, D Bhakta, A J McMichael, I dos Santos Silva. Heterogeneity of breast cancer risk within the South Asian female population in England: a population- based case–control study of first-generation migrants. British Journal of Cancer, 2004;90(1):160–166.

59 cases, including 28 screening and 31 symptomatic cases were studied. The age range for screen detected cancer was 51–73 years (mean 60.5) and 28–79 years (mean 48.5) for symptomatic cases. 4% of the screening, but 16% of the symptomatic cases

Jain A K. South Asian Women at the Crossroads- rising breast cancer incidence, poor breast cancer awareness and poor screening uptake. http://behalal.org/health/uk-south-asianwomen-at-the-crossroads/ NHS Evidence October

An Integrated Approach to Health Service Delivery sharing of information among team members related to patient care and the establishment of a comprehensive treatment plan to address the biological, psychological and social needs of the patient.

Dr Divya Verma Deputy Manager - International Business Fortis Healthcare Limited, India

Abstract: As stated by the WHO Director General (2007): ‘We need a comprehensive, integrated approach to service delivery. We need to fight fragmentation’. Integrated healthcare, often referred to as interdisciplinary healthcare, is an approach characterised by a high degree of collaboration and communication among healthcare professionals. What makes integrated healthcare unique is the

Integrated healthcare is not about structures or common ownership or bearing insurance risks; it is about networks and connections – often between organisations – that focus the continuum of healthcare delivery around patients and population. An integrated approach is required to achieve better health delivery outcomes and patient satisfaction. The poster will focus on the basic models of integration, and also some principles that should be kept in mind to achieve successful health systems’ integration.

The Physician • Vol 3 Issue 1 • November 2014

Abstracts

From Zero to Comprehensive Fracture Liasion Service within Existing Resources Hywel Dda University Health Board, Glangwili Hospital, Carmarthen, Wales Email: guptaabhaya@hotmail.com

Introduction Osteoporosis is a chronic condition, with the economic impact of fractures being huge. The Fracture Liaison Service (FLS) is an efficient and cost-effective service for patients with fragility fractures. A 50% reduction in hip fractures can be achieved during three years of bone therapy (meta-analysis), with additional benefits in QUALY by prevention of falls and fractures. The National Osteoporosis Society advocates the universal adoption of the FLS model throughout the NHS. Local results from the National Audit for Falls and Bone Health (2007) identified only 12% of patients clinically assessed for osteoporosis risk, with 8% having a DEXA scan performed, 44% prescribed medication and information provision being low. The UK’s recommendations were that ‘PCTs commission a pathway for secondary prevention of falls and fractures that include FLS targeting [of] high risk groups’. However, locally, there was a lack of osteoporosis strategy or clinical leadership.

the osteoporosis service at Glangwili Hospital, Carmarthen, in October 2010. Developments included pathways for case finding using a systematic, proactive approach; targeting highest risk patients with a ‘respond to first and prevent second fracture’ approach; treatment algorithms; management protocols; Aclasta infusion; Denosumab and Teriparatide injection protocols; and the development of patient information leaflets. Patients aged above 50 years and with recent fragility fracture are identified through their A&E attendance. Hip fractures are seen in the new Acute Hip Fracture Unit. Admitted fragility fracture patients are assessed in the trauma wards. Referrals are also received from GPs/clinicians. Suitable patients attend a weekly clinic. A standardised risk assessment questionnaire is completed, appropriate investigations performed, and a DEXA scan requested, adhering to the NICE guidelines. The FRAX algorithm is used for treatment decisions, with verbal and written information given.

Methods

Written management plans are sent to the GP. Several osteoporosis drugs are now approved in the local formulary. Furthermore, an Osteoporosis Support Group was set up in 2007 by a specialist nurse in Carmarthen.

Dr Abhaya Gupta (AG) identified the need, and commenced

Conclusion •

A new Fracture Liaison Service has been established – previously non-existent – to close the secondary fracture prevention management gap. Initially devised for the Carmarthen population, referrals are now being received from the Llanelli and Pembroke area within the Hywel Dda Health Board.

•

A comprehensive and proactive systematic approach for managing people at highest risk of osteoporosis has now been established. A ‘signal fracture’ is used as a trigger and opportunity to prevent further fractures. The top-down approach in the ‘pyramid model’ provided by the Department of Health for identifying and targeting highest risk is used.

•

FLS integrates with the Hip Fracture Unit established by AG.

•

FLS promotes training and research opportunities: several poster presentations have been done at international conferences.

•

A new service can be established within existing resources, and without the need for business plans and unnecessary delays.

The Physician • Vol 3 Issue 1 • November 2014

Abstracts

Lessons-

Carmarthen Fracture Liaison Service

•

Through strong leadership, determination and enthusiasm, the highest quality care across primary and secondary care boundaries is possible.

•

Problems can be turned into opportunities by constructive, sensible problem-solving approaches.

•

Explore new tools and existing resources for creating a system locally.

•

Rapid change requires local clinical champions.

6. Gupta A, Chenna S, Gupta S. Understanding patient preferences for available osteoporosis treatments. Poster at IOF-ESCEO conference Rome, Italy April 2013. Abstract in Osteoporosis International. 2013;24 suppl1.S128.

Disclosure No financial gain; no conflict of interest Relevant Publications 1. Gupta A. Commentary: Hip fracture: then and now. Geriatric Medicine. 2010;40(10):567. 2.

Gupta A, Thurston A. Osteoporosis: new opportunities. Geriatric Medicine. June 2012.pp.37–43.

3. Gupta A. Medical management of hip fractures and the role of orthogeriatrician. Reviews in Clinical Gerontology. Nov 2012;22(4):261– 73. 4.

Gupta A. The effectiveness of geriatrician led comprehensive hip fracture care in UK. J R Coll Physicians Edin. 2014;44:20–6.

Gupta A, Havelock W. A new future for hip fracture care – Orthogeriatrician led and in ‘Acute’ Hip Unit’. Accepted for publication in Clinical Medicine 2014.

Gupta A. Efficacy of a geriatrician led hip fracture program. Poster at IOF-ESCEO conference Rome, Italy April 2013. Abstract in Osteoporosis International. 2013;24 suppl1.S131.

8. Marshall K, R.S, S.C, Gupta A. Assessment of renal functions & associated metabolic abnormalities in hip fractures. Poster + Oral presentation at World Congress on BMJD. Brussels Nov 2013. 9.

Eeranti R, M.S, SC, Gupta A. Bisphosphonate prescribing in patients with hip fracture. Poster at World Congress on BMJD, Brussels Nov 2013.

10. Frankland S, Gupta A. An observational study of S Creatinine levels in hip fractures. Poster at World Osteoporosis Conference, Seville April 2014. Abstract in Osteoporosis International. 2014;25 suppl2.

Posters

11. Frankland S, Gupta A. Prevalence of anaemia in hip fracture patients. Poster at World Osteoporosis Conference, Seville, April 2014. Abstract in Osteoporosis International. 2014;25 suppl2.

1. Gupta A et al. Orthogeriatric input in secondary prevention of fragility fractures. Poster at IOF Asia-Pacific meeting, Singapore. Dec 2010. Abstract in Osteoporosis International. 21(5):Dec2010.

12. Manupati S, K.S, Gupta A et al. Osteoporosis risk assessment in a Welsh DGH. Poster at World Osteoporosis Conference, Seville, April 2014. Abstract in Osteoporosis International. 2014;25 suppl2.

2. Gupta A, Gupta S. Vertebral osteopenia and management of osteoporosis. Poster at IOF Conference. Dubai. October 2011. Abstract in Osteoporosis International. 22(5):S737.

13. Siddarth K, S.M, Gupta A. Appropriateness of osteoporosis treatment in medical inpatient population. Poster at World Osteoporosis Conference, Seville, April 2014. Abstract in Osteoporosis International. 2014;25 suppl2.

3. Gupta A, Gupta S. Vertebral fracture audit improves local services. Poster at IOF Conference Dubai. Oct 2011. Abstract in Osteoporosis International. 22(5):S737.

14. Gupta S, Gupta A. Oral health attitudes and practices amongst patients with osteoporosis. Poster at World Osteoporosis Conference, Seville, April 2014. Abstract in Osteoporosis International. 2014;25 suppl2.

Gupta A, Chenna S, Lorch A. A new collaborative acute hip unit improves care of osteoporosis and adherence to guidelines. Poster at IOF-ECCEO conference March 2012 Bordeaux, France. Abstract in Osteoporosis International. 2012;23(2):S115.

15. Siddarth KV, Shilpa Manupati & Abhaya Gupta. Appropriateness of osteoporosis treatment within a medical in-patient population in a Welsh district general hospital. Poster at ECTS Prague, May 2014. Bone Abstracts (2014) 3 pp.344; doi:10.1530/boneabs.3.PP344.

Gupta A, Lorch A, Chenna S. A new consultant led fracture liaison service. Poster at IOF-ECCEO conference March 2012 Bordeaux, France. Abstract in Osteoporosis International. 2012;23(2):S115.

16. Shilpa Manupati, Siddarth Kadidal Viswanath, Abhaya Gupta & Srinivas Chenna. Osteoporosis risk assessment in a Welsh district general hospital. Poster at ECTS Prague May 2014. Bone Abstrac

The Physician • Vol 3 Issue 1 • November 2014

Abstracts

Comparison of Prognostic Indices in Symptomatic and Screendetected Invasive Breast Cancer in Asian and Caucasian Women Steele A,1 Jain A K,1,2 Randhawa N,1 Foden P,1 Morris J1

matched Caucasian breast cancer patients, diagnosed by the same mode.

Professor Anil Jain, Consultant Radiologist;

Results:

anil.jain@manchester.ac.uk

University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK

The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK

Introduction: In the United Kingdom, ethnic minority women have reported lower breast awareness and lower breast screening uptake rates, and have presented with breast cancer symptoms later than Caucasian women. Our study aims to compare prognostic indices in symptomatic and screen-detected breast cancer between Asian and Caucasian patients.

Material and methods: Of the 310 Asian women diagnosed with breast cancer between 1999 and 2014 at the Nightingale Centre and Genesis Prevention Centre, Manchester, the 217 women with invasive cancer were selected, comprising of: Group 1: Screen-detected (n=57) Group 2: Symptomatic (n=160) Data on invasive tumour size, grade, lymph node status and NPI were obtained for comparison with equal numbers of age-

The Asian symptomatic women had larger invasive tumour sizes (median 25.0 mm, IQR 17.1–35.8 mm), compared with the Caucasian patients (median 17.0 mm, IQR 12.0–26.4 mm) (p<0.001); higher proportions of Grade 3 tumours (64.4%) (p=0.007) and patients with more than one lymph node involved (46.2%) (p=0.004), compared with the Caucasian patients (48.8% and 30.0%, respectively); worse NPI scores (median 4.6, IQR 4.3–5.6), compared with the Caucasian patients (median 4.3, IQR 3.3–4.7) (p<0.001); and higher proportions of patients in the Poor Prognosis Group (33.8%), compared with the Caucasian patients (11.9%) (p<0.001). Multiple logistic regression showed that invasive grade and tumour size were statistically significant discriminators after adjusting for the other variables in the model. Lymph node status was borderline significant. However, there was no statistically significant difference between the Asian and Caucasian patients with screen-detected invasive tumours.

Conclusions: Prognostic indices in Asian women are worse in symptomatic breast cancer, but are similar in screen-detected invasive cancer, compared with age-matched Caucasian women. Hence, greater initiatives need to be implemented to promote breast cancer awareness in Asian women so they can seek breast clinic referral without undue delay, along with more concerted efforts to improve breast screening uptake amongst them.

Effect of coding system on the medical readmission rate in a NHS district general hospital Tariq Memon, Amit Badshah, Prashanth R Mamilla, A Kamour

Background:

Payment by Results (PbR) guidance, commissioners will no longer pay for any eligible emergency readmissions to a hospital within 30 days of discharge following a planned hospital stay1. As of 1st April 2012 this policy was extended so that Trusts would potentially incur charges for any unplanned readmission within 30 days following elective and emergency admission1.

In April 2011, the Department of Health introduced a policy of non-payment for emergency readmissions to English hospitals within 30 days of discharge. According to the 2011/2012

The Care Quality Commission, The independent of health and social care in England, uses among other indicators, hospitalreadmission rates to identify unexpected performance (outliers)

Corresponding author: Dr Tariq Memon, Tariq.Memon@nhs.net

The Physician • Vol 3 Issue 1 • November 2014

Abstracts

that may be linked to problems with the quality of care. Aim: to study the effect of coding system on the readmission rate of patients discharged from the medical discipline in Weston General Hospital, an NHS district general hospital. Methods: Retrospective data analysis of 75 patients randomly selected out of 299 patients identified by the coding department as 30-day readmission, from the period of 3rd sept to 23rd sept 2014. Results: out of the 75 cases identified, 55 were medical readmission, and 20 surgical. 28 medical cases (51%) were coded appropriately as medical readmission (95% confidence interval 0.3707 to 0.6465). 27 cases (49%) were labelled incorrectly as medical readmission (95% confidence interval 0.3535 to 0.6293). Analysing these miscoded cases found 4 patients (15%) were never readmitted within 30 days of their discharge, 12 patients (44%) were either admitted from ambulatory care unit (ACU) to the hospital, or followed up in the ACU following discharge form hospital. 11 patients (41%) were coded as medical readmission despite being previously assessed and managed by other disciplines, eg, Emergency or surgical teams. Conclusion: the coding system in our trust has inadvertently

increased the number of patients labelled as medical readmission due to inability to identify the nature of readmission, inappropriately coding ACU patients as readmissions, and including patients were not readmitted to the hospital in the following 30 days after their discharge. A robust coding system, including training of the coding department staff, is required with continues monitoring and auditing to ensure correct coding of readmitted patients to avoid financial consequences and negative reviews by the Care Quality Commission. 1. Department of Health. Payment by results guidance for 2011–12. 2012. (Online). Available at http://webarchive. nationalarchives.gov.uk/20130507170152/https:// www.gov.uk/government/uploads/system/uploads/ attachment_data/file/151911/dh_126157.pdf.pdf. Accessed on 14th November 2014 2. Care Quality Commison. CQC indicators for mortality and emergency readmissions using Hospital Episode Statistics (HES). Guidance for NHS providers on new HES indicators in the NHS QRP 2013. (Online). Available at http://www.cqc.org.uk/sites/default/files/ documents/nhs_hes_qrp_data_item_guidancefor_ publication.pdf. Accessed on 14th November 2014.

Do Disparities Exist in Surgical Treatment and Post-Mastectomy Reconstruction between Asian and Caucasian Patients Diagnosed with Breast Carcinoma? Randhawa N,1 Steele A,1 Jain A K,1,2

Results:

Professor Anil Jain, Consultant Radiologist;

88 Asians and 88 Caucasians had mastectomies. 50 Asians and 60 Caucasians were offered immediate reconstruction (IR). The IR rate was 54.0% (n = 27) in Asians, and 66.7% (n = 40) in Caucasians. This difference was statistically significant (0.026). Similarly, the delayed reconstruction (DR) rate was 14.3% (n = 3) in Asians and 78.9% (n = 15) in Caucasians (p < 0.000).

anil.jain@manchester.ac.uk 1 University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK 2 The Nightingale Centre and Genesis Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK

Aim: To investigate differences in post-mastectomy reconstruction rates between Asian and Caucasian women.

Methods: The sample consisted of 161 Asians and a matched cohort of 161 Caucasians who received surgical treatment for breast carcinoma at University Hospital South Manchester between 2009 and 2014. Chi-square tests were used to evaluate differences in immediate and delayed reconstruction rates between the two cohorts. Patient and tumour characteristics were evaluated as predictors of immediate breast reconstruction.

The IR rates were higher in patients under 50 years at 73.6% (n = 39), compared to 49.1% (n = 28) in patients above 50 years (p = 0.009). The IR rates were similar for patients diagnosed with invasive and non-invasive breast carcinoma, at 61.1% and 60.0%, respectively (p = 0.977). No statistically significant difference was seen in the IR rates between employed and unemployed patients. Similarly, no statistically significant difference was seen in IR between married and single patients.

Conclusion: Disparities exist in reconstruction between Asian and Caucasian women. Asians are less likely to accept reconstruction compared to Caucasians. Age is a predictor of IR. Tumour characteristics, such as invasive status, are not. Employment status and marital status are also not predictors of IR.

The Physician • Vol 3 Issue 1 • November 2014

Quality Improvement

Why We Need the Model for Improvement? Dr Tricia Woodhead BM MBA MRCP(UK) FRCR Associate Medical Director for the Patient Safety and Quality Improvement Programme, West of England Academic Health Science Network Patient Safety Advisor to the Royal College of Radiologists

Over the last 15 years healthcare has increased in complexity. There are many reasons for this, but three of these stand out within the NHS.

Quality Improvement Coach, Royal College of Physicians

First is the disruption of the core clinical team as a result of the European Working Time Directive. This reduced the maximum hours worked by any individual and required a significant reorganisation of junior medical training arrangements. What was a clear team under the guidance of a small number, or even one senior doctor has become a relay race with a demonstrable reduction in the continuity of the threads of information and decision making that result in care being effective, efficient and holistic. Second is the increasing and legitimate development of evidencebased care. This has rightly resulted in greater explicitness about what should happen when treating and managing an illness. This has brought together the various sciences within medicine to clarify what works, and in what sequence or combination the best outcome can be achieved. NICE, national recommendations, specialist documents and the increasing medical literature have all produced greater clarity on the science, but there is often a lack of clarity on how a system might be constructed to deliver it. This has been left to the system itself, sometimes local and sometimes regional, but often the assumption has been to ‘just do it’. Third brings these two changes into direct confrontation. It is a fact that, universally, health care has a high error rate. Human factors impact on judgement, awareness and knowledge at the point of urgent decisions. These all contribute to a 1/10 chance of not doing the right thing. Systems designed to deliver highly reliable, complex care and protect humans from poor decision making have lagged behind the need to do so. Not unexpectedly, as errors and omissions have become explicit through complaints and litigation, so has the demand to fix the problem. This has remained a massive challenge. The demand for evidence to be implemented and praying it will happen does not work. Educating and training does not always lead to any better than 1/10 error rates. The hope is that identifying the gap through audit will, by itself, close that gap by motivating staff to comply with best practice and prevent a recurrence. We know that this is not how other complex systems achieve their admirable goals of 3, 4 or even, amazingly, 6 sigma reliability.

The Model for Improvement has its origins in the manufacturing and engineering industries after the Second World War. Increasing competition for markets as well as the rapidly increasing ability to produce complex products required a new approach to replace the ‘Taylorism’ of the pre-war period. Setting up a controlled production line, discipline and training, and ‘binning’ the detected defects at the end of the line became a business model for those heading for bankruptcy. Spotting the problem as it happened and ensuring the workforce strived to anticipate the error before it evolved into lost resource or income was the new way to win markets and achieve business success. The Model for Improvement has four key perspectives that drive the process of planning, doing, studying and taking actions (PDSA). First, there is variation in the delivery of a standard piece of work. Understand why this is happening before you design an answer. Second, there will be theories on what needs to be done. These will each arise from a different, but relevant perspective. This must be harnessed and incorporated into the ‘solution building’ or success will be undermined. Third, ‘The System’ that is currently in place will be delivering the results you are getting. If the results are not delivering the new evidence or, worse still, are unreliable in their output, no amount of insistence that they do better will gain the impact that rethinking the system will achieve. Only by changing the system to deliver new practice or less than 1/10 failures will succeed. Fourth – but in healthcare this is of maximum importance – is human behaviour. We must accept the ‘human condition’. People will forget, be distracted, be overly focused on their part of the complexity and not the negative impact of their behaviour on the rest of the system. On the whole the workforce strive to do a good job; however, the system will have made that potentially more difficult due to it not being designed to accommodate new science, demands or expectations.

The Physician • Vol 3 Issue 1 • November 2014

Reviews

When 60% of the admissions are over 75 years of age and have complex multisystem illnesses that are finely balanced until a relatively minor deterioration, the production line for an acute single problem in an otherwise stable physiology is in trouble. When over half the ward need support and assistance to drink fluids, eat and move about to prevent pressure ulcers, yet fall when they do so, the way a staffing team share the responsibility with each other to care has to rapidly adapt. Of course some teams, leadership and parts of the system can get a grasp of this. However, for many this is not without distress and failure that results in needless harm. Over the last 20 years the application of the Model for Improvement, adapted to healthcare and relevant to the increasing complexity of healthcare, has produced results. Building ‘the will’ across and deep within the workforce so as to deliver highly reliable care requires attention and effort. This does not happen by dictating, but by demonstrating confidence in small tests of potential improvement and the continuous use of data to share and learn from. Ideas generated by collaboration and not managed teams, gain the magic ingredient of discretionary effort in the redesign of work. The desire for excellence and continuous improvement is a human characteristic, not least in those whose reason for their work is a desire to care and make a difference. Encouraging and recognising this brings dividends of engagement in daily improvement whatever the baseline position. The challenge of the successful execution of new ideas and delivery models is driven far faster and more successfully if there is close attention to ‘how’ we measure success, and how we see our progress along that route in real time. The aggregation of data into blocks of weeks or months hides the richness of any data set. Developing high reliability is about continuous measurement of where ‘we are’, a clear knowledge of the current destination and close attention to adjustments that are needed before we hit a wall.

this sounds like Nirvana then it is compared with top down, ‘spray and pray policies’ and directives. The Model for Improvement gives staff a sense of purpose and the tools with which to deliver more reliable care for patients and families. The Royal College of Physicians has led the way in promoting this approach with core medical trainees and now consultant training (Learning to Make a Difference). Within the South West we have developed a region-wide programme for Foundation doctors in this approach. We are reaping the value of fresh eyes when they arrive in a new trust and then seek to address gaps they are able to see. Doctors need

to take this approach, add it to their clinical skills and reaffirm their role in the NHS.

Useful references: https://www.rcplondon.ac.uk/search/node/learning%20to%2make%20a%20 difference https://www.youtube.com/watch?v=SCYghxtioIY www.ihi.org/knowledge/Pages/HowtoImprove So what could you do by next Tuesday? This is the discipline of continuous improvement: 1.

Review the www.rcplondon.ac.uk ‘Learning to make a difference’ web page.

The dashboard is about what happens now and a few minutes ago; the headlights are where we need to be looking. As for the rear view mirror, this is where audit sits and this is why audit, as a tool for change, is no longer valid as a measure of what is happening or what needs to. Where we have been is of limited use in deciding how we get to our destination, when that destination is a new one.

If you are a consultant, start with the project sponsor’s guide.

If you are a doctor in training, start with the trainee guide.

Review the web link on how complexity can be organised to enable

Take the most recent audit you participated in and review the findings.

Almost all people in healthcare aspire to doing a better job tomorrow than they did yesterday. Most patients would prefer not to be a recipient of less than the best care possible on the day they seek it.

With colleagues, spend 30 minutes developing a driver diagram of the main

Tying these two needs is more likely to be achieved if we focus on higher levels of reliable best practice. The Model for Improvement enables the system to change under the guidance and input of clinical teams at the patient’s bedside, building their commitment to what they design. Data that they collect, using measures that really do tell them how well or not they are doing, builds increased will and motivation. If

improvement.

‘WHATs’ that need to change to improve the situation the audit has uncovered. 7.

Then with colleagues, consider what could enable those ‘WHATs’ to change: What secondary drivers would shift the problem?

The guides will give examples. Keep it simple. Remember that multiple small improvements will add up to a big shift if they are organised to cover the main themes or ‘WHATs’.

Then, get started testing out the ideas, one patient, one day at a time using the Plan-Do-Study-Act cycle of learning and adapting, adopting or abandoning the ideas as you go.

The Physician • Vol 3 Issue 1 • November 2014