IngentaConnect Table Of Contents: The Royal College of Surgeons of England

IngentaConnect: Bulletin of The Royal College of Surgeons of England: "The Bulletin of The Royal College of Surgeons of England is published monthly, with the exceptions of August and December. The primary aims of the Bulletin are to keep fellows, members and affiliates of the College informed of all College activities and to provide a forum for the debate of current issues of interest and/or contention within the profession."

Healthcare innovations don't come easy. Below is a link to No incentives, no innovation pp. 10-12(3) article written by Hackett, Jon. The complete story is available in pdf-format. I quote parts of the story where Mediracer, the nerve conductivity measurement device for carpal tunnel syndrome diagnosis, is mentioned.

Jon Hacket writes: In addition to Mr Petri I spoke to Tim Green, one of a team of orthopaedic surgeons from Leicester, whom Mr Goldberg cites as another example of innovation and best practice on the ground. Mr Green told me about the carpal tunnel syndrome (CTS) service that the team set up 3 and which now does 98% of such procedures in Leicestershire:

‘We’ve done 6,500 carpal tunnels now in the last 11 years, all audited; all have pre and post-op Boston hand scores, patient evaluation measures, etc.’

It was in fact their theatre manager, Malcolm Clarke, a nurse, who overcame the orthopaedic team’s scepticism that there was a need for change: ‘it turned out to be about 10% of our waiting lists plus plastic surgery, sports medicine, neurosurgery and everybody else was doing them too,’ says Mr Green.


120-week waiting list reduced to 6 weeks

Before setting up the Before setting up the service, there was a 120-week waiting list for CTS operations in the area: approximately 40 weeks to see a consultant, 40 weeks for a nerve conduction study and 40 weeks to wait for an operation.

This has now been reduced to 6 weeks from referral to operation to discharge, with most patients even having one hand done at a time to prevent both hands being immobilised.

Part of this is facilitated by the use of a Mediracer® CTS Test Device, a Finnish invention that carries out nerve conduction tests.

The team were at one stage involved in the clinical trials and marketing of the device. When the local primary care trust shifted services to the local community and sought providers for CTS procedures, the five-man team set up a company and moved assessment and surgery to three GP clinics in the area.

Much interest has been generated by the practice-based clinic from other surgeons, nurses and physiotherapists, GPs with a special interest and most of all, GPs wanting to replicate the service in their own surgeries.

The clinic initially faced opposition: ‘Just about every aspect of the service has been under attack at some point.

The nerve conduction machines have been attacked; the concept of nurse operator has been attacked; and the fact that it’s in GP surgeries isn’t terribly popular either with other people, although the patients are very keen on it,’ says Mr Green.

As with Mr Petri, the Leicestershire CTS service has been criticised for possible detriment to surgical training opportunities.

Again, Mr Green says that the converse is true. ‘Chris Kershaw and I are both intercollegiate examiners so we’re very aware of training needs and training issues. This way SHOs can come in, they can see it done properly and they can do several, one after the other, in a nice quiet environment.

The juniors love it: we get very good feedback.’ Mr Green says that opposition or scepticism to the system is soon overcome when people see the service in action: ‘It would be nice if people actually came to see it because when they do they are usually convinced.

When they see it on the ground suddenly it all makes sense. Now we’re doing it in the community, the GPs are happy too because their health centres are being used for things they think it should be used for.’


Thankfully, the service has now been recognised as an example of excellence by the Department of Health, partly due to the care closer to home initiative.

Malcolm Clarke, the nurse who leads the service, says: ‘Every six months I go down to the Department and audit hospital figures against GP practice figures, from viewpoint of patient satisfaction and a clinical point of view.

We’re keeping the quality as high in the GP practice as in the hospitals. The only difference is that it allows the patient to have his or her treatment quicker and it frees up space and time in the hospital because we don’t use beds, we don’t use theatres.

The patients walk in, they have their operation and they walk out about 20 minutes later.’ In fact, Mr Clarke adds that in his experience delays in implementation mostly occur at the primary care trust level, rather than higher up.

"It is beyond the scope of this article to discuss the pros and cons of the specific practices introduced by Messrs Petri and the Leicester group," Writes Jon Hacket. "But though they are the first to acknowledge that their own solutions may not work everywhere, they indisputably worked well in their own respective trusts."

By implication, there would be at least some other trusts in the country in which the same systems could be replicated with demonstrable benefit.

In each case an innovation on the ground radically cut waiting lists with an obvious benefit to patients and the health service.

There will always be a debate around the safety or desirability of new ways of working – this discussion must be had – but these two cases show some of the challenges and obstacles faced in disseminating innovative practices.

Helge: I'll write more about this in the near future.

Health Care Policy Questions in UK and Mediracer

I got this information through Veijo Lesonen with a more specific reference to this PDF and page 7 that I'll be quoting below the NHS Policy Exchange Information

Health: "The traditional model of the NHS has been characterised by a highly centralised management structure; successive governments have failed to delegate responsibility to a local level. Policy Exchange believe that Healthcare providers need to become embedded in their local communities and that strong public involvement in decisions about health and social care priorities is critical. Our research, whether into improving healthcare innovation or the role of the private sector, is from patients’ perspectives."

The quote on page 7 starts here.

The artificial barrier between health and social care is a further division. Social care is not part of the NHS system; yet caring for those with long-term conditions requires effective communication and collaboration between different professional teams that span this divide. This often proves difficult.

Cultural silos

“There’s no question that one of the barriers to innovative medicine in the UK is the medical profession. And they’re very, very conservative … I would argue, exceptionally so, to the disadvantage and detriment of their patients.”

Managers naturally rely on the advice and ideas of senior clinicians, because they lack clinical
training, and the culture of the NHS old guard is often characterised as conservative, parochial, and territorial. Clinicians are justifiably protective of their autonomy over clinical matters, but in some circumstances this can be used to resist uncomfortable changes, such as innovations that disrupt their professions, or the push for greater transparency through clinical audit. It is very difficult for managers to lead service change in the health service, and thus to respond to pressures from commissioners and the centre to improve quality.

Case Study 1: Mediracer diagnostic device (link to pdf)

Carpal tunnel syndrome (CTS) causes pain and tingling in the hands and is 3-5% prevalent in the
adult population. Currently, diagnosis requires referral to a neurophysiologist, which can add up to six months to the treatment pathway. A new hand held device for diagnosing CTS has now been developed, which can be used in outpatient and primary care settings. The technology has been taken up by a team in Leicester, who created a one-stop clinic for diagnosis and treatment of CTS.

In less than two years they had secured over 90% of referrals from the Strategic Health Authority (SHA) saving the NHS £1.7 million and earning an innovation award from Medical Futures. Since publicising their work, the team has encountered significant opposition from third parties. For example, neurophysiologists argue that the test is not as accurate as the gold standard (the new test is sensitive (94%) and specific (98%) compared to a conventional EMG test performed by a specialist).

Instead of looking for ways to incorporate the greatly improved pathway and make sure problem cases are referred for further tests, there has been a resistance to dialogue.

This technology could greatly reduce waiting times and Medical Futures estimates the potential national savings to be over £72 million.

There are also divisions between different professional groups, who can have diverging interests. Tightly-knit professional networks can operate as channels for new ideas to spread.

But they also serve to create cultural divisions between professions, reducing the spread of innovations that impact on multiple clinical areas and require close inter-professional collaboration.

The simple rule for adoption in the NHS is; the more parties that are involved, the less likely it is to happen.

Helge: It looks like the climate for innovation adoption isn't much different in many other countries. Medical innovations are suffering while the field is limited to very large organisations with deep pockets. Mediracer has stubbornly continued to fight against a likewise stubborn opposition. But what if we would have a more adaptive environment? What could it mean for patients? And how about health care costs?

Talking with Viejo Lesonen

Good morning Veijo Lesonen, I'd like to talk with you about the Medical Futures Innovation Award. Congratulations. When did you get the award?

"We got the best orthopedic diagnostic method innovation award in June 2007 and in London," Veijo Lesonen, the Finnish neurophysilogist and managing director of Mediracer Ltd. confirms.

The showcase of the 2007 Medical Futures Innovation Awards took place at a prestigious venue in central London. Hosted by Joanna Lumley and Rory Bremner it was a fantastic event attended by over 750 distinguished guests, truly a Who's Who of health care.