HEALTHCARE IN THE NHS THROUGH INTEGRATION THE OFFICIAL PUBLICATION OF THE CLINICAL COMMISSIONING GROUPS ASSOCIATION

A2: 2015, BS/EN 13624: 2013. BS/EN 16615:2015 (Quantitative test method for the evaluation of bactericidal and yeasticidal activity on non-porous surfaces with mechanical action employing wipes). Developed & Made in the UK

ADVERTISING FEATURE Foreword From April 2022 the Health and Care Bill will firmly secure a raft of reform schema in order to create the very best conditions for local and national organisations to improve patient care as Integrated Care Systems (ICS`s) are placed on a statutory footing thus empowering them to better join up health and care services. Trusts are looking to deliver the new policy and legislation in a way that best fits their systems in tandem with their system partners. This change is evolving against the backdrop of a challenging operational landscape with pressures from workforce shortages and care backlogs due to the ongoing COVID-19 pandemic. Focus is on the transition of Clinical Commissioning Groups and the importance of agreeing and evolving responsibilities, collaboratives and partnerships with a view to improve population health outcomes and levelling up healthcare inequalities. Collaboration will be key in delivering the tasks at hand. The reforms will help enable the use of technology in a modern way, establishing technology as a better platform to support staff and patient care. The NHS has faced incredible pressures this year and we have recognised the three big truths we can all agree on; pride in our health services, enduring success and in the shared social commitment it represents. As Commissioning Editor, I would like to thank the distinguished authors in this edition who were commissioned to contribute their professional opinions. We would also like to thank all the organisations and societies who contribute to the NHS. This edition appears at a pivotal stage in history, as the NHS faces rapid and profound changes. It will require us, within our own capacities, to work together and share the load. Wishing you all well and do keep safe. I look forward to working with you all in the coming year. Louis Selwyn FRSM, MMJA Commissioning Editor & Chief Co-ordinator HEALTHCARE IN THE NHS THROUGH INTEGRATION

Healthcare in the NHS through integration Please Note: This publication is produced as an independent information source. The information in this publication has been provided by and with the permission of the organisations and individuals concerned, or obtained from sources within the public domain. The views expressed in this publication are not necessarily those of either the publisher Clinical Support Services (CSS) or the Editors. They are not endorsing any company or product in this publication. It is not the intention to print any matter that discriminates on the grounds of race, sex , sexuality or disability. This material is in no way intended to replace the professional medical care, advice, diagnosis or treatment from a doctor, specialist or healthcare professional. Answers to specific problems may not apply to everyone. Neither the Editors or Publisher shall be held responsible for any damage, injury or loss caused as a result of any therapy, treatment or advice recommended or contained within this publication If you notice medical symptoms or feel ill , you should consult a doctor. All details, information and prices are correct at the time of going to press. The publishing of any article or its position in relationship to an advertisement for any product , commodity or service is not taken to imply any form of endorsement or recommendation by the author, publisher or editors, nor if applicable the advertiser of any product , commodity or service so advertised. Whilst every effort has been made to ensure that the information contained in this publication is accurate and up to date, neither the Publisher or the Editors can be held responsible for the accuracy or otherwise of any statement made in any advertisement or within the editorial/ advertisement feature content of this publication. © 2022. The entire content of this publication is protected by copyright. No part of this publication maybe reproduced, stored in a retrieval system, or transmitted by any means digital, electronic, mechanical or otherwise without the permission of the copyright owner. Commissioning Editor & Chief Co-ordinator : Louis Selwyn FRSM MMJA Production Manager & Multi Media Developer : Iain Gwynn Publication & Website Specialist Contributing Authors : Professor Debi Bhattacharya Professor Ingvar Bjarnason MRCpath Dsc FRCPath FRCP Dr J Bolodeoku MBBS MSc MBA Dphil (Oxon) FRCPath Professor Nicola Carslaw Dr Susan Childs Dr Anand Chitnis BSc MB ChB FRCGP DRCOG Professor Anthony Chu FRCP Mr Steven Cutts BSc Hons, MBBS, FRCS (Tr & Orth) Dr Michael Heber FRCGP Dr Bianca Kuehler Professor Graham MacGregor CBE FMedSci Dr Ishak Nadeem Mr John F Nolan MBBS FRCS (Orth) Professor Hugh Pennington CBE FRCPath FRCP (Edin) FMedSci FRSE Dr Clifford Richards MBE Melanie Scott RGH, RHAD Sion Scott Dr E David Macrae Tod OBE JP FRCGP MBch (ED) DipCrim (Lon) Mr Gavin Walsh Published by : Clinical Support Services Crown House 27 Old Gloucester Street London WC1N 3AX e-mail : [email protected]

6 The Existential challenge of COVID-19 and Climate change and it’s impact on mental health by Dr Ishak Nadeem 10 A spotlight on Pulse Oximetry - Not all pulse oximeters are created equally! by Dr. Basil Matta MA FRCA FFICM, Senior Medical Director, Masimo* 12 Harnessing behavioural science to implement the National Overprescribing Review recommendations by Sion Scott, Lecturer in Behavioural Medicine, University of Leicester & Debi Bhattacharya, Professor of Behavioural Medicine, University of Leicester 14 Pandemic must lead to better disinfectant product standards by Dr Philip Norville, Clinical & Scientific Director at GAMA Healthcare* 16 The NHS and IT after COVID-19 by Steven Cutts BSc Hons, MBBS, FRCS (Tr & Orth) 20 Specialist Pain clinics at the Chelsea & Westminster following COVID-19: We continue no matter what by Dr Susan Childs: Consultant Clinical Psychologist, Lead Therapist for Pain Management Services 24 2021: The year that health tech came of age by Ric Thompson, Managing Director, Advanced Health & Care 25 Off the Cuff politics by Steven Cutts BSc Hons, MBBS, FRCS (Tr & Orth) 26 Supply Chain Excellence by Alexandra* 28 Note on Long COVID by Professor Hugh Pennington 30 White Water Rafting - a journey through difficult times by Dr Anand Chitnis, GP and Clinical Director NSC North Primary Care Network 34 SANE - a leading UK mental health charity improving quality of life for anyone affected by mental illness by SANE 38 Evolution of Multidisciplinary Services for Chronic Pain by Dr Bianca Kuehler, Consultant Pain Management 39 Physiotherapy in a Chronic Pain Service by Mr Gavin Walsh: Lead Specialist Physiotherapist at the Chelsea and Westminster Hospital 42 myGP® - Reducing unnecessary appointments in primary care by iPLATO Healthcare* 44 The role of osteopaths as AHPs to support MSK service delivery Matthew Rogers, Head of Professional Development Institute of Osteopathy 46 The efficacy of the probiotic Symprove as assessed from random clinical trials by Ingvar Bjarnason, Department of Gastroenterology, King’s College Hospital* 50 The Perfect Storm by Melanie Jackson RGN RHAD, ENT Nurse Practitioner, Head of Nursing & Clinical Lead 53 Obesity: Treat and Prevent - An evidence based action plan to reduce death from COVID-19 by Graham MacGregor, Chair of Action on Sugar and Action on Salt Professor of Cardiovascular Medicine 58 Whatever the day throws at you: there’s a friend for everyone by FISHERMAN’S FRIEND* 60 Indoor air pollution and relevance for the NHS by Professor Nicola Carslaw, Department of Environment and Geography, University of York 62 It’s time to clear the air on the NHS backlog by Christian Hendriksen, Co-founder and CEO, Rensair* 64 RCGP Practice Development by Dr Michael Heber FRCGP 65 Ground attack alone will not defeat drug-resistant bacteria by Christian Hendriksen, Co-founder and CEO, Rensair* 66 How digitally enabled self-management can help transform services in mental health: lessons from the front line by Dr Louise Morpeth, Brain in Hand* 69 Hand-held devices (CardioChek®, Mission®) to smart phones (elemark™, 1drop™) for self-testing of blood cholesterol by J Bolodeoku MBBS, MSc, MBA, DPhil, FRCPath , FRSB* 74 Refuge - For Women and Children, Against Domestic Violence by Refuge 76 The Road Ahead: Communicating post Coronavirus by Eastern Voice and >[email protected]

12 HEALTHCARE IN THE NHS THROUGH INTEGRATION Harnessing behavioural science to implement the National Overprescribing Review recommendations The National Overprescribing Review estimates that 10% of medicines prescribed in primary care are unnecessary or harmful(1). The review concludes that overprescribing is caused by systemic and cultural factors. Failure to embed deprescribing into the prescribing process is a significant contributor to overprescribing. The principles of Good Prescribing Practice (Figure 1) require prescribers to monitor the appropriateness of the medicines they prescribe and proactively deprescribe any that become inappropriate before they cause harm. Despite this, deprescribing in both primary and secondary care is largely ‘reactive’ in response to an adverse drug event such as a side effect(2,3). Practitioner motivation to reactively deprescribe is likely to be very high given that inaction leads to certain patient harm. For example, reactively deprescribing an anticoagulant for a patient presenting with a gastric bleed. Proactive deprescribing, however, requires a complex weighing of future potential harm versus benefit(3). Uncertainties regarding the likely benefits and potential harms is a barrier to proactive deprescribing(4). For example, a practitioner may be reticent to proactively deprescribe an antihypertensive for a patient even if the risk of falling and resulting fracture is greater than the risk of a cardiovascular event. Figure 1 Principles of Good Prescribing Practice (5) One strategy proposed for identifying and resolving overprescribing is the introduction of Structured Medication Reviews. These are a review of all medicines that a patient is using to assess them for safety, effectiveness and tailored to the patient’s needs. Structured Medication Reviews are intended to ‘take considerably longer than an average GP appointment’ and be primarily undertaken by prescribing pharmacists thus introducing extra resource for increasing deprescribing activity in primary care. Stakeholder engagement is essential for achieving behaviour change, however, purely focussing on what people think they need to deliver the change, often fails to address all barriers and enablers(6). Staff commonly cite the need for extra resource as the solution. However, given extra resource such as time and workforce, staff will often increase existing activities with which they are familiar and have a known pathway of recognition rather than undertake the desired new behaviour. Another commonly delivered ‘solution’ to effect a change in practice is education and training. Whilst having the required knowledge and skills is clearly essential, behaviour change is rarely achieved by addressing only these barriers/enablers (6). Asking staff what help they think they need, places the onus on them to correctly identify their barriers and enablers to undertaking the desired behaviour and then select the most appropriate solutions. The field of behavioural science has offered a scientific approach to garner meaningful input from stakeholders to shape the development of strategies to support implementation of a new behaviour(7). Stakeholders’ thoughts and concerns regarding the required change in practice can be analysed to identify and prioritise the key barriers/enablers to implementing a new behaviour(8). For each key barrier/ enabler, a range of theory and evidence based solutions have been collated into a taxonomy(9). Stakeholders can then be facilitated to select solutions from the taxonomy according to criteria such as the extent to which it is likely to be acceptable to everyone, affordable for the organisation and not introduce inequity(10). Applying behavioural science to address the determinants of opioid deprescribing in primary care has identified six key components needed to support prescribers(11). Figure 2 provides these six components that are yet to be included in all primary care strategies. by Sion Scott, Lecturer in Behavioural Medicine, University of Leicester Debi Bhattacharya, Professor of Behavioural Medicine, University of Leicester

13 HEALTHCARE IN THE NHS THROUGH INTEGRATION Figure 2 Opioid toolkit Whilst there is likely to be some overlap between the determinants of opioid deprescribing and proactive deprescribing in the primary care context, they are not the same behaviour. For example, patient reluctance to have their opioids deprescribed is addressed in the toolkit through education to modify unrealistic patient expectations of pain management and opioid tapering(11). In contrast, patients expect prescribers to proactively deprescribe(12). However, stakeholder engagement with prescribers identified that a barrier to them proactively deprescribing is the belief that patients are resistant(13). Accordingly, the component to address this barrier should target the practitioners’ misconception. The determinants of proactive deprescribing in the hospital context have been fully characterised and an intervention co-designed by a team comprising experts in behavioural science working with patients, geriatricians and pharmacists(10). The National Institute for Health Research funded CHARMER (CompreHensive geriAtRician-led MEdication Review) study will evaluate the intervention across up to 42 NHS hospitals. This will provide the evidence for the safety, effectiveness and cost-effectiveness of proactive deprescribing which is essential to underpin commissioning decisions. Differences between the primary and secondary care contexts are likely to yield different determinants and therefore the CHARMER intervention is unlikely to be suitable for implementation in primary care. The CHARMER research programme, however, provides a blueprint for primary care teams to work with experts in behavioural science to implement the National Overprescribing Review recommendations and evaluate any resulting interventions for their safety, effectiveness and cost per quality adjusted life year as there are no pre-existing trials delivering >[email protected] for more information. ADVERTISING FEATURE

16 HEALTHCARE IN THE NHS THROUGH INTEGRATION The NHS and IT after COVID-19 After World War One, the role of women in British society changed forever. The pressures and opportunities provided by the world’s first total war compelled government and society to integrate women into the work force on a large scale. This situation was repeated in the second world war and it’s easy for our own generation to forget just how fantastical certain aspects of the modern working environment would have seemed to people prior to 1914. At this stage, it’s still an exaggeration to compare the impact of COVID-19 to the Great War but the wildly altered circumstances have changed the way people operate, including people who work in the NHS. Quite a lot of medical consultations are now being performed on the telephone. Just about everyone has a phone these days and about half of the population has a smart phone. A couple of weeks ago, I tried to contact my own GP for the first time in years and discovered that he was only willing to speak to me on the telephone. A blood test request form was soon despatched to the reception desk and I soon trooped over to pick the thing up without ever having to meet the doctor in person. The results were entirely normal. In a way, I feel like I’ve wasted the taxpayer’s money but it can be reassuring to hear. As a medical professional myself, I’d be the first to admit that there are risks associated with this policy. There’s a reason we get taught how to examine people at medical school and it you cut the physical examination out then we will pay a price for it. Sooner or later, major organic pathology is going to be missed by a doctor purely because he hasn’t see or examined the patient. That isn’t to say that there is nothing to be gained by telephone consultations. Those of us who have discovered skype during the lock down can testify to the fact that it represents a different experience from a simple telephone conversation. But if we factor in the relatively cheap and simple cameras that come with the modern lap top computer than the virtual consultation can be taken to a new level. There are an awful lot of by Steven Cutts BSc Hons, MBBS, FRCS (Tr & Orth)

17 HEALTHCARE IN THE NHS THROUGH INTEGRATION minor surgical procedures when it’s useful to at least glance at a post operative wound, say two weeks down the line and then mention in the notes that the wound looked good. For minor hand and wrist surgery, we could inspect a wound quite easily with a skype call. Even a patient sat at a desk in a conventional work place would probably be willing to display their hand to the doctor via a web cam. Being able to store a screen shot of this kind of thing would be even more useful since if the patient developed a problem later on we could compare the next image to the previous one. Right now, it isn’t at all easy to do any of these things. For self employed patients, the advantages of the virtual clinic are even more obvious. Self employed people only get paid if they do any work. If they find themselves compelled to take half a day of work to see me in the outpatient clinic they could easily lose 10% of their weekly income, purely to sit in a waiting room until it’s OK to be seen at my convenience. Worse still, the treasury loses the tax revenue they would have collected on one of the few groups that are ultimately funding the NHS. In reality, we could easily perform many of these consultations in under five minutes using video conferencing kit that is available on just about every modern lap top and smart phone. The perennial argument about who has to pay for parking in the NHS car park would also fade away since they wouldn’t even have to drive here. Plenty of older, more sedentary patients could avoid having to request a volunteer NHS driver to pick them up. In practise, if I have any apprehensions at all with a telephone consultation then I usually invite the patient to attend a face to face consultation in a week or two but that isn’t to say that there aren’t a lot of occasions where the telephone alone can do the job. A picture paints a thousand words and patients (or their GPs) who photograph their own pathology with a smart phone and send it by e-mail have huge potential for the future although again – hospital authorities may soon clash with clinicians over the matter of patient confidentiality. Remember that in practise any info we ever take from a patient is confidential and if anyone manages to hack into the digital traffic has committed a major offence. Quite a lot of musculoskeletal pathology deserves an MRI scan these days and quite a lot of the scans that come back are negative. It takes about six weeks to turn around an MRI scan and what I often find is that within six weeks the forces of nature have corrected the patient’s pathology and their aches and pains have simply gotten better. It’s an expensive way to give nature another six weeks but it often works. If we ring a person at home to tell them that their MRI scan is normal and they respond by saying that their aches and pains have resolved without treatment then it’s hard to say how much resources we’ve actually saved. Long before COVID came on the scene, nosocomial infections were an issue in health care and if you don’t even turn up in the hospital at all then you’re never going to catch anything in the hospital waiting room, let alone when you actually see your doctor. Content provided by Steven Cutts BSc Hons, MBBS, FRCS (Tr & Orth) Medical Consultant, Orthopaedics and Trauma Surgery, James Paget, University Hospitals, NHS Foundation Trust

20 I have written and provided specialist pain management services at the Chelsea & Westminster Hospital for over 14 years now. Every Trust has a unique and differing inward population into their services and in the last decade I have dedicated myself to understanding our unique populations and writing / providing appropriate pain management services for all. More recently I have become engaged with the NWL CCG who are making a valiant attempt to think with a macro plan for pain services in this commissioning body. Watch this space for a new thoughtful, evenly accessible pain service across these boroughs. The bulk of our population has changed since the onset of the pandemic. Traditionally, we would have seen these patients with moderate levels of pain with related mood issues. Patients still present with a sense of being worn down by constant painful sensations and a downward sliding ability towards loss of function in their lives - who have avoided many life activities due to pain and ended up having their entire life focus around their pain. I wonder whether post COVID difficulties with getting a GP appointment has influenced the loss of patients who are more physically and psychologically able with pain, as we have noticed a reduction in this population. I wonder whether the more able pain patients perhaps are waiting for things to ‘settle’ before seeking help or that only patients who are active in asking are getting referred or even that other services are managing these patients effectively. Whatever the reason there does seem to be a shift in the populations being referred. I don’t think we could attribute this to the fact that the service was closed as we remained open (with reduced capacity) through-out all of the waves of COVID-19. We continue to offer a wider range of programmes and therapy input stretching from patients who have chronic pain but still manage to live their lives (but often overdo and end up in a repetitive cycle of boom and bust) to patients who are afraid to make even basic movements associated with everyday life (these patients need encouragement to live without fear of increasing pain). It is not the patients so much but how we offer these services that has shifted post COVID. During the first wave the hospital was very stretched and we saw many of our team step bravely up to work in ITU supporting roles. During this time we continued on – managing all that we could and shifted as many services as we could into telephone and video appointments. Both our patients and our clinicians had to work adaptively to offer a type of service that had previously only been offered in few places with little proven efficacy. This did mean that some of our specialist services (such as those aimed at helping survivors of torture, translated group services and psychologically supported exercise groups for people with high pain who need the concept of a basic activating routine and help with fear of pain) did have to be paused in part. We have restarted some but other services such as the Arabic speaking women’s group has requirements we still cannot provide at the moment. These will return as the tide changes back towards allowing multiples of people in a single room setting. There are still restrictions upon how many people can be in any one room and groups by their nature require a big space with access to gym equipment. During the waves of COVID-19, the few By Dr Susan Childs: Consultant Clinical Psychologist, Lead Therapist for Pain Management Services Specialist Pain clinics at the Chelsea & Westminster following COVID-19: We continue no matter what HEALTHCARE IN THE NHS THROUGH INTEGRATION

charity for training in Eye Movement Desensitisation and Reprocessing therapy training as the level of people with pain who have trauma co-morbid with pain is thought to be rising. This will allow us to help people with an issue that feeds their pain picture without waiting extended time for a specialist service elsewhere. We have worked with patients to help them manage their reactions to their pain, modify their behaviours and identify the things that value and helped them to step towards these in the same model as we promote: living alongside difficulty. We have mirrored the same processes with the way we work and what we offer: identifying our professional reactions, modifying services and holding the things we value about the NHS nearby. So, even more in this post COVID world I can say: we have struggled to keep providing through-out COVID but we will not give up. We stand with people who struggle with their lives because of pain that doesn’t go away. We will continue to speak for the unheard populations not matter what the world throws towards the NHS. Content provided by Dr Susan Childs: Consultant Clinical Psychologist, Lead Therapist Chelsea and Westminster Hospital NHS Foundation Trust HEALTHCARE IN THE NHS THROUGH INTEGRATION

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T: 0330 122 9458 @advanced one-advanced Streamlined secondary care software Docman Connect is a cost-eff ective solution for transferring documents and >[email protected]. by Ric Thompson, Managing Director, Advanced Health & Care How health tech can enpower patients to do more for themselves and reduce pressure on health services

25 HEALTHCARE IN THE NHS THROUGH INTEGRATION Off the Cuff politics Young as I like to think I am, I can still remember the days when hospitals had a subliminal military style discipline and a real sense of order. As soon as you walked onto the wards of a London teaching hospital, it became obvious that you had entered another world. Doctors and nurses occupied much more distinctive territory than they do today. In those dim and distant, pre-smart phone days your average clinician wouldn’t think about turning up on a ward round without a stethoscope and his regimental white coat. Those days have gone. Somewhere in the late noughties, the government decided that white coats should become a thing of the past and that the future would be much better for it. I’m still not convinced they were right. In the aftermath of this minor but momentous decision, standards of dress plummeted for junior doctors everywhere. Even at the time, a number of colleagues considered the decision a deliberate attempt to de-professionalise doctors but the official motivation had been something else: bacterial infection. Ties and white coats were deemed a vector for unscrupulous bacteria and it was suggested that patients were being infected by white coat bourne spores. With hindsight, the actual evidence for this theory was tenous to say the least but I think that the people who suffered the most from it were the patients. A lot of patients aren’t particularly young. Nor are they entirely with it. The elderly pick up on visual cues and the sight of a man in dark suit accompanied by a woman in navy blue and a younger doctor in a white coat was an easy image to get a grip on. It doesn’t really matter if you can’t remember a name or a face. The patients understood the hierarchy and they knew which opinion was the single most significant. The uniforms said it all and when a friend or relative visited the ward and wanted to know who to speak to, they could usually spot a doctor from a maintenance engineer quite easily. I remember as a junior doctor myself a neurosurgical patient passed this disparaging verdict on one of our then consultants: “he looked like someone who had come to do the gardening.” As I remember it, he was a good technician but even today, a lot of patients are looking for something more than that. There are a lot of people walking up and down the corridor in a typical hospital ward and it’s a lot harder to figure out who is who than it used to be. Some microbiologists have openly stated that the infection risk associated with traditional dress codes has been wildly exaggerated. There is no evidence that the white coat is a vehicle for the spread of infection, said Stephanie Dancer, a microbiologist at Hairmyres Hospital in East Kilbride. In contrast, “hand-touch contact, airborne delivery, environmental reservoirs, and human carriage are all implicated in transmission”. In reality, The white coat has been a symbol of the medical profession since it was borrowed from laboratory workers in the mid-19th century. It was widely believed that the colour white would link the profession to such worthy concepts as purity and cleanliness. Many physicians have pointed out that no study has conclusively linked white coats with the spread of infection to patients. Recent evidence has shown that the bacterial load on coat sleeves is equivalent to that found on surgical scrub sleeves after 8 hours of hospital duties. In spite of this, it remains the recommendation of the NHS that healthcare workers should have a dress code of bare-below-elbows outfits. It would have been better to have a trial of the altered dress code for several years before insisting that it should be imposed nationally. By comparing the performance of different units with the old and the new we could have made a more objective judgment as to how best to proceed with modern medicine. No such work was ever done. Remember that these machinations have implications that go far beyond the risk of bacterial infection. Something more than a mere aesthetic has been lost. The boundaries between clinician and managerial authority have been changed and neither the profession or the public have the same sense of confidence in who knows what or how things should be done. Content provided by Steven Cutts BSc Hons, MBBS, FRCS (Tr & Orth) Medical Consultant, Orthopaedics and Trauma Surgery, James Paget, University Hospitals, NHS Foundation Trust by Steven Cutts BSc Hons, MBBS, FRCS (Tr & Orth)

26 HEALTHCARE IN THE NHS THROUGH INTEGRATION Supply Chain Excellence Alexandra has a proud history of more than 160 years and has built excellent working relationships with NHS Trusts throughout the country, offering both high quality products and unbeatable value for money, without compromising integrity. Before the Coronavirus pandemic, Alexandra was already a Tier One supplier to the NHS in England for medical scrubs and gowns. Alexandra also has a long history of supplying uniforms for generations of student and qualified nurses, and other healthcare professionals throughout the UK. As a solutions-based company Alexandra has continued to develop over the last 18 months to ensure that they provided the highest quality personal protection and uniform items to those working on the COVID frontline in the NHS and private health care sectors. When the COVID crisis erupted in March 2020, scrubs quickly became the predominant product request from the NHS - with a 600% increase in demand within a week. By adapting their strengths and leveraging worldwide relationships, Alexandra pivoted their supply chain to provide new products to existing clients, as well as picking up additional healthcare opportunities. Alexandra also established new supply routes in the UK and Europe for products that had traditionally been sourced in the Far East; the increased demand of gowns for the NHS saw them set up supply routes in England and Wales. As well as ensuring that they could get the right product into the country and to the right people, wit h t he expansion of their UK network of manufacturers and suppliers, Alexandra secured Tier One Supplier status for PPE to the NHS in Wales. By focusing on using UK-based manufacturers, Alexandra was also able to support the domestic economy and environment, and worked closely with companies to improve response times. During the pandemic, over 90 per cent of Alexandra’s manufacturing capacity in UK and international factories was switched to support the NHS, and they also marshalled their extensive supply chain network to source Personal Protective Equipment (PPE). In a matter of weeks, Alexandra changed their business focus from around 80% of production being tunics and trousers, to 95% being scrubs, to meet the demand of frontline key workers. Alexandra are active members of the worldwide Ethical Trading Initiative (ETI) and Sedex, helping to drive ethical improvements in worker’s rights and ethical improvements in global supply and manufacturing chains. Through this, they have been able to make sure that all new and existing factories are audited and quality checked to ensure that they never deal with any sub-standard product or producers to ensure they give the same level of service as when manufacturing and sourcing medical gowns for the NHS. by Alexandra Mi Hub is the UK’s largest supplier of workwear solutions, trading internationally through their Dimensions, Affinity, Alexandra and Yaffy brands. ADVERTISING FEATURE

27 Alexandra continue to have regular meetings with NHS Supply Chain and have ongoing discussions with the Government’s COVID-19 Response Team and the Welsh Government to identify demand, prioritise it and then find solutions to make sure that the demand is being met. The NHS labelled Alexandra as their ‘model supplier’. Alexandra hosted a virtual visit from Leader of the Opposition, Sir Keir Starmer, who was keen to hear how the company had developed its operations during the COVID crisis, to meet the needs of the NHS. During the visit, the team at Alexandra demonstrated that they take great pride in listening to their customers and how their response to the COVID-19 crisis, enabled them to use their technical expertise and customer service ethos, to deliver bespoke solutions for several NHS Trusts throughout the country. For example, Chelsea and Westminster NHS Trust approached Alexandra when they had just 48 hours of gowns left. Initially the focus was meeting their immediate needs but then, in further discussions, it became clear that the Trust was getting through huge numbers of single-use gowns that were neither comfortable nor hygienic. As such, Alexandra’s technical and design team worked with the Chief Nurse to develop a unique fabric and coating combination to create a gown which can be washed up to 25/30 times; it has also created a better fitting garment with Velcro on the neck rather than ties for ease of use and wearability. Alexandra also worked with healthcare customers to develop a new, re-usable theatre cap designed to maintain its antibacterial properties, even when washed by commercial laundries up to 30 times. It is clear that throughout the COVID-19 pandemic, the team at Alexandra pooled their collective knowledge, expertise and resources to further establish the NHS at the heart of their business. Alexandra are clearly very proud, not only of what they have done for frontline health and social care workers, but also the way in which they have done it. As such, Alexandra’s response to the pandemic was recognised in December 2020, when they won the Healthcare and Pharmaceutical category in the prestigious, national Supply Chain Excellence Awards. Content provided by Alexandra. For more information please visit www.alexandra.co.uk or call 0333 600 1111 HEALTHCARE IN THE NHS THROUGH INTEGRATION ADVERTISING FEATURE

28 This is a short note; it will probably be out of date very soon. It focuses on microbiological issues. The virus initiates infection by binding to angiotensinconverting enzyme 2 (ACE2), which occurs on the surface of many cells in the body, including alveolar cells in the lungs, and myocardial, kidney tubular, and small and large blood vessel endothelial cells. Damage to the vascular endothelium may well be an important factor in explaining the persistence of symptoms after recovery from an acute infection. Direct evidence supporting the hypothesis that this explains persistent muscle weakness is not yet available. Before COVID-19, it was known that about half of the survivors of prolonged mechanical ventilation develop the post-intensive care syndrome, developing anxiety, depression, neurocognitive impairments and PTSD. The commonest post infection clinical syndrome is the post-infection irritable bowel syndrome (IBS), usually initiated by gastroenteritis caused by a microbial pathogen, but a pathogen that has been eliminated from the patient, and whose persistence is not the cause of the IBS. It is a functional condition. Its diagnosis rests entirely on symptomatology. Time will tell regarding the proportion of long COVID cases that will fall into the functional category. So far there is no evidence that the virus can persist, as does Rickettsia prowazekii when it causes Brill-Zinsser disease. R.prowazekii, the cause of classical typhus fever, also infects endothelial cells and also has a much greater impact on the elderly. Many have tested positive twice at different times for COVID-19. These have not been recrudescences but second infections. Thomas Hugh Pennington, CBE, FRCPath, FRCP, FMedSci, FRSE is emeritus professor of bacteriology at the University of Aberdeen, Scotland. ‘COVID-19: The Postgenomic Pandemic’ is the title of his book about COVID-19 science, which he hopes will be published later this year. Note on Long COVID by Professor Hugh Pennington HEALTHCARE IN THE NHS THROUGH INTEGRATION

References 1. MIMS Online. Accessed November 2021. 2. Zemtard® 120 XL. Summary of Product Characteristics. July 2018. 3. Zemtard® 180 XL. Summary of Product Characteristics. July 2018. 4. Zemtard® 240 XL. Summary of Product Characteristics. July 2018. 5. Zemtard® 300 XL. Summary of Product Characteristics. July 2018. 6. British National Formulary Online. [Available at: https://bnf. nice.org.uk] Accessed November 2021 *Please note: patients should not be transferred from one diltiazem preparation to another without full clinical assessments and retitration. Adizem-XL® is a registered trademark of Mundipharma. Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Galen Limited on 028 3833 4974 and select the customer services option, or e-mail [email protected]. Medical information enquiries should also be directed to Galen Limited. Zemtard® XL Prescribing Information Please refer to the Summary of Product Characteristics (SPC) before prescribing Zemtard XL. Presentation: Hard gelatin capsules containing prolonged release diltiazem hydrochloride beads for oral use. Zemtard 120 XL: Brownish-red and orange capsules marked “DIL 120”, each containing 120mg diltiazem hydrochloride. Zemtard 180 XL: Pink and grey capsules marked “DIL 180”, each containing 180mg diltiazem hydrochloride. Zemtard 240 XL: Light blue capsules marked “DIL 240”, each containing 240mg diltiazem hydrochloride. Zemtard 300 XL: Light blue and white capsules marked “DIL 300”, each containing 300mg diltiazem hydrochloride. Indications: Treatment of mild to moderate hypertension. Prophylaxis and treatment of angina pectoris. Dosage and administration: Capsules should be swallowed whole (not chewed) with half a glass of fluid. Adults: The recommended dose is between 180 and 300mg given once daily. Doses of up to 360mg/day in hypertension and 480mg/day in angina may be of benefit in some patients. Elderly and patients with impaired renal or hepatic function: Recommended starting dose of 120mg daily. The dose should not be increased if the heart rate falls below 50bpm. Children: Not recommended. Contraindications: Hypersensitivity to diltiazem or any of the excipients; severe bradycardia (below 40 bpm); in sick sinus syndrome or in second- or third-degree AV block, except in the presence of a functioning ventricular pacemaker; in left ventricular failure with pulmonary congestion; diltiazem should not be given concomitantly with dantrolene infusion; in combination with ivabradine; pregnancy; in women of childbearing potential not using effective contraception and while breastfeeding. Warnings and Precautions: Close observation is necessary in patients with heart failure or reduced left ventricular function, bradycardia (risk of exacerbation), or with first-degree AV block detected on ECG (risk of exacerbation and rarely, of complete block), prolonged PR interval. Prior to general anaesthesia, the anaesthetist must be informed of ongoing diltiazem treatment. Depression of cardiac contractility, conductivity and automaticity, as well as vascular dilatation associated with anaesthetics may be potentiated by calcium channel blockers. Treatment should commence with reduced doses in elderly patients and in patients with impaired liver or kidney function (possible increase of plasma concentrations). The contraindications and precautions should be closely observed and close monitoring, particularly of heart rate, should be carried out at the beginning of treatment. Sudden withdrawal of diltiazem might be associated with an exacerbation of angina. Calcium channel blockers, such as diltiazem, may be associated with mood changes, including depression. Early recognition of symptoms is important, especially in predisposed patients (drug discontinuation should be considered). Use with caution in patients at risk of developing an intestinal obstruction. Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine. Interactions: Concomitant use contraindicated: Dantrolene (infusion), ivabradine. Concomitant use requiring caution: Lithium, nitrate derivatives (prescription of nitrate derivatives should only be carried out at gradually increasing doses), theophylline, alpha-antagonists (combination should be considered only with strict monitoring of blood pressure), amiodarone and digoxin (particularly in elderly and with high doses), beta-blockers (combination must only be used under close clinical and ECG monitoring, particularly at the beginning of treatment), other antiarrhythmic agents (concomitant use is not recommended, combination should only be used under close clinical and ECG monitoring), carbamazepine (plasma carbamazepine concentrations should be assayed and dose adjusted if necessary), phenytoin, primidone, rifampicin (patient should be carefully monitored when initiating or discontinuing rifampicin treatment), cimetidine and ranitidine (patients currently receiving diltiazem therapy should be carefully monitored when initiating or discontinuing therapy with anti-H2 agents, an adjustment in diltiazem daily dose may be necessary), immunosuppressants: ciclosporin (it is recommended that the ciclosporin dose be reduced, renal function monitored, circulating ciclosporin levels assayed and that the dose should be adjusted during combined therapy and after its discontinuation), sirolimus, tacrolimus and everolimus; atazanavir (reduce dose of diltiazem), ritonavir; barbiturates, cilostazol (avoid concomitant use). General information to be taken into account: Caution and careful titration are necessary in patients receiving diltiazem concomitantly with other agents known to affect cardiac contractility and/or conduction e.g. other calcium channel blockers and anti-hypertensive drugs. Plasma concentration of both drugs may increase when diltiazem is given with nifedipine. Diltiazem is metabolized by CYP3A4. A moderate increase of diltiazem plasma concentration in co-administration with a stronger CYP3A4 inhibitor has been documented. Diltiazem is also a CYP3A4 inhibitor. Co-administration with other CYP3A4 substrates may result in an increase in plasma concentration of either drug. Co-administration of diltiazem with a CYP3A4 inducer may result in a decrease of diltiazem plasma concentrations. Midazolam, triazolam (special care should be taken when prescribing short-acting benzodiazepines metabolised by CYP3A4 in patients using diltiazem); anxiolytics and hypnotics, corticosteroids (patient should be monitored when initiating methylprednisolone treatment, adjustment of methylprednisolone dose may be necessary); atorvastatin, simvastatin and lovastatin (when possible, a non CYP3A4-metabolised statin should be used together with diltiazem, otherwise close monitoring for signs and symptoms of a potential statin toxicity is required). Other interactions: General anaesthetics, imipramine and possibly other tricyclic antidepressants, MAOIs; itraconazole, mefloquine. Refer to SmPC for full details on interactions. Fertility, pregnancy and lactation: Diltiazem has been shown to have reproductive toxicity in certain animal species (rat, mice, rabbit). In the absence of adequate evidence of safety in human pregnancy, diltiazem should not be used in pregnancy or in women of childbearing potential not using effective contraception. Breastfeeding while taking this drug should be avoided. If use of the drug is considered essential in nursing mothers, an alternative method of feeding should be instituted, since diltiazem is excreted in breast milk at low concentrations. Effects on ability to drive and use machines: On the basis of reported adverse drug reactions i.e. dizziness, malaise and hypotension, the ability to drive and use machines could be altered. However, no studies have been performed. Patients should be warned not to drive or operate machinery until the effect of diltiazem has been established. Undesirable effects: Very common (≥1/10): Peripheral oedema; Common (≥1/100 to

30 HEALTHCARE IN THE NHS THROUGH INTEGRATION White Water Rafting - a journey through difficult times Life is like travelling down a river - sometimes the river is calm and the surroundings beautiful, sometimes that’s peaceful and yet other times it is boring. Sometimes there are rougher waters - perhaps a bit scary; perhaps rather exciting, and then there are times when the river becomes dangerous with rapids that are severe and high waterfalls. We are in boats as we go through life, and everyone must go down their river of life, and navigate their rapids. Sometimes we may have to change our boat and the route we are taking. So how does this relate to you? The rivers of life can divide into different tributaries and you may have different experiences depending on which one you go down. Taking different routes is sometimes a choice in life with good or bad consequences. Other times the route you take is defined by the river itself - you have no choice. These are life’s ‘curved balls’, perhaps what people refer to as ‘fate’. Lifestyle can influence how your river flows - regular exercise and a balanced diet can lead you one way; smoking, excess alcohol, an unhealthy diet can lead to another. Some are just unlucky in their river and rapics come along unexpectedly and throw them out the boat. Rivers sadly can lead to the rapids of diabetes and the waterfalls of cancer and stroke. Other rapids are those of loss - a job, a network of friends; the loss of loved ones. Some rapids are broad with high waterfalls at one end and easier parts at the other. The challenge is how to navigate them and find the easier route. You may be unprepared for these rapids. You may have no paddle, helmet or life jacket; you may have no training on how to steer a boat to calmer waters. As a river approaches the rapids the water changes - it is noticeably different. The noise level changes; there is a sense of foreboding. Rivers just before rapids do interesting things. As the flow moves in different directions it can swirl creating ‘eddies’. These eddies can circle a boat around which can be confusing and scary. But they can also be useful as they can, if one knows how to, divert a boat away from the rapids and towards a calmer pool at the side - a haven before the difficult part of a journey. Also in the boat is your family and perhaps friends and workmates - so if the boat turns over it isn’t just you who gets thrown out, it is your relationships and your children. You need help navigating these rapids safely, and that is what doctors and other healthcare workers do. On the side of the river are many professionals doing things to help - throwing out advice or “medication”. This might be that helmet, paddle and a life jacket. Sometimes doctors may say “Stop here awhile. You can’t avoid the journey but perhaps we can prepare you better for it - give you training and resilience. Perhaps show you what the waterfall looks like - it may not be as frightening as you think. We can teach you how to put on your helmet and life jacket and how to row.” Some professionals say “I’ll get in the boat with you and help you over the rapids because I am a professional and have done this before.” These can be the ‘experienced white water river guide’ who can illuminate a way around the hazards of the waterfall. We know sometimes no one can get in the boat with them - the patient has to go over their rapids alone, but hopefully prepared and accepting of their fate. Often we say “this ride is going to be rough, so we can arrange for experts to be at the bottom of the waterfall in case you fall out to pick you and your family up. We can help you through this to another calm and beautiful part of the river...” The expert guides may also be on the side of the bank or up on a cliff or rock looking ahead. They give advice to all the boats on the river, - educate, instruct on changing directions to go left or right or straight on. Experts can often see through the mist rising from the turbulent rapids, developing a clearer and wider picture of the river overall, which aids our knowledge, understanding and safe passage. Most patient’s illness journeys are like this. Coronavirus is like this. But the coronavirus part of the river is one we have never seen before and we are all going down whatever - there doesn’t seem to be any diversion we can take. And this set of rapids is long and very rough in parts. And what is more, all us professionals - doctors and nurses and others are all in boats. We are no longer on the banks with a choice about going down the river. We have to go down it too, along with our families and friends in our boats. We are, as people say, “all in the same boat.” However we are good at navigating rapids. We know that if we work together the boats are safer. If we try and go over the waterfall one at a time, boats may fall over more often. So we need to go down the river in packs supporting each other close enough to help but at a by Dr Anand Chitnis, GP and Clinical Director NSC North Primary Care Network

31 HEALTHCARE IN THE NHS THROUGH INTEGRATION safe distance so we don’t damage each other’s boats and paddles. As doctors we know a lot about what will help us get to the safer section of rapids - washing our hands; avoiding close contact; staying in our homes. So we all do the same thing together. However, if we send all the boats down at once there won’t be enough room in the calmer part of the rapids for everyone at the same time, and some will get pushed to the severe rapids, and thrown over the highest part of the waterfall. When that happens more of us will fall out of our boats, and once we are in the swirling river, more of us will drown. With so many going over the waterfalls, the professionals trying to save us will become overwhelmed and unable to save as many people. We need to pause as many boats as we can so we can get more prepared for the journey. We need to learn more about these rapids and understand how to get over them more safely - we need to delay so we can develop better, safer boats - a vaccine or proven drug treatments. We need to know who are the best professionals to be in the riskiest boats - we need testing to see who they are. We need to get our emergency services at the bottom of the rapids more prepared for all the boats that are coming, especially those with the vulnerable in them. They are more likely to tip over and more likely to drown. You can help by listening to the professionals. Don’t think you should just carry on your journey, when you are asked to stop. Remember in your boat and the boat next to you are others. You may get over the rapids ok, but you may knock over other’s boats and tip their occupants into the swirling eddies to drown. You may tip out your own family members. You may fall out and drown, leaving them to fend for themselves. You assume you have coronavirus and stay in the ‘bubble’ of your raft so as not to damage others or hole their boat. We may reach an easier part of the river and think it is all over; but be careful - more rapids and waterfalls may be up ahead. We cannot be complacent. We have to watch the river ahead and remain alert. And as health professionals we need to be careful. We could say, “it is too dangerous to go into this river in these boats. This is not the time.” But we can’t just stand on the banks and watch, or avoid going down it. The river of life will pull us in whatever. Along with our families. So instead we choose how to do this. We take care of our own boats, so we can be around to help others with theirs. We are ready to pull boats along with us; we need to be willing to join those who are struggling. We bring along our best paddle, lifejacket, helmets. We remember we are trained better than anyone else in navigating uncharted rivers. If we have to go down it, which we do, then we do so with planning and forethought; through working together to get the best ideas and the best routes to take. We plan for the worst eventualities and hope we can save as many as we can from falling out of their boats. We have seen other countries go down this river and go over the worst of these waterfalls. We must learn from them, and take a different route. We must make the best equipment available and use it wisely. We must build facilities at the bottom of the waterfall to manage the unfortunate victims. We must appreciate and support all the others who help us journey safely - the unsung heroes - cooks, cleaners, suppliers, repairers. We need to have courage ourselves, and think clearly. And most of all we need to trust and support each other in our neighbouring boats so that we will all be there to help. We can navigate these rapids and waterfalls and get to the next stage of the river, where it will be calm and beautiful. And that is often a time for reflection and learning. What have we just been through? What did we do well and what did not help? And how can we prepare better for the next set of rapids that may come along? Content provided by Dr Anand Chitnis, GP and Clinical Director NSC North Primary Care Network

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38 ADVERTISING FEATURE HEALTHCARE IN THE NHS THROUGH INTEGRATION Multi-disciplinary pain clinics are nothing new. The founding-father of pain management Dr John Bonica who devoted his career to the study of pain, believed in a team approach, incorporating various specialties to treat acute and chronic pain. Therefore the first pain multi-disciplinary clinics were already established in the 1950s. In July 2020 the International Association for the Study of Pain published a revised definition of pain. The definition is: ‘An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” This definition and the original one from 1964 make it clear why it is so important to address the management of chronic and even acute pain from a multidisciplinary approach, taking into consideration the underlying medical condition and the complexity of each patient’s emotional condition, cultural background, previous treatments and genetic components. Unfortunately, even in today’s multidisciplinary pain clinics, the biological/medical model delivered by medical doctors often comes first and when all the medical interventions and treatments are not successful a referral to the psychologist and physiotherapists is made. This linear model, with the patient being handed down the line, starting with the doctor and ending with therapies, does not always benefit the patients maximally. Ideally, the patient meets or gets input from the entire treatment team (doctor, physiotherapist psychologist and nurses) right from the start and a treatment plan should be formulated together. Sometimes the best developments happen during the most difficult times and due to the COVID-19 situation we found ourselves with a huge back-log of patients. Two thirds of the doctors were deployed elsewhere. Despite these difficulties we tried to keep our service running and called most scheduled patients independent of our usual speciality. Afterwards all the patients and pathways were discussed with the team and a treatment plan was developed. We found that this actually improved patient care and now we do continue with this model. Currently we call about ten to twelve patients in such a remote assessment MDT clinic between four clinicians (nurse, doctor, physiotherapist and psychologist) and afterwards we discuss each plan and pathway. We will need to audit this clinic but so far the patients have a quicker access to pain management programmes, injections or mediation reviews. Some patients get followed up (this usually will be face to face, but this is really not required for every patient), others can be discharged back to their GP’s with advice and a third group will enter a pain management programme, plus doctor’s advice where needed. We don’t know for sure how the future will look like, but we find these assessment clinics are an ideal solution for these difficult times. As a doctor, I feel that I have been learning a whole lot and we all benefit from each other’s expertise. This new model of working also increases feedback later on in the treatment of patients, when they usually would not have another appointment with us. I feel we have gone from a linear model to a completely rounded one. Content provided by Dr Bianca Kuehler, Consultant Pain Management Specialist Doctor in Pain at Chelsea and Westminster Hospital Evolution of Multidisciplinary Services for Chronic Pain by Dr Bianca Kuehler, Consultant Pain Management The doctor’s role

39 ADVERTISING FEATURE Physiotherapy in a Chronic Pain Service Assessments and treatments for Musculoskeletal pain conditions have traditionally strived to identify structural or movement impairments which can be fixed. Developments in subjective questioning, physical examination and diagnostic investigation have provided great success for the majority of acute injuries and pain. The biomedical model has been the dominant model for many a year and for the most part has provided good value from the National Health service, for those seeking help. Unfortunately, evidence would inform us that approximately 15-25% of acute pain presentations persist to become a chronic condition; long after tissue healing is complete. Whilst it is important to ensure there is no significant sinister pathology causing the painful symptoms it is often detrimental to keep the treatment focused on fixing a structural problem through passive treatments and multiple diagnostic investigating. As with other long term health conditions (eg diabetes) the focus should shift towards helping people live well with pain in order to positively influence its impact on their lives. Waiting for the pain to stop inevitably leads to more pain and secondary physical and psychological problems. Such as muscle weakness, joint stiffness, weight gain, anxiety, depression and disengagement from important life activities. We know that people in pain have tried very hard to ‘fix’ their pain problem, often at great time and financial sacrifice. When people attend an interdisciplinary pain service they are offered an alternative Biopsychosocial model of care. The aim of which is to help them begin rebuilding their lives alongside their painful symptoms, utilising expert medical, physical and psychological knowledge. We start most interventions with education modules. We teach people about the pain system and the difference between acute pain that’s essential and adaptive to keeping us safe, and chronic or persistent pain which is less adaptive and providing too much protection. We explore how other factors such as stress and sleep interact to amplify the pain experience and influence a person’s ability to make steps towards recovery. When people realise that persistent pain is not a sign of new or on going damage and they can be less fearful of the impact it might have then they can start to move and be more active and engaged in their lives despite it. Helping people to understand the meaning of their symptoms and what the MRI findings mean, relative to findings we see in pain free populations. Helping people to move with confidence and build strength to be a better partner, parent or employee are what an interdisciplinary pain service strives to deliver. Where can we improve? Appropriate early intervention is paramount. Over reliance on medication and passive medical intervention alone is not working for some pain sufferers. We need to look at optimising the skills and experience of the Allied Health Professions workforce. First contact practitioners with specialist pain experience can help people at the start of their problem not years down the line when chronicity is established. Improved pathways across primary, secondary and tertiary care services to ensure knowledge and expertise is shared across the sector. Investment in support for long term conditions at a community level so that those that need the support can access it over the long term rather than reacting to crisis and flare up situations. Life can be better for Persistent Pain sufferers, if the people and the health system can step towards the Biopsychosocial model of care. Delivering Physiotherapy during COVID times: Like everybody, physiotherapists have had to be innovative with its response to work force pressures whilst continuing to provide support to the people with persistent pain. The up scaling of video conferencing and telehealth has had its challenges but for the most part the on-going support to people in pain during these difficult times has been invaluable. Face to face and virtual Physiotherapy services have advanced rapidly during COVID and we have to hope the positive changes that have been implemented continue to form part of the future strategy for the management of persistent pain and other long term health conditions. Content provided by Mr Gavin Walsh: Lead Specialist Physiotherapist at the Chelsea and Westminster Hospital by Mr Gavin Walsh: Lead Specialist Physiotherapist at the Chelsea and Westminster Hospital HEALTHCARE IN THE NHS THROUGH INTEGRATION

In June 2021, NHS England revealed how it will measure integrated care systems’ (ICSs) performance to determine the level of support and oversight needed. The move to an ICS structure is critical to realising efficiencies in how health and social care operates. The idea is that, by uniting all health and care providers in a region, efficiency, quality of care, and sustainability will be improved. ICSs will be judged on a range of approximately 70 metrics, with performance against these measures resulting in various levels of support and scrutiny from the centre. The first of five oversight themes is Quality, Access and Outcomes, which encompasses 44 of the metrics – all of them centred on delivering longawaited changes in system efficiencies and patient outcomes. Strata Health has two decades of experience in optimising the logistics of access, placement and system flow and have analysed what we feel are the six most significant opportunities for digitally supporting the delivering of these metrics in 2021/22. 1. Primary and community service response times: Improving discharge and reducing delayed transfers of care A longstanding theme within discharge planning is discharge-to-assess or D2A. It is finally becoming a mainstream goal of hospital discharge standard operating procedures. D2A strives for a rapid discharge home to enable patients to recover in their normal environment. By doing so, patients can then request supportive services as needed with a clear idea of the help they need to remain in their home. The key to getting this right is (once home) we must enable patient access to services from pathway 0 (used for patients who need minimal support) right through to pathway 3 (patients who require bed-based 24-hour care even when they leave hospital) – building up just the right support packages from social prescribing to social care to health intervention, and then enabling patients to be placed into those services. Doing so can avoid the outdated process of prescribing a standard package of care just because “that’s what’s always been done”. Strata Transition (Transfer of Care) is a transparent access and placement tool that spans the entire ICS and enables D2C and the onward support required after D2C to be managed electronically, greatly increasing efficiency. 2. Restoration of elective and cancer services It is important to maximise elective activity and transform the delivery of service, which can be done by: • Managing waitlists (including new ways of delivering care in the community). • Increasing referral treatment levels (cancer care). Waitlists are longer than we have seen in recent memory and are set to continue to grow into 2022, with estimates that we will have a situation in which one in every six people in England is waiting for NHS care. To manage waitlists effectively, services must do two things: first, create logic that determines who should be prioritised next for treatment; second, deliver care in the most efficient way, balanced against limited resources and utilising new technologies such as remote consultation when feasible. By supporting bespoke matching algorithms, Strata Matching helps logically manage waitlists, increasing the referral quality and throughput of appropriate and vetted referrals. Strata Waitlist/Capacity can present available capacity and/or expected wait times, further supporting a reduction in waitlists across the NHS. Strata Health UK Chief Executive Clint Schick discusses how simple, cost-effective access and placement tools will enable joined up working in 2021 and beyond Uniting health and social care 1

44 (0) 333 002 0233 [email protected] www.stratahealth.co.uk https://twitter.com/StrataHealthUK 2 Clint Schick, Chief Executive, Strata Health UK

42 HEALTHCARE IN THE NHS THROUGH INTEGRATION ADVERTISING FEATURE myGP® - Reducing unnecessary appointments in primary care myGP, developed by iPLATO Healthcare, is the number one downloaded medical app in the country, and has been achieving unprecedented results in reducing unnecessary appointments in primary care. It’s estimated that 27% of all GP appointments booked are avoidable or inappropriate, where the patient could have been seen by a member of the multidisciplinary team, visited a pharmacist, administered self-care or an alternative self-referral service without seeing their GP. >[email protected] Healthcare Building Specialists www.brp-architects.com [email protected] 01858 464 986 With over 140 medical projects completed across the country and many more in the design and procurement process, brp architects specialise in the design management and delivery of primary and specialist healthcare premises. Understanding that many GP clients only go through the process once and adopting a nurturing, hand holding approach has proven to be the key to successful project delivery. Every project is unique, however, the considerable number of healthcare facilities we have been involved with brings with it a raft of benefi cial, sector-based experience from which we draw, smoothing the process, enabling us to guide clients through the strict legislative process, avoid many of the pitfalls and provide high quality, ordered solutions that are imaginative, state of the art and represent value for money. Projects successfully delivered range from those on tight, urban, brownfi eld sites to green belt environments, from internal alteration, to extension and refurbishment to new-build, and from stand-alone facilities for single GP practices to multi-user, multimillion pound premises of thirty or more clinicians. A number of our schemes can be viewed in the Health Section of our website. photographer credit: bottom-left ©matt livey

44 The role of osteopaths as AHPs to support MSK service delivery With NHS backlogs a challenge for the foreseeable future, we share how osteopaths are making an impact in the NHS and consider how, as one of the Allied Health Professions, they can be recruited to support NHS MSK service delivery. The 2017 NHS England report ‘AHPs into Action’ suggests that AHPs have the potential to be skilled-up to the top of their licences to be utilised to support future healthcare and wellbeing service delivery. However, the NHS Long Term Plan acknowledges the fact that over the past decade workforce growth has not kept up with the increasing demands on the NHS required to facilitate this transformation. Since its publication, the impact of Brexit and COVID have further compounded the challenges that the NHS faces, with immediate priorities now focused on making inroads into backlogs. Recommendations by the NHS Long Term Plan to help to address workforce shortages include a breakdown of professional silos to encourage interprofessional working and to recruit outside of traditional professional groups. This could work particularly well to address the deficit in clinical roles that the NHS faces within MSK services. Osteopaths: A highly trained and available MSK Allied Health Profession Osteopaths are highly trained, regulated healthcare professionals who are known for their expertise in the management of the musculoskeletal (MSK) system and its relationship with other systems in the body. The profession was awarded Allied Health Profession (AHP) status by NHS England in 2017 recognising the positive impact that osteopaths are already making in the NHS as well as the potential for osteopaths to further support NHS workforce supply. However, currently, only 5% of osteopaths are working in NHS roles, suggesting this skilled workforce is under-utilised by the NHS. The challenges and the opportunities Despite the obvious benefits of expanding workforce supply in this way, a lack of awareness about osteopaths as a potential workforce solution in the NHS still presents a barrier. A recently published report compiled by an independent panel of leading NHS healthcare professionals, chaired by Professor Adrian Newland CBE, identify some of these challenges and makes recommendations for overcoming these issues. There is also the potential for more innovative projects exploring NHS services partnering with independent osteopathic teams working in the private sector who may be able to reduce the pressure on NHS colleagues. With 5,000 osteopaths registered in the UK - approximately a third of which have indicated a significant interest in either part or full-time NHS employment - this represents a flexible, motivated and highly trained workforce that would be willing and able to support NHS workforce supply if the opportunity arose. Here we share how osteopaths are already being successfully deployed across several NHS roles and services. NHS Consultant Osteopath The Spinal Unit at Queen’s Medical Centre Nottingham is a recognised national and international referral centre for complex spinal pathologies. Many of those attending the unit either do not need or cannot have spine surgery and therefore require conservative management of their condition. For 14 years, the centre employed osteopaths at the consultant level and delivered multimodal, non-pharmacologic care to patients with chronic and complex spinal pain comprising of standard osteopathic manual therapy, rehabilitative exercise and pain neuroscience education. The osteopathic team was able to demonstrate clinically significant improvements in pain, function and health-related quality of life in this complex patient group. • 83.2% of patients reported that the intervention had ‘helped’ or ‘helped alot’ • 96.2% of patients were ‘satisfied’ or ‘very satisfied with the care they received • Therapeutic complications were rare (1.2%-7%) and there were no serious adverse events. by Matthew Rogers, Head of Professional Development Institute of Osteopathy HEALTHCARE IN THE NHS THROUGH INTEGRATION

45 Consultant Spinal Surgeon and Head of Spinal Service at QMC at the time Mr Bronek Boszczyk said, “Having osteopaths in the team has offered us a different approach to working with patients with chronic and complex spinal pain, and we value their input. The osteopaths who have worked in the team have all been highly professional, skilled at recognising when to refer on to others in the team, and have provided high-quality care to our patients. The work that the osteopathic team carry out is supported by robust clinical audit, which has demonstrated their value in reducing the numbers of patients requiring long term pain management and surgery.” First Contact Practitioner Osteopath It is estimated that between 25 - 30% of GP consultations in primary care relate to MSK presentations. However, the GP workforce is under pressure with some commissioners predicting that up to 26.1% of full-time equivalent GPs are due to retire in the next five years. First Contact MSK Practitioners (FCP) have been introduced to provide a streamlined and cost-effective service, promoting self-management, enhancing patient care and reducing GP workload. Osteopaths are now being recruited into FCP roles across the country and a recently published pilot study has demonstrated that osteopaths can provide this service safely and effectively in an NHS primary care setting. • 94% of patients would recommend the service to a friend or family (Net Promoter Scale) • 97% of patients were managed independently by the FCP osteopaths without the need for GP intervention. Just 1% required referral to secondary care • FCP services deliver a return on investment of up to £2.37 for every £1 spent. MSK Clinicians (Band 5 – 8A) In addition to these more specialist roles, osteopaths have demonstrated that they can integrate quickly and effectively into MSK outpatient teams as Band 5 – 8a clinicians in several different locations across the country, supporting existing MSK services. Examples include the Sussex MSK Partnership and Plymouth Community Back Pain Service. Osteopaths: training and regulation Osteopaths are regulated by law and must complete a four-year degree-level training programme before qualifying and undertake regular continuous professional development to maintain registration. The statutory regulator is the General Osteopathic Council, which ensures the same level of patient safety as the General Medical Council and Health Care Professionals Council. As autonomous primary care providers in the private sector, they are trained to deliver the full suite of clinical examinations (neurological, abdominal, CVS, respiratory) and red flag questioning to be able to identify medical MSK masqueraders, such as cancer, fracture, infection, rheumatological issues and visceral referral. For more information You can read more on the the effectiveness, patient experience and return on investment of osteopathy in the following reports • Quality in Osteopathic Practice Report • Introducing Osteopathy to Primary Care: The Role of the First Contact Practitioner • The Role of Osteopaths as AHPs in the NHS The above plus additional reports and research on osteopathy are available from www.iosteopathy.org/ research-and-reports The Institute of Osteopathy is the professional body representing two-thirds of UK osteopaths and aims to ensure that patients can expect the highest possible standards of care from the osteopaths that serve them. Content provided by Matthew Rogers, Head of Professional Development, Institute of Osteopathy. For more information you can contact Matthew Rogers on Matthew@ iOsteopathy.org. HEALTHCARE IN THE NHS THROUGH INTEGRATION

46 HEALTHCARE IN THE NHS THROUGH INTEGRATION The efficacy of the probiotic Symprove as assessed from randomised clinical trials Bacteria emerged from hyperthermophiles about 3.5 billion years ago. They not only adapted to their environment but also changed it creating the oxygen enriched atmosphere that is the pre-requisite for much life on Earth. This apparently altruistic gesture is offset by their destructive nature, as bacteria cause more human deaths than any other single reason, including wars. Man has had to adapt to bacteria and nowhere is this in evidence better than in the gastrointestinal tract. There is a case for considering this interaction as mutualistically beneficial, but there is also a strong case for considering these bacteria as parasitic (1) with limited benefit to the host. Nevertheless, humans have taken advantage of the properties of some bacteria, for example lactobacillus to preserve foods, mostly dairy products. This gathered momentum with the inclusion of Lactobacillus casei to yogurts in 1930 and this was successfully marketed as conferring a beneficial effect to humans. Most doctors were sceptical to such claims, until efficacy >[email protected] ADVERTISING FEATURE

Thousands of healthcare professionals recommend Symprove Here are the reasons why: For more information please visit: symproveforprofessionals.com *Lacticaseibacillus rhamnosus NCIMB 30174, Enterococcus faecium NCIMB 30176, Lactobacillus acidophilus NCIMB 30175, Lactiplantibacillus plantarum NCIMB 30173. Symprove is a live liquid-based probiotic containing four strains of bacteria* Evidence-based: Independent research conducted at University College London and King’s College London. Safety: Well tolerated, long history of safe use. All strains are fully characterised. Survival: In vitro/in vivo research demonstrating viability of bacteria through the gut. Formulation: Manufactured to ensure bacterial tolerance through the gut.

50 HEALTHCARE IN THE NHS THROUGH INTEGRATION The Perfect Storm For as long as I can remember colleagues within the wider ENT community and in particular Audiology have talked about the perfect storm of Adult Hearing Loss. An ageing population, coupled with the incredible pressure on NHS Audiology departments and the ever changing and evolving world of digital and virtual communication, has meant that the public’s ability to access timely and effective treatment for adult hearing loss was always going to come under enormous pressure. But let’s face it, the figures were always pretty scary. Hearing loss is a major public health issue, estimated to affect more than 11 million people across the UK. One in six of the population has hearing loss of at least 25dB in their better ear. This estimate includes around 6.7 million people who could benefit from hearing aids (as they have hearing loss of at least 35dB in their better ear). There are also an estimated 900,000 people in the UK who have severe or profound levels of deafness (hearing loss of at least 70dB in their better ear)* Furthermore, the UK’s population is getting older. By 2035, it is projected that those aged 65 and over will account for 23 per cent of the total population (ONS, 2012). It is estimated that by 2035 one fifth of the UKs population, that’s 15.6 million people, will be living with hearing loss. Now factor into this a global pandemic that has put intolerable pressure on the entire NHS system, and the perfect storm becomes the category 6 perfect hurricane. The solutions are unclear but it seems sensible that all community audiologists must be utilised to provide a mix of solutions to those millions of patients who require help. The strange paradox of living with hearing loss However, simply exploring the numbers is not always helpful when discussing age related hearing loss. Behind every case is a person with a family, circle of friends and often work colleagues who may have noticed the deterioration in someone’s hearing before the patient does. A common misunderstanding of the condition is also at play. As we age and our hearing deteriorates, we don’t ‘go deaf’ – we do however lose the ability to distinguish speech, particularly when listening to conversation in background noise. Patients complain that it sounds as though other people are mumbling or not speaking clearly or that all of the words are running into each other. “So, how can hearing aids possibly help? – I’m not deaf – I can hear a car backfire from 2 miles away but I can’t understand what my partner is saying to me when we are in a busy restaurant!” These experiences are common and sadly we know from research that on average people wait up to 10 years from first experiencing a hearing loss, to taking the first steps to doing something about it. The often-stated plan of ‘I’ll wait until it gets worse before I seek help’ can have unintended but serious consequences. Links are now established between untreated hearing loss and the onset of premature dementia This recently from the RNID Unaddressed hearing loss in mid-life was predicted to be the highest potentially modifiable risk factor for developing dementia. It is potentially responsible for 9% of cases. This is hugely important. Can addressing hearing loss – for example, by using hearing aids – reduce this risk? It’s vital we find out. So, the numbers and the evidence speak for themselves – the argument for hearing assessments to be made regularly available for all over 50s is a strong one – after all, timely and effective intervention must be better for a condition that has no cure. by Melanie Jackson RGN RHAD, ENT Nurse Practitioner, Head of Nursing & Clinical Lead