Hitting the sweet spot

There are around 20,000 people in Cardiff and the Vale who live with type 2 diabetes and this is one of the reasons we have focused our attention as a health board on this particular health issue. Diabetes is one of those long term health care illnesses that are sometimes referred to as ‘long term conditions’.

In some parts of the world, there has been a move to downplay the disease specific treatment pathways and at least in planning terms try and aggregate up the care that people with many different kinds of long term conditions need. There are good reasons for this – not least that many people have to contend with more than one form of long term condition. Indeed in our health board the Primary, Community and Intermediate Care Clinical Board has done some fantastic work looking at some common conditions that are amenable to treatment without a need for admission to hospital and have shown that it is possible to organise some of these treatments along pathways that overlap or share many similar components.

diabetes-528678_640However there is a dilemma: how can we balance the depth of knowledge required about possible treatment options for individual patients with the growing patient numbers and increasing treatment complexity?

Sharing knowledge and sharing the care we offer is a challenge when the knowledge that individual practitioners have of necessity is getting deeper, but arguably narrower too. It is worth persevering with as doing so helps us see the whole patient rather than responding to the patient one illness at a time. All of this is the natural territory of primary care which is where the vast majority of our population’s contact with our services takes place. The fact that the public continue to see primary care as a real strength of our system is a real tribute to those who work in this part of our NHS. There is no denying that the pressure on primary care is rising due in part to the ageing of the population but also as the result of more complex and demanding treatment choices – which includes diabetes.

So how can this dilemma about the depth of knowledge acquired by a few and the breadth of knowledge required by many be handled?  That was the question that our physicians who look after patients with diabetes asked themselves. The facts are startling: the prevalence of type 2 diabetes is around 5% in South Wales but the condition accounts for 9% of our expenditure and audit data shows that 18% of all inpatients will have diabetes. Recognising the increasing demands that diabetes places on the NHS, the physicians are in the final stages of developing an integrated model of type two diabetes care with closer integration between primary and secondary care providers than has been possible in the past. The model aims to deliver care as close to the patients home as possible and to provide support and education to primary care (General Practitioner and Practice Nurse primarily) as well as allowing secondary care to better understand the difficulties of managing a complex chronic disease such as diabetes in the community.

The model is centred on the principle that each of six consultants in diabetes will be attached to between eight and ten named general practices and will remain with those practices for community clinics, case notes review and advice by email. The expectation is that this will allow primary care physicians to get access to senior decision making in a timely manner and without having to make a formal referral to the hospital outpatient clinic with the delays that may be incurred. Having a named consultant will offer continuity of care and will facilitate the development of closer links between primary and secondary care. GPs will quickly develop enhanced skills through discussion with the hospital specialist that will allow them to feel more confident in managing patients with increasingly complex needs.

Because of the increasing number of patients with type 2 diabetes and the increasingly complex treatment options and algorithms available it is often difficult for general practitioners to decide on the best treatment for an individual. Capacity in secondary care clinics is limited and increasingly restricted to managing the most complex type 2 diabetes cases as well as type 1 patients. It is important to recognise that each person’s diabetes management and treatment targets needs to be individualised and as patients are often taking many other drugs for other co-morbid conditions it can be challenging to decide on the best option. Giving access to consultant Diabetologists for help with complex decision making will allow most patients to have their treatment delivered by their GP in the practice without the need to travel or wait.

The physicians have a big and positive vision for the future. They aim to facilitate the delivery of high quality care to patients, whilst reducing inequalities in care from area to area and assuring an accountable and auditable service is maintained. This project is one of the biggest reorganisations of service delivery in the field of diabetes for many years and as such offers the opportunity to be innovative and forward thinking, keeping the patient at the heart of the service.

You might say that really is hitting the sweet spot.

Keep Well

 

That was the week that was

Last week Cardiff was at the centre of the largest security operation ever undertaken in the UK. Leaders from 28 countries were in town to attend the NATO summit and anyone in and around Cardiff cannot fail to have been impressed by the sight of huge numbers of police officers from around the country patrolling the streets, many of them armed with automatic weapons.

NATOIn fact there were more than ten thousand officers deployed. It is a sign of the times we live in that these precautions are necessary, and at the end of last week there will have been a collective sigh of relief, mingled with some pride that Wales and Cardiff and Newport had done the nation proud.

We have all heard of VIPs – very important people and from time to time we might go to an event when one of these types is around. What do you call someone like the President of the United States, though? Well it turns out these are VVIPs, very, very important people.

As you can imagine planning an event like the summit takes many months of careful preparation and a great deal of collaboration with many organisations, both in government at UK and Wales level, security forces, the police and many more. One element of the plan was thinking through what might happen if one of the VVIPs were to be taken ill, or if there had been some other kind of larger scale problem such as food poisoning, or even the possibility of some kind of security incident.

Nations take very seriously the health and well being of their leaders as you can imagine. In the weeks leading up to the summit, our emergency unit, critical care unit and theatres were visited by a number of embassies and officials from countries attending the summit, along with a White House team. This is because UHW was the designated receiving hospital for the region during the summit. As is normal in these circumstances they wanted to assure themselves about was the standard of care their leaders might expect to receive in the event of a problem and the kind of facilities that would be available and whether a VVIP could be looked after securely.

The UHB's Angela Stephenson, Sharon O'Brien and Linda Donovan.

The UHB’s Angela Stephenson, Sharon O’Brien and Linda Donovan.

To say that they were impressed with what they saw would be a huge understatement, and we were delighted to receive a certificate from Dr Ronny Jackson, President Obama’s personal physician that reads:

“Your professionalism reflects great credit upon yourself and is in keeping with the highest traditions of medical care. Thank you for a job well done.”

NATO2It wasn’t just the VVIPs that we needed to think about though. What about all those police officers? What would they do if the needed medical attention? How about the protestors, what would happen if there was significant disorder and people go hurt? Our response to these challenges was lead by Angela Stephenson, the UHB’s Strategic Partnership and Planning Manager. Angela is clear that every part of the UHB played a role in the months of preparations for the summit, from operational service to staff in clinical boards. Angela is also pleased that the messages we relayed to the public about what we were doing were understood and we are grateful that the public played their part in minimising any disruption to our services.

Our primary care teams organised access for the police to their services for the duration – something that proved to be required when quite a few police officers suffered nasty insect bites as they searched undergrowth and bushes. Sharon O’Brien, the UHB’s Lead Nurse for Emergency Medicine, worked closely with the foreign teams to offer the reassurance that led to the endorsement from the White House.

She said: “During the Summit all the staff within the Emergency Unit were incredibly professional working with all the different delegations and embassy staff as part of the preparatory visits.

“I would like to thank all the nursing and medical staff who worked so hard to ensure that the Emergency Unit and the City Centre Triage and Treatment Unit were fully prepared and equipped for this Summit and I would like to thank Assessment Unit staff for their help in looking after the White House security delegation including the FBI whilst they were based in the Assessment Unit.

“All the staff were very proud that the White House felt able to endorse the EU and the care we offer and that the department could cope with such a massive event.

“We have shown that we are prepared for the major events and all this work has helped to reinforce that.

“I am very proud to be part of such a dedicated team and one that has won such prestigious, international recognition.”

Well I can’t do anything but agree – as once again we have done Wales proud and have shown as we always do that when the chips are down we deliver for those who need us, whether they are VVIPs or people like you and me. Congratulations, thank you and well done to everyone involved.

Keep well.

PICTURE CREDIT: UHB Media Resources, Ann Beswick

Crossing Continents

There is a lot of international attention on Cardiff this week because of NATO and I’ll say a bit more about what’s been happening behind the scenes next week. However, with an eye on international matters I’d like to share something about how people in our organisation are helping and supporting communities in Africa, who don’t enjoy the privileges of a Welsh NHS service that is both comprehensive and modern and which is provided in a society that has by comparison a high standard of living.

OLYMPUS DIGITAL CAMERAThe UN Millennium Development Goals included an ambitious target to halve global poverty by 2015. As part of the Welsh Government’s contribution to this challenge it supports an International Learning Opportunities (ILO) Programme, which aims to provide public and third sector workers the opportunity to work on development projects in sub-Saharan Africa. The current focus is on Uganda and Lesotho. The idea behind this programme is to enable those who take part to develop their leadership skills by sharing their existing skills and knowledge in a new and challenging environment.

One of our experienced mental health nurses, Simone Joslyn, took up the challenge and travelled to Mbale in Uganda between February and April this year to work at a health centre with a maternity unit. As you can imagine this provided her with an amazing opportunity to enrich and develop her skills and experience in a totally new environment.ILO1

Talking about her experience Simone says:

 “During my placement I was able to improve my communication and managerial skills, utilize change management and assist in the delivery of babies, something that I had never done in Wales. The people I worked with and met showed such grace and inner strength and I returned to Wales feeling humbled by the relationships I forged.

 

“At Bushikori Health Centre, where I was placed, the facilities were not what we are used to in Wales but the care and attention given to the patients was as good. I am in awe of their kindness and the care that they offer and learnt much to bring back to my area of work.”

I think it’s remarkable that we work with colleagues who are prepared to extend themselves and give so generously of their knowledge and skills to a part of the world that really needs international support. This is no holiday as Simone would confirm and the challenges are real.

It’s also wonderful that one of the values that I hope we all share, kindness, is something which really stood out for Simone during her visit. Surely this lies at the heart of any good health care organisation, and Simone’s reflections are a reminder that being kind to the people who need us, and to our colleagues we work alongside is something that really can change lives for the better.

I’m sometimes asked how I decide something is OK to do or not. This is because many people still feel that they will ‘get into trouble’ for having a go at something, or trying to make a change. I always say that if in doubt people should ask themselves three questions.

  • Is what I’m proposing to do safe? I might like to help shorten the waiting list for orthopaedic surgery by offering to do a few hip replacements – but that is definitely not going to be safe.
  • Am I going to be spending someone else’s money without their say so? Apart from being good manners, it is also important that we take good care of taxpayer’s money.
  • Will it make us proud? As opposed to something we would be ashamed of or make us look bad, or which wouldn’t fit with our values.

I reckon Simone has definitely made us proud through what she has done, and I’m guessing that working in Mbale has developed her confidence to work through a problem and make things happen. After all, if things can be made to work in Mbale, why not Cardiff?  I’ll leave the last word to her.

 “I’d urge anyone who thinks they could benefit from the ILO programme to apply. My time in Uganda was a fantastic experience and one that I will never forget. No other training programme that I know of offers this kind of exposure and opportunity and I feel honoured to have been involved and supported by Cardiff & Vale UHB. It enhances your practice and your values like nothing I have ever known.”

Keep well.


OLYMPUS DIGITAL CAMERA If you are interested in learning more about the Wales for Africa programme then visit
http://www.wales.gov.uk/walesforafrica

Hope

What will you be doing ten years from now? I’m not sure I know, unless I win the lottery – but then I’d have to start buying tickets wouldn’t I? If we think about what the next ten years might have in store for us here in the health board we might start with what we already know to help us understand what the future might look like. Let’s begin with the size of the population we will be looking after ten years from now.

Cardiff, the capital city of Wales, is booming and it has become one of the fastest growing parts of the UK with unemployment falling and output growing. In the education sector Cardiff University is strengthening its position as the only Russell Group University in Wales and the other higher education sectors are flying high too.

The contrast with other parts of Wales is quite marked as the population growth forecasts demonstrate.New Picture (20)

As you can see the population in our part of the world is going to grow at least twice as fast as the rest of Wales and much more than that in many cases. This is before we factor in the growth the city council have pencilled into the housing stock in Cardiff, with 47,000 new homes to be built according to the Local Development Plan.

10883720543_b4fd2aac29_zWhat will this mean for health care services? The obvious conclusion is that there is going to be significantly more demand for healthcare, and here we will be experiencing a trend line that moves twice as fast as anywhere else. We need to ensure that the external economic growth taking place in the capital is matched by a commensurate adjustment in the way that resources in the NHS are shaped overall. This is a complex area and there are many nuances and difficulties to overcome, but we are making the case that equity of access to healthcare must have some linkage to equity of resources to provide that access. I will keep you posted on this situation.

It looks like in future we are going to have to become really expert at helping our population stay well and we will also need to ensure that we get even better at selecting the right treatments for the specific problems patients have. To help us with this latter challenge, there is a new era approaching when we will be able to match an individual’s genetic signature to a treatment that is tailored to their individual characteristics, including the responsiveness to the proposed treatment.

Although all LHB’s are now designated University Health Boards, I like to think that there remains something distinctive about our organisation. As I have mentioned before, we contribute more than half of the entire Wales research output, and we have many internationally renowned staff who are leaders in their field. Our close working relationship with Cardiff University is one of our great strengths and provides us with one of the most important ways in which we will be able to meet the challenges ahead.

As an illustration, we know that today, lung cancer is a devastating disease and the UK’s biggest cancer killer. It accounts for more than one in five cancer deaths and is the second most common cancer in men and women in the UK. Working with Cancer Research UK, Rachel Butler and the Medical Genetics Team want to change these odds for people with lung cancer.

Genetic testing is already used to detect DNA changes in lung cancer that point to whether a patient will (or will not) benefit from a particular drug, this is known as Personalised or Stratified medicine. Stratified medicine identifies key molecular changes common to different people’s cancers. Patients can then be grouped based on these shared genetic faults, allowing some people to receive a targeted treatment matched to their group. The challenge has been developing targeted treatments that show a long-term benefit for patients while accommodating the cost of widespread molecular testing in the NHS.

Cancer Research UK are preparing to launch an ambitious UK clinical trial for non-small cell lung cancer (NSCLC) called the Matrix trial which tests multiple drugs in multiple groups of patients. Each treatment has been developed to target precise genetic faults, which we’ll be testing for using our specialised ‘next generation sequencing’ system developed specifically for the programme. Our All Wales Genetic Laboratory here at Cardiff and the Vale is one of just three UK laboratories that will be providing the specialist genetic testing that will determine which drugs the lung cancer patients will receive.

Recruitment starts during Autumn 2014 from across the whole of the UK – we expect to recruit 15-20 patients to each of the 16 treatment arms. Additional treatment arms may be added as new therapies linked to genetic markers become available. If a treatment shows promise, then there’s the potential for that arm to break off from the main trial and grow into a larger independent trial with more patients who share that genetic profile.

Early evidence suggests that this genetic approach to the treatment of lung cancer will have a significant impact on patient outcomes.

There’s hope for you.

Keep well.

Picture credit: Diego Torres Silvestre

Picture perfect

Thank you to the people who provide feedback to me via my blog page. I’m learning that you can’t please all of the people all of the time. In fact, that could be the subtitle of my job.

This week I’m going to cut to the chase and talk about someone excellent. Here’s how to spot him – spend a day or two lurking in the corridors of UHW and look out for a man carrying a gold cane and a diamond encrusted key. Easy.

DSC_2699The man is Paul Crompton and he heads up the Media Resource Centre here. What’s he done? Well, Paul was nominated by Professor Michael Peres of the Rochester Institute of Technology and Professor Norman Barker of John Hopkins Medicine for the prestigious Schmidt Award and was made a fellow of the Bio- communications Association for his “outstanding contribution to the progress of bio-communications.”

The award dates back to 1948 and Paul is only the sixth British person to become an award winner. Some of you might remember Professor Ralph Marshall who founded the Media Resource Centre and who was honoured in 1998. The winner’s get, you’ve guessed it, a diamond encrusted key and a gold headed cane – a traditional symbol of high achievement and honour, the latter of which they get to keep for a year.

This is an international award and Paul travelled to Minnesota this year for the annual meeting of the BCA. Paul says, “When it came to the actual Schmidt presentation, I was quite taken aback. Unbeknown to me, Professor Peres had gathered some video interviews with colleagues from Cardiff and the US, which he played whilst recounting some of the work I have done in the past 20 years.

“Being counted amongst the Schmidt Laureates, as they are known, is a real honour; many of the names being icons of our profession.

“One major thank you has to be the team I work with in Media Resources. I am nothing without them. They constantly rise to the challenges we face and support me with their skill, hard work and commitment in delivering the services we provide our patients and clinical colleagues.”

Congratulations and well done to Paul – another example of the excellence that, when we pause and a take a breath to look around us, we can find throughout the UHB.

On a final note I’d just like to pass my on-going gratitude to everyone who is working in our busy unscheduled care system, whether in CRTs, the wards, EU, doctors, therapists and every other member of this chain of committed people who work each day directly or indirectly to support the sick and the vulnerable. Your hard work and dedication is something I’m really proud of – and I want to let you know that I understand the current pressures you are working under and am working hard to find ways of getting some more resource to support the teams who are most hard pressed.

Keep well.

Stigma

It’s interesting how society places a value judgement on some illnesses. If you are unlucky enough to break your leg in a fall you are likely to find people sympathising with you and there is no question that you’ll seek out treatment and benefit from everything our health service can offer.

The same is true of cancer, heart disease and almost all other physical complaints. Sometimes there is a suggestion that people are contributing to their own ill health, by smoking for instance, and there is a debate to be had about the extent to which any health service should always be there for us come what may if we are not prepared to take some responsibility for own health.

This is a difficult area, but many people argue it is not unreasonable to expect that as patients we should make some contribution to getting better or preventing recurrence. Our own Optimising Outcomes Framework takes us a little in this direction by requiring patients who choose to have non-urgent elective procedures to participate in smoking cessation and/or weight reduction programmes before we agree to list them for a procedure. This is because there is evidence that some avoidable harm can be prevented if people take these steps and that the chances of a successful outcome can be improved.

In the world of mental health there is still a fairly widespread reluctance to acknowledge that mental ill health is just as much a part of the human condition as cancer or heart disease.

People do not choose to be mentally unwell, just as people do not choose to have cancer. Yet those who suffer may go unsupported or be unable to be open about the problem – which can compound a sense of isolation that can be a part of the disease process.

It’s not their fault and very few people actually want to be unwell – but still there is judgement and with it an implied projection of moral weakness or a failure of character in the person with the problem. Ridiculous!

In the physical world there are examples of this kind of judgement being applied, although it is much less common. Here are some facts for you about a disease that suffers from this sort of prejudice. It is:

  • The 8th leading cause of death
  • More prevalent than any one cancer, or HIV
  • Potentially lethal – two variants of this disease kill three people every minute – that’s 1.4 million in 2010 compared to 1.2 million who died from malaria.
  • Often silent and people may not realise they are infected – one in three people on the planet have been exposed to the virus.

Full team with Minister and AdamThe disease is hepatitis, which is a cluster of similar viruses that attack the liver. Hepatitis C is a real menace because the body is generally unable to clear the virus itself. Four out of five people develop a chronic infection, which may then lead to cirrhosis and liver cancer after 15-30 years. If you are infected you will face many challenges as the treatment is prolonged (24, 48 or even 72 months are required) and some variants of the virus are much harder to eradicate.

There is no vaccine and so it is vital that the risk of exposure is reduced. For those who are infected this is a major responsibility they have once diagnosed as this will help to contain the spread of the disease. It is possible to spread the virus through contact with the blood or other body fluids (i.e. saliva, semen, vaginal fluid) of an infected person, although it is unlikely to be contracted through kissing or the use of cutlery.

The virus is able to live outside of the body for a relatively long time, which means that the risk of exposure from shared razors, toothbrushes or other household articles is much greater. If you are a drug user then you can be infected by using the equipment for injecting drugs (not just the needle) or by sharing a straw or note if you snort cocaine. Unsterilised tattoo or body piercing equipment is another route for infection.

Unfortunately there is a degree of stigma associated with the disease which may prevent people who believe they may have been exposed from coming forward. As a society this is very harmful, and places us at increased risk as the virus doesn’t know who we are or what we do for a living and makes no judgement about whether or not anyone deserves to be infected.

This is why Delyth Tomkinson, Brendan Healy and colleagues from across the NHS in Wales have been at a stall in the Hayes in Cardiff centre this week. Delyth and colleagues from the Welsh Hepatitis Nurse Forum have been championing the cause of promoting access to testing and treatment for this disease.

Minister getting tested(web)This is particularly important as there are thought to be 14,000 people with undiagnosed disease in Wales. Getting a test is simple – talk to your GP or pick up a self-referral from the cashiers desk in the concourse at UHW and our team will take care of the rest. I think Delyth and the rest of the team are great ambassadors for the health board – and their powers of persuasion are not to be underestimated – just ask the Health Minister, Mark Drakeford who agreed to be tested to show his personal commitment to the cause.

On World Hepatitis Day our team were out there sending a very clear message that prevention is better than cure; that getting tested is simple and easy to do and will reduce the chance that the disease will spread by ensuring people who are infected know they are and so can ensure they protect those around them and of course get the treatment that may eradicate the virus for them.

If putting a value judgement on a virus isn’t nonsensical enough, the consequence of allowing stigma to persist is that those who like to judge are putting themselves and their families at greater risk by creating a climate where the very thing that would protect us all is less likely to happen.

I’d like to think that those of us who work at the health board believe we should never fail to challenge prejudice of any kind. Making value judgements about the health challenges people face is a world apart from a mature conversation between a health care professional and the patient about what they can do to help themselves.

Keep well

Matter over mind?

Summer is well and truly upon us. The heat of the July sun contrasts strongly with the same sunshine on a winter’s day. As the Earth tilts slightly towards the sun this tiny movement increases the sun’s power and we feel the difference. The margins are so small – if the Earth were only in a slightly different plane of space life might never have got going.

For the ancient civilisations this natural phenomena of the seasonal fluctuations warranted an explanation. Lacking the insights we have today, people found the answers in myths of gods – myths that were layered and developed over millennia, developing and changing shape as the civilisations themselves waxed and waned.

We know that between 1425 and 1200 BC, on the island of Crete there were a people that we now call Mycenaean. Archaeologists have discovered clay tablets with scratchings on them that turn out to be a development of an earlier Minoan language, known as Linear B. From these tablets it is possible to make out the first appearance of a goddess who would later be named Demeter by Homer.

DementerDemeter was the goddess of the harvest, who presided over the grains and the fertility of the Earth and from Homer we have the story of Demeter and her daughter Persephone, who was abducted to the underworld by Hades. Demeter searched for her beloved daughter ceaselessly, preoccupied with her loss and grief. While she searched, the seasons halted and living things stopped growing and then began to die. In time Zeus intervened and Persephone was returned to her mother, but only after she had eaten pomegranate seeds given to her by Hades. Having done so, Persephone was bound to Hades and must return to him for one third of the year – during which time nothing will grow – winter in other words.

Dementia is a Latin word derived from the word root mens or mind and de which means removal or separation – so dementia becomes ‘removal or separation of the mind’. The term was first used in 1861 to describe the symptoms of what we now know as dementia. Language just like mythology is layered and also changes shape and meaning over time as do memories.  Is there an echo of Demeter in the word dementia? I don’t know, but there’s something about poor Demeter frantically searching for her lost daughter and forgetting to undertake her duties that resonates with me.

Launch1(web)It certainly did last week when we launched our Three Year Dementia Care plan. At its heart it has three themes: prevent, delay and cope. There is no cure for dementia and the number of people with dementia is set to rise. Currently there are thought to be 45,000 people with the disease in Wales, and in our population the number of affected people is set to increase by 60% over the next 25 years.

We have worked together with people with dementia, their carers and the professionals who have expertise in this field to develop our plan. Clearly prevention and delay have to be key cards that we play in our battle with this disease.

Interestingly the prevention component of our plan draws on evidence that is locally derived. The Caerphilly Cohort Study led by Professor Peter Elwood OBE from the School of Medicine at Cardiff University, monitored the health habits of 2,235 men over a 35-year period. It found that five behaviours are integral to having the best chance of a disease free life: taking regular exercise, a healthy body weight, a healthy diet and a low alcohol intake.

Plan Cover EnglishThe people who consistently followed four or five of these behaviours experienced a 60% decline in dementia and cognitive decline – with exercise being the strongest mitigating factor – as well as 70% fewer instances of diabetes, heart disease and stroke, compared with people who followed none.

So let’s all enjoy the sunshine then and also make an effort to take some exercise. It might be easier to do so now while the days are long and warm, rather than when they shorten and the cold sets in. The evidence is clear that we can lay down the foundation of a healthier and more fulfilling older age for ourselves and those around us by taking a few steps now to modify our behaviour.

Keep well