UCL ELIZABETH GARRETT ANDERSON
INSTITUTE FOR WOMEN’S HEALTH
UCL Elizabeth Garrett Anderson Institute for Women’s Health
First Quinquennial Review
2004–2009
UCL Elizabeth Garrett Anderson Institute for Women’s Health
First Quinquennial Review
2004–2009
UCL EGA IfWH 1st Quinquennial Review
Foreword
It is a great pleasure to be writing the foreword for the 1st Quinquennial Review of the UCL Elizabeth
Garrett Anderson Institute for Women’s Health (IfWH).
The Institute was established in 2004 to bring together the academic team in women’s health at University
College London (UCL) and the clinical team at University College London Hospitals (UCLH) NHS Foundation
Trust, with a ten-year objective to establish the leading European centre for women’s health. The Institute is
built on a long tradition of excellence in obstetrics and gynaecology and has a direct historical connection
with the work of Elizabeth Garrett Anderson, the first female doctor in the UK, who founded the New
Hospital for Women in London in 1872, later renamed after her. That hospital was the predecessor of our
new EGA Hospital Wing at University College Hospital (UCH) which opened in 2008 and the staff in the
IfWH share Elizabeth Garrett Anderson’s commitment to improving the health and quality of life of women
through excellence in research, education and clinical care. Many of the challenges have changed in the last 137 years, but her ethos and
determination to make a difference and improve the lives of others remains an inspiring link.
The strategy adopted five years ago in creating the IfWH was to integrate existing activity, broaden its scope, make a series of strategic
recruitments, improve space allocation and develop the Institute’s infrastructure. The environment of UCL, one of the world’s leading
universities, and UCH, one of the UK’s leading hospitals along with the support of their leadership has made much of this possible.
Excellent progress has been made and the IfWH has become established as a key component of UCLH, UCL and this year the new
UCL Partners Academic Health Science Centre. The Institute now includes activities in neonatology, sexual health and cancer, as well
as obstetrics and benign gynaecology and has numerous collaborative links within and outside UCL. These include collaborations in
epidemiology, statistics, computational medicine, imaging, genomics, proteomics, psychology and ethics, as well a series of initiatives
in the developing world. During the last five years more than 20 new senior clinical and academic staff have been appointed, a new
laboratory established and a major new hospital opened. All aspects of the clinical service have expanded, income has risen and
academic output including publications has improved, so that by most metrics the IfWH is amongst the leading European centres in
women’s health.
A great deal has been achieved, but all of the Institute team are aware that much more needs to be done if the vision to have a major and
sustained impact on the lives of women in the UK and globally is to be achieved. This review was commissioned by the IfWH team with the
long-term objective in mind, so as to assess the achievements of the last 5 years, identify strengths and weaknesses and to obtain advice
from an expert international panel about the future development of the Institute. It is a great pleasure to welcome the review panel, which
will be chaired by Sir John Pattison and consist of experts in clinical, research and educational aspects of women’s health. I am grateful to
the panel for giving four days to the review and look forward to a challenging, but enjoyable process, which will provide important advice
about the next stage of development of the Institute.
It has been a great privilege to lead on the creation and establishment of the IfWH and I am enormously grateful to the outstanding clinical,
academic and administrative team who have worked tirelessly and with massive commitment to make the achievements described in this
document possible.
Ian Jacobs
Director
UCL EGA Institute for Women’s Health
3
UCL EGA IfWH 1st Quinquennial Review
CONTENTS
Introduction
6
Overview of UCL Elizabeth Garrett Anderson IfWH
8
Neonatal Medicine – Clinical
Neonatal Medicine – Research
17
26
Maternal and Fetal Medicine – Clinical
Maternal and Fetal Medicine – Research
35
45
Reproductive Health and Benign Gynaecology – Clinical
Reproductive Health and Benign Gynaecology – Research
55
64
Women’s Cancer – Clinical
Women’s Cancer – Research
71
79
Undergraduate Education
Postgraduate Education and Training
89
95
Global Health
101
Clinical and Academic Administration
109
Appendices
http://www.instituteforwomenshealth.ucl.ac.uk/staffintranet/appendices.pdf
Publications
http://www.instituteforwomenshealth.ucl.ac.uk/staffintranet/publications.pdf
5
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
INTRODUCTION
Template for Quinquennial Review
of Institute for Women’s Health
The University College London Elizabeth
Garrett Anderson Institute for Women’s
Health (IfWH) was created in 2004 with a
mission to bring together individuals with
expertise across the spectrum of women’s
health, from basic science to clinical
skills, with the objective of making a major
contribution to the health of women in the
UK and internationally, through research
excellence, innovation in education and
outstanding clinical care.
The review panel consists of the following members:
In order to assess the initial five years
of the IfWH and help guide the next
five years a quinquennial review was
commissioned by Professor Ian Jacobs,
IfWH Director, with the support of
Professor Malcolm Grant, University
College London (UCL) President and
Provost, and Sir Robert Naylor, University
College London Hospitals (UCLH) Chief
Executive. Sir John Pattison agreed
to chair the review and undertook a
preliminary visit and review in April 2008.
The full review with an external panel will
be held from 29 June to 2 July 2009. This
document has been prepared to inform
the review panel about the activity and
status of the IfWH.
Professor Jenny Higham (Imperial College London, UK), Education
Sir John Pattison, Chairman
Professor David Edwards (Imperial College London, UK), Neonatal Medicine
Professor Steve Thornton (University of Warwick, UK), Obstetrics
Professor Gerard Visser (Utrecht University, Netherlands), Fetal Medicine
Professor Allan Templeton (University of Aberdeen, UK), Reproductive Medicine
Professor Andrew Berchuck (Duke University, USA), Cancer
The review will consist of a site visit, with presentations, and group and one-to-one
discussions taking place over the course of three days, following which a report will be
prepared.
The chapters in this document summarise activity at the IfWH and follow a template given
on page 7, which was agreed with Sir John Pattison. The template was followed for each of
the twelve areas of activity at the IfWH as listed in the Contents.
Review the progress made by the
IfWH in advancing the tripartite
mission of research, education and
clinical care during the last five years.
Assess the status of the IfWH
nationally and internationally.
Identify areas of particular strength
and weakness in the activities of
the IfWH.
Provide guidance to the IfWH
management team on future
development of the IfWH.
Indicate to the senior management of
UCL, UCLH, Royal Free Hospital and
UCL Partners the steps necessary
for the IfWH to achieve the objective
of becoming the leading European
Centre for Women’s Health within the
next five years.
6
2. Strategy, Aims and Objectives
Describe the strategy, aims and objectives of your theme and how they will be achieved.
3. Resources
Describe the resources available to you, such as: (a) space; (b) finances; (c) staff;
(d) equipment. Comment on their suitability for the tasks you face, identifying the key
strengths as well as areas of deficiency.
4. Performance and Measurement of Quality of All Activity
Define the key performance criteria and output measures for success of your theme.
The nature of these criteria will be different for clinical, research and educational
activities. For each area of activity described in section 1 provide evidence of quality of
performance, based on these criteria.
5. Areas of Excellence
This is an opportunity to highlight and provide further details of areas of outstanding
performance which have been identified in section 4. Are these areas of activity in
which the theme is a leader (a) nationally; (b) in Europe; c) globally?
6. Challenges
Describe the key problems you have had to tackle during the last three years, the
progress made in dealing with these and outstanding issues.
7. Impact and Importance
Explain the importance of your area of activity to the health of women. Provide up to
ten examples of activities in your area which have made an important contribution to
women’s health during the last five years.
The purpose of the full review is to:
1. Overview
Describe each area of activity in the theme: how it is organised, managed and led,
members of the team and their roles.
8. Future Developments
What are the key developments you expect to see in your area over the next five years?
Bird’s eye view of Women’s Health: in the foreground are Podium, Tower and EGA Wing
of University College Hospital next to Univeristy College London Cruciform Building
7
UCL EGA IfWH 1st Quinquennial Review
OVERVIEW OF UCL ELIZABETH GARRETT ANDERSON
INSTITUTE FOR WOMEN’S HEALTH (IfWH)
CREATION OF IfWH
The concept of an IfWH at UCL and UCLH was proposed in 2003
by Ian Jacobs in discussions with Leon Fine, then Dean of the
UCL Faculty of Clinical Sciences, and David Fish, UCLH Medical
Director, about a move to UCL/UCLH. The proposal was based
upon the perception of a unique opportunity to have a major
impact on women’s health in view of several factors:
A rich tradition of excellence and innovation in women’s health
at UCL and partner hospitals, stretching back over 100 years.
Existing strengths in clinical care in all specialist areas of
neonatal medicine, obstetrics, gynaecology and cancer.
Academic excellence in a range of disciplines which
could be readily complemented by recruitment of a large
gynaecological oncology group.
Firm plans for a new hospital build at UCLH to include a new
Women’s Hospital wing.
The international profile of UCL with excellence in a range of
areas of basic science and applied research of relevance to
women’s health.
Willingness of the senior leadership and staff within Women’s
Health (WH) at UCL and UCLH to work together in linking
clinical care, education and research in women’s health.
The developing national and international agenda to facilitate
translation of basic science progress in to clinical impact
through effective translational research.
The proposal for integration of clinical and academic activity in
Women’s Health was formalised in June 2004 by the establishment
of the UCL Elizabeth Garrett Anderson Institute for Women’s Health
(www.instituteforwomenshealth.ucl.ac.uk) as a joint venture
between UCL and UCLH.
IfWH VISION
As an initial step in the development of the IfWH a series
of working groups involving clinicians and academics were
established in June and July 2004, which was followed by the 1st
IfWH Strategic Away Day in July 2004, at which the mission of the
IfWH was agreed:
To bring together individuals with expertise across the spectrum
of women’s health, from basic science to clinical skills, with the
objective of making a major contribution to the health of women in
the UK and internationally, through research excellence, innovation
in education and outstanding clinical care
Through the strategic planning process a number of strategic
developments and priorities were agreed and planned with the
objective of creating the leading European Centre for Women’s
Health within ten years. Progress towards this objective is ahead
of schedule as a result of developments since 2004, including
recruitment of over twenty senior clinical and academic staff,
acquisition of new clinical and research facilities, generating
substantial grant income, productivity in publications and a
successful global health initiative.
Context of IfWH
The IfWH was established as a joint venture between one of the
world’s leading universities, UCL (www.ucl.ac.uk) and one of the
leading NHS Hospital Trusts in the UK, UCLH (www.uclh.nhs.uk).
UCL and UCLH are both located in Bloomsbury in Central London
and have close interactions in a range of areas, including
translational research through the UCLH/UCL Comprehensive
Biomedical Research Centre, in which Women’s Health is a theme
(www.ucl.ac.uk/cbrc). It was always intended that the IfWH would
have close links with local healthcare organisations and this has
been facilitated by the establishment of UCL Partners Academic
Health Science Centre (www.uclpartners.com), bringing together
as Board Member organisations UCL, UCLH NHS Foundation
Trust, Royal Free Hampstead NHS Trust, Great Ormond Street
Hospital for Children NHS Trust and Moorfields Eye Hospital NHS
Foundation Trust, along with a number of organisations in North
London, including Whittington Hospital, Primary Care Trusts and
Mental Health Trusts. UCL Partners (UCLP) received accreditation
from the Department of Health in February 2009. The partnership
aims to achieve integration in delivery of the tripartite mission of
research, clinical care and education, so as to have a major impact
locally, nationally and globally. UCLP serves a population of over
1.5 million, has a turnover in excess of £2.1 billion per annum and
is amongst the largest biomedical centres in Europe. At the core
of the strategic plan for development of UCLP is a series of UCLP
Programmes, based upon disease and system-based areas of
strategic importance to the Partners. Crucially from the perspective
of the IfWH, Women’s Health is amongst the initial seven approved
Programmes, reflecting the progress which has been made in
Women’s Health in the last five years. In many ways creation of
the IfWH provided the model for UCLP Programmes, which cross
conventional boundaries and barriers between the university and
NHS, and their academic and clinical activities. UCLP provides
an outstanding opportunity to further develop the IfWH, which in
July will seamlessly assume its position at the core of the UCLP
Women’s Health Programme.
ORGANISATIONAL STRUCTURE
OF IfWH
The IfWH is an overarching structure for strategic planning
in Women’s Health, which acts through consensus without
governance authority. The Institute is led by Director Professor
Ian Jacobs and three Deputy Directors, Professors Judith
Stephenson, Donald Peebles and Neil Marlow. A Strategic
Planning Committee brings together senior clinical and academic
staff, providing a framework for discussion and planning of joint
developments. The Clinical Division of the IfWH is the governance
structure for delivery of clinical care at UCLH (Clinical Activity
section below). This is led by Clinical Director, Tim Mould with
General Manager, Susan Sinclair, as well as Clinical Leads for
specialist areas. A meeting of the Clinical Board, which involves
key staff, takes place monthly. The Academic Division of the
IfWH at UCL (Research Activity section below) is led by Director
Professor Jacobs with Head of Administration (interim appointment
of Marcia Jacks whilst Gemma Escorial is on maternity leave).
There are research departments of Neonatal Medicine, Maternal
and Fetal Medicine, Reproductive Health and Benign Gynaecology,
and Women’s Cancer, as well as Education and Training
Department. There is a monthly meeting of the Academic Division
Board attended by senior academic and administrative staff.
8
There are important clinical and educational activities at Royal
Free Hospital and Whittington Hospital which it is hoped will
increasingly be linked with the IfWH following the establishment of
UCL Partners.
Research Activity
Women’s Health research is a theme in the UCLH/UCL CBRC,
has over £30 million research funding from MRC, CRUK, WT, DH
and NIHR and is organised around 4 main areas primarily on the
Bloomsbury Campus:
Neonatal Medicine
Head of Research Department – Dr Nicola Robertson
This group has a focus on neonatal neuroscience and
neuroimaging and an international reputation for work on the
aetiology, prevention, management and outcomes of perinatal
brain injury translated into the use of therapeutic hypothermia
for neonatal encephalopathy. There are major collaborations with
the Institute of Neurology (piglet model), Institute of Child Health
(neuropsychology, respiratory physiology, medical physics, global
health, cardiology and pathology), University of Nottingham and
the National Perinatal Epidemiology Unit in Oxford.
Maternal and Fetal Medicine
Head of Research Department – Professor Donald Peebles
Research ranges from mouse models of perinatal brain injury and
sheep models of viral vector delivered therapy, to a national study
of non-invasive diagnosis for rhesus disease, the use of statins
to prevent pre-eclampsia and pre-implantation genetic diagnosis.
There are joint appointments and collaborations with child health,
anatomy, cardiology, neuroscience and HSR.
Reproductive Health and Benign Gynaecology
Head of Research Department – Professor Judith Stephenson
Research includes paediatric and adolescent gynaecology,
subfertility, ultrasound diagnostics, chronic disease including
obesity, diabetes, PCO and sexual health including teenage
pregnancy, abortion and sexually transmitted infections. Research
in oocyte physiology and chromosomal disorders has links with
physiology and sexual health with population health.
Women’s Cancer
Head of Research Department – Professor Ian Jacobs
This research effort is focused on the use of genetics, epigenetics,
proteomics, epidemiology and systems medicine, to develop
methods for risk assessment, early detection and prevention of
women’s cancers. The laboratory programme is linked to a clinical
trials unit which has conducted large scale population based trials
including the largest RCT of cancer screening worldwide.
Clinical Activity
Neonatal Medicine
UCLH is the perinatal centre for the North Central London Perinatal
Network (NCLPN). Outcomes for very immature infants at UCLH
match those of other centres recognised internationally for quality
of care. WH runs the largest transitional care service in London,
providing special care for babies with their mothers. There is a
close clinical partnership with Great Ormond Street Hospital for
Children (GOSH), for babies with surgical, cardiac, metabolic,
renal and neuromuscular conditions.
9
Overview
Overview
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
Maternal and Fetal Medicine
Global Health
There are delivery units at both UCLH and Royal Free Hopital (RFH),
which are managed independently with respectively 4,000 and
3,500 deliveries annually. UCLH provides tertiary maternal and fetal
medicine services, accepting referrals as a Perinatal Network hub
in North London. There are specialist services linked with Neonatal
Medicine, Neurology, the Heart Hospital, Mortimer Market and
GOSH as well as the RFH haemophilia centre.
In 2005 the Institute team launched a major programme of activity
in the developing world, involving clinical care, education and
research, encompassing the following initiatives:
Services at UCLH and RFH include specialist services in
urogynaecology with physiotherapy, rapid access gynaecology
diagnosis and outpatient treatment, paediatric and adolescent
gynaecology, endometriosis, minimal access surgery, assisted
conception, family planning and sexual health.
Cervical screening programme in Lagos, Nigeria.
Women’s Cancer
Resource and Income Generation
UCLH is the gynaecological cancer centre for the North London
Cancer Network (NLCN) with a catchment population of 1.5 million
women. The service involves multidisciplinary expertise in surgery,
radiotherapy, medical oncology, nursing, pathology, imaging and
palliative care. There are also specialist services in familial cancer
and cervical/vulval pre-invasive disease. A NL Breast Cancer
Partnership has recently been established involving UCLH, RF and
Whittington with links to Barts and The London.
Education and Training
Undergraduate Education
Lead – Heulwen Morgan
Module in Women’s Health and Communicable Diseases for 400
students within Phase 2 (Year 4); Web based learning; Major
contributions to biomedical sciences, intercalated BSc courses,
Student Selected Components and modules in Phase 1 (years 1
and 2); Taught course in Ethics in Reproduction + Women’s Health:
3rd year biomedical sciences BSc module in Fetal and Neonatal
Physiology for 60 students/year.
Postgraduate Education and Training
Lead – Ray Noble
Established MSc in Prenatal Genetics and Fetal Medicine: New
MSc in Haemoglobinopathies with international collaboration and
distance learning components: MSc in Reproductive Science and
Women’s Health to start in September 2009.
PhD Programme
Integrated Programme, with milestones/assessment formally
established in 2007 and has 32 PhD students (22 full-time,
9 part-time) covering each of our research themes.
Subspecialty Training
Royal College of Obstetricians and Gynaecologists (RCOG)
recognition for Subspecialty Training in Fetal-Maternal
Medicine, Reproductive Medicine, Gynaecological Oncology,
Urogynaecology and Community Gynaecology and Diploma in
Obstetric Ultrasound. Royal College of Paediatrics and Child
Health (RCPCH) National Grid for Neonatal Medicine.
Clinical Academic Training
The IfWH has been awarded six academic clinical fellows, three
clinical lectureships and two new-blood senior lecturer posts in the
last three years.
10
Centre for Reproductive Ethics jointly with Nelson Mandela
Medical School, Durban, South Africa.
Training programme in ethics and reproduction in medical schools
in India.
Academic Resource
Staff
The UCL Academic Division of the IfWH has a total of 111 staff
and in excess of 30 PhD students. The capacity and capability of
the academic team has been enhanced in recent years through
recruitment of a number of senior staff, funded by success in
income generation with minimal increase in HEFCE funding.
There have been 18 senior academic staff appointments and/or
promotions in the last 4 years during which just 2 senior academics
have left the IfWH.
Infrastructure and Facilities
Efforts have been made during the last 3 years to rationalise the
infrastructure in WH with the long term objective of housing the
majority of activity in an ‘Institute’ building. Some progress has
been made with the move of the cancer group from the Windeyer
to the Paul O’Gorman Building. Discussions are in progress about
relocating the Chenies Mews staff and facilities to the Rockefeller
building but the IfWH still occupies space at a number of sites.
These premises include a broad range
of molecular, cell biology and proteomic
technologies, clinical research facilities
and office based research space.
Animal studies are performed in the UCL
Biological services labs in the Cruciform
Building, the new facility for piglet studies
in Queen Square and through a long
standing collaboration with the Royal
Veterinary College in Camden.
Finance
Income to the UCL IfWH has steadily
increased since the Institute was
established with an overall increase in
funding of >100% from £3.4 million to
£8.1 million annually. Research Council
funding has increased from £0.6 million
to £1.7 million, and charitable funding
from £0.2 million to £1.7 million, whilst
HEFCE income has increased from £2.6
million to £3.7 million. This has been
achieved through success in grant income
generation from the MRC, CRUK, DH, NIH,
EU, AMRC and the Eve Appeal. As a result
the ratio of HEFCE:other funding sources
has improved from 1:0.3 to 1:1.1. Major
efforts are underway to further increase
grant, industry and charity income.
Clinical Skills Laboratories at UCL, RFH and Whittington for UG
teaching and examinations.
IfWH Gynaecological Cancer Research Unit, 1st Floor, Maple
House – High quality clinical trials unit for gynaecological cancer
with space for academic staff, researchers and support staff
Level 0
Staff
At UCLH there are 44 obstetric, neonatal,
and gynaecology consultants, 37 training
grade doctors, 110 midwives/nurses and
a further 30 allied health professionals.
At RFH there are 281 senior and junior
grade doctors, nurses midwives and allied
health professionals. The senior staff
have expertise across all specialist areas
within neonatal medicine, obstetrics and
gynaecology.
Infrastructure and Facilities
The EGA Wing at UCLH is a new purpose
built £70 million maternity and gynaecology
building which opened in 2008.
The building provides:
Level –1
Integrated benign gynaecology/breast
outpatient unit. Dedicated area for
outpatient diagnostics and treatment
including six scanning rooms, four
procedure rooms, three recovery rooms,
25 outpatient clinic rooms, dedicated
physiotherapy/psychologist rooms and
reproductive medicine lab.
Paediatric outpatient department – shared
with UCLH Paediatrics, an new clinical
research unit.
Level 1
Integrated Antenatal clinic. 26 clinic rooms
and specialist areas comprising obstetric
day unit, obstetric ultrasound and fetal
medicine unit.
Level 2
Twelve bedded labour ward, two dedicated
theatres, and four bedded special care
area + Neonatal unit with 17 ICU cots and
15 special care cots.
Level 3
39 bedded antenatal and post natal maternity
ward, as well as a six bedded ‘Home for
home’ Birthing Unit with two birthing pools.
The UCLH Tower includes a 30 bedded
surgical ward on level T13 for patients
with benign and malignant gynaecological
conditions with 22 theatre lists per week.
Consultant gynaecological surgeons cover
all lists. UCLH Trust has 40 ICU beds.
UCLH has a PERT system which meets the
recommendation of the Comprehensive
Critical Care Review published in 2000.
HEFCE
Other Overseas
EU
6
UCLH Trust Headquarters at 250 Euston Road – office space for
support staff and some clinical academics.
Royal Free Hospital – office space for academics and support of
undergraduate teaching.
Clinical Resource
8
Chenies Mews – laboratories and offices: Neonatal Medicine
Research, Maternal and Fetal Medicine Research, including
PGD group, and Academic Administration (Teaching and Human
Resources). In poor condition and in urgent need of relocation.
£m pa Funding
Reproductive Medicine and Benign Gynaecology
Uganda Women’s Health Initiative, a programme of neonatal
resuscitation, prevention of post partum haemorrhage, cervical
screening, palliative care and radiotherapy provision involving over
5,000 women and babies with research in premalignancy and
perinatal brain injury, the latter leading to a Lancet publication.
Institute of Neurology in Queen Square –
Facilities for large animal imaging (new 9.4
Tesla MR system) for neonatal group were
relocated from EGA Hospital on its closure
to Institute of Neurology laboratories at
Queen Square.
Government Bodies
UK Industry
4
UK Central
UK Charities
Research Councils
2
Margaret Pyke Centre – office space for Reproductive Health and
Benign Gynaecology staff.
Paul O’Gorman Building – state of the art new IfWH laboratories
for 30 staff with Translational Research Laboratory and facilities for
molecular, cell biology and epigenetic studies.
Cruciform Building – proteomics laboratory forming part of UCL
core proteomics facility.
0
2003–4
2004–5
2005–6
2006–7
2007–8
UCL IfWH Funding 2003–2008
11
Overview
Overview
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
Continuing the expansion of our external grant award portfolio.
Increasing NHS income through planned development of specialist
services increasing our referral base.
Overview of Areas of
Excellence
The Women’s Health Theme has a track record and an international
reputation across a wide range of activity. There are few other
centres in the field of WH which combine:
The scope of activity in women’s health from neonatology through
obstetrics, gynaecology, reproductive health to cancer;
Clinical, research and educational activity in each of these areas:
Basic science, translational, clinical and applied research.
Examples of particular areas of excellence are as follows:
Research Excellence
The UCLH Rosenheim Wing includes gynaecological oncology
outpatients with 20 rooms used for gynaecological oncology multidisciplinary clinic weekly. There is a private Assisted Conception
Unit based at the Eastman Hospital, which has state of the art
facilities for IVF and other related techniques.
At RFH there is a five bedded labour ward and three bedded
birthing unit, two dedicated theatres, a two bedded special care
area and a neonatal unit with 14 special care cots. There are 31
ante natal/post natal beds. The emergency gynaecology unit has
three rooms, a three bedded observation area and one scanning
room. The gynaecology outpatient facility has 24 rooms and there
is a 17 bedded ward for women’s health. There are 14 theatre
operating lists per week.
Finance
The UCLH annual budget has risen from £40 million in 2004 to £48
million in 2008. The service was run within budget in 2008. At RFH
the WH budget rose from £18 million in 2004 to £21 million in 2008.
The service was run within budget in 2008.
Income Generation
We have ambitious plans for income generation. These involve:
Building on our success in fund raising for Gynaecological Cancer
via the Eve Appeal (www.eveappeal.org.uk) by establishment of
a new charity HOW (Health of Women) which is being developed
with the involvement of Marion Allford Associates. We will also
continue working closely with the Arem Foundation which has
supported our efforts in global health.
Developing our intellectual property portfolio to optimise the
benefits of our unique biobanks and the diagnostic markers in
development with a range of commercial partners.
12
Optimal management of babies requiring relatively low levels of
care and transitional care.
Major contributions in endometriosis, ultrasound, endocrinology
and assisted conception.
A strong multidisciplinary approach to infant care, with a very
functional and supportive multidisciplinary team.
Key cluster randomised trial of pupil-led sex education (RIPPLE) to
reduce sexual risk behaviors, and delay first intercourse in young
women; inclusion in DH shortlist of Sex and Relationship Education
(SRE) programmes to accelerate the Teenage Pregnancy Strategy.
Parental satisfaction – high levels of trust, encouraged by staff
approachability, optimism and honesty.
Maternal and Fetal Medicine
Evaluation of sexual risk reduction interventions (DH Sexual Health
Strategy) including evidence base for Chlamydia screening in NICE
guidance on STI prevention in under 18 year olds.
Exceptional breadth and depth of expertise available for the care
of women with complex pregnancies and unusually high number
of sub-speciality trained consultants.
UK Network of community-based sexual and reproductive health
services established and directed by Margaret Pyke Centre.
The Fetal Medicine Unit (FMU), established in the 1990’s was
a pioneering unit in the UK. The tradition of innovative clinical
practice has continued e.g. the development and implementation
of the integrated test for Down syndrome screening (NICE
recommendation for national Implementation).
Use of Pre-implantation Genetic Diagnosis to prevent inheritance
of a range of genetic disorders. First examples in cancer
syndromes including most recently first baby born free of BRCA1
gene mutation through Pre-implantation Genetic Diagnosis.
Neonatal Medicine
Women’s Cancer
Robertson, Marlow, Wyatt
Jacobs, Menon, Widschwenter, Ledermann, Williams,
Gayther, Tobias
Internationally leading pre-clinical and clinical work in asphyxial
encepahalopathy; world first in evaluation of xenon as a perinatal
neuroprotective agent, with a pilot trial of therapeutic hypothermia
in a low resource setting; imaging the term and preterm brain (MRI,
MRS and NIRS).
University London Hospital – Tower with adjacent Podium
Leading European centre for research into intersex abnormalities
and paediatric gynaecology.
Internationally respected perinatal cohort studies, such as EPICure
(2 NEJM publications >360/240 citations respectively).
Neuropsychological investigation of preterm development.
Leader in Europe for Neonatal EEG and Seizure detection.
Leader nationally in NIDCAP and developmental care.
RCTs in UK, Europe and international settings – PI on 3 MRC, one
Dutch MRC, Australian MRC and one Wellcome Trust funded trials
– (I NEJM; 4 Lancet publications to date).
Maternal and Fetal Medicine
Peebles, Raivich, David, Nicolaides, Jauniaux, Williams, Chitty
A leader nationally in pioneering an approach for PGD.
European leader Perinatal Brain Injury. Development of models
of bacterial infection in the developing brain and investigation of
factors causing neurological damage and cerebral palsy.
International reputation in Maternal Medicine – described the
association between obstetric complications (pre-eclampsia, fetal
growth restriction) and later cardiovascular morbidity;
Pioneering the use of non-invasive methods of prenatal diagnosis
Changed understanding of the role of oxygen in placental
development, showing that hyper-oxygenation not hypoxaemia
impairs placental growth causing pregnancy complications.
Patented novel therapy for severe fetal growth restriction (cell/gene
therapy group) which has attracted significant financial support
from Ark therapeutics.
Reproductive Medicine and Benign Gynaecology
Stephenson, Creighton, Serhal, Saridogan, Hardiman,
Conway, Jurkovic
Internationally leading research in molecular regulation of oocyte
and embryo development.
Development of Risk of Malignancy Index: used nationally and
internationally as a standard approach to triaging patients with
ovarian cancer to specialist units.
Ovarian cancer high risk screening: leading international trial
of screening women at high risk (UKFOCSS) with protocol for
screening high risk women and early detection of many cancers.
Ovarian Cancer Population Screening: internationally leading
research programme. Numerous publications and global impact,
1st evidence of survival benefit, largest RCT performed worldwide
(UKCTOCS 202,000 participants – www.ukctocs.org.uk) reports 2014.
Cancer epigenetics: understanding role of epigenetics in cancer
development and role in risk prediction/screening/diagnosis. Nat
Gen paper describing epigenetic stem cell origin of cancer.
1st use of ffDNA detection in maternal circulation for assignment
of fetal gender and Rh typing.
Spectrum of multidisciplinary services and links with GOSH.
Excellence in health care provision for low risk women with a
Birthing centre containing three birthing pools and high level
midwifery support, led by a consultant midwife.
Multidisciplinary joint haemophilia/obstetric and gynaecology clinic
at RF.
Reproductive Medicine and Benign Gynaecology
Urogynaecology including uroneurology and laparoscopic
urogynaecology service.
Specialist endometriosis therapy unit.
Minimal access surgery expertise at UCLH and RF in all fields of
gynaecology.
Margaret Pyke Centre and Mortimer Market Centre provide
internationally renowned contraception and sexual health services.
Cancer genetics: lead position within international Ovarian Cancer
Association Consortium, largest group analysing of SNP’s in
ovarian cancer risk.
Leading rapid gynaecology ultrasound diagnostic service.
Intra-operative radiotherapy trials in breast cancer.
Private and NHS fertility and assisted conception service with
leading UK outcomes.
Clinical Excellence
Specialist paediatric and adolescent gynaecology service with
expertise in intersex.
Neonatal Medicine
Women’s Cancer
Extensive experience of managing a complex range of neonatal
conditions.
Clinical Gynaecological Oncology Service: provision of the highest
standards of care and new advances in surgical and therapeutic
approaches, to a catchment population of 1.5 million women in
North London.
Published outcomes for very immature infants match those of other
centres recognised internationally for quality of care.
Set standards for NCL Perinatal Network centres e.g. referrals out
of network now very few and almost all babies of <27 weeks of
gestation appropriately receive intensive care at UCLH.
Familial Cancer Clinic: screening referral centre for ovarian cancer
for South East region.
Low central venous line infection rates.
Cervical Cancer Screening and Colposcopy: RFH is a leading
centre for colposcopy and is 1 of 3 national pilots for HPV testing.
The IfWH has introduced screening programmes for cervical
cancer in Nigeria and Uganda, involving over 8,000 women, which
are now being rolled out nationally.
High breast feeding rates, good nutritional status and rates of
babies receiving breast milk.
Specialist centre at RFH for management of vulval disease,
inlcuding pre-malignancy.
Senior (consultant) presence 12 hours/day and for any complex
case at night.
Very low readmission rates after discharge from NNU and in
infancy and childhood.
Leading national and international centre for highly complex
laparoscopic surgery in women with gynaecological cancer.
13
Overview
Overview
UCL EGA IfWH 1st Quinquennial Review
Innovative contribution to the development
of the curriculum. Heulwen Morgan,
Carole Saunders and Therese Bourne
received a Dean’s Team Excellence award
in 2007. Ray Noble received the Provost’s
Teaching Award in 2007.
The final year BSc course in Fetal and
Neonatal Physiology is recognised
as the most popular and successful
in biomedical sciences with excellent
feedback from students and external
examiners. This now attracts more than
60 students each year.
Student Selected Component (SSC) in
Ethics in Women’s Health is popular and
has high student feedback scores.
Neonatal Medicine
Neil Marlow, Professor (from Nottingham); Dr Nicola Robertson, Senior Lecturer promoted
Reader (from Imperial); Janet Rennie, Consultant (from Kings).
Maternal and Fetal Medicine
Donald Peebles, promoted to Reader then Professor; Gena Raivich, Reader promoted to
Professor (from Berlin); Kypros Nicolaides, Professor (from Kings); Anna David, Lecturer,
received HEFCE Senior Lecturer Award; Maggie Blott, Consultant (from Newcastle);
Melissa Whitten, Lecturer promoted Consultant/Senior Lecturer.
Reproductive Health and Benign Gynaecology
Judith Stephenson, Professor (from UCL Population Health); Hayden Homer, Wellcome Trust
Clinical Fellow (from Newcastle); Greg FitzHarris, Lecturer and MRC New Investigator (from
Canada); Naaila Aslam, Consultant (from Kings); Davor Jurkovic, Consultant (from King’s).
Women’s Cancer
Ian Jacobs, Professor (from Bart’s/QMUL); Usha Menon, Senior Lecturer (from Barts/QMUL);
Simon Gayther, Senior Lecturer promoted Reader (from Barts/QMUL); Martin Widschwendter,
Lecturer promoted Senior Lecturer and Reader (from Innsbruck); Alexey Zaikin, Professor (from
Essex Univ); Lucy Side, Senior Lecturer/Consultant (from Oxford); Nicola MacDonald, Fellow
promoted Consultant; Jayant Vaidya, Senior Lecturer (from Dundee).
Innovative ‘Midwifery firm’ at the
Archway campus.
Grant Funding
Innovative ethics teaching in medical
schools in India with British Council
funding.
Grant income has grown steadily since 2004 and includes peer reviewed awards of over
£30 million from MRC, DH, CRUK AMRC and NIH (see figure on p11). WH is a theme in the
UCLH/UCL CBRC.
Postgraduate Education and Training
Publications
MSc in Prenatal Genetics and Fetal
Medicine is renowned internationally with
excellent reviews from external examiners.
Many students continue studies at the
Institute at PhD level.
From 2001 to 2008 the WH theme produced over 500 publications including publications in
Nature Medicine, Nature Genetics, New England Journal of Medicine and The Lancet. The
publication output places the IfWH as one of the leading centres worldwide in WH.
Subspecialist training in neonatal, fetal
and reproductive medicine and cancer
with outstanding record of training
specialists, which are now in post
throughout UK and worldwide.
High quality PhD programme with over
30 students across the spectrum of WH.
An analysis commissioned from Leiden University by UCL compared publications in 365
World Universities from 2001 to 2006 and normalised citations in a range of fields with 1.0
being average and >1.2 being high impact. There was no category specifically for WH but
UCL scored 1.43 in Obstetrics and Gynaecology, 1.26 in Reproductive Biology and 1.28 in
Developmental Biology.
25
20
H-index
Research
15
It is important to acknowledge that this performance reflects the
broad achievements at UCL and not just the activity within the
IfWH. In Neonatal Medicine, Maternal Health and Fetal Medicine
the work of the UCL Institute for Child Health is an important
contributor. The same applies to Reproductive Health (UCL Division
of Population Health and Epidemiology) and Women’s Cancer
(UCL Cancer Institute). These related strengths illustrate the added
value of locating the IfWH in a centre of excellence with the scope
and quality of UCL.
6000
New UCL hires
Cancer
Reproductive Medicine
Fetal Medicine
Neonatology
5000
4000
3000
2000
1000
5
Ki
ng
’s
Co Co
Vr pe lle
ije n ge
Un hag
iv en
B
Ka rus
ro sel
lin
Im ska
pe
ria
l
UC
Lo L
uv
H ain
Ca elsi
mb nki
rid
Mi ge
lan
O o
Ed xfo
inb rd
u
B rg
St olog h
Ge na
or
ge
s
Lu
nd
O
Ch slo
Liv arite
er
po
Pa
o
Tu l
ris
r ku
V
(D O
es ur
ca lu
Ab r tes
er )
de
e
Lu n
be
ck
0
Athens analysis H-index top 25 European Centres
14
demonstrates that in all areas of research activity in women’s
health UCL is amongst the world leaders.
10
Research Assessment Exercise
This is a national UK wide review of
research performance performed every
5–8 years. In the 2008 RAE WH was in the
UCL UoA4 submission which received
the highest rating of any UoA return in
Biomedicine in the UK.
We have undertaken a detailed review of publication key words
related to specialist areas of women’s health which is included as
Appendix 1.2. This analysis which compares UCL and its affiliated
institutions to other organisations in the UK and internationally,
An independent analysis undertaken by Athens University compared publications in
Obstetrics and Gynaecology in 95 leading European Centres by H Index (a measure of
publication quality by citations). UCL Obstetrics and Gynaecology ranked 6th.
30
Metrics and Other
Measures of
Excellence
A separate analysis of publications in women’s health
commissioned from 4D Biomedical Cambridge supports the
contention that UCL is one of the leading centres worldwide for
WH. The uncorrected analysis placed the IfWH 4th worldwide after
Harvard, Karolinska, Yale and University of Washington. When the
analysis was corrected for recruitment to the IfWH since 2004 UCL
was 2nd only to Harvard worldwide and equal to the Karolinska
Institute in Europe (see graph below).
0
U
I CL
ng mpe
’s ria
Co l
lle
g
Ox e
Ca for
mb d
Ed ridg
inb e
u
Gl rgh
Ma asg
nc ow
he
Liv ster
Bi erp
rm oo
ing l
ha
Ca m
rd
if
Br f
i
s
Ne to
w l
Ka cast
ro le
lin
s
He ka
lsi
Er nki
a
He smu
ide s
Am lbe
ste rg
rd
am
Le
ide
n
Mi
lan
Jo Ha
hn rv
s H ard
op
kin
U
s
of
W UC
as SF
h
Ma ingt
y
o C on
Br
igh
l
am St inic
an anfo
d Y rd
ou
ng
s
UC
Du L
ke A
Un
iv.
UC Ya
Be le
rke
ley
Undergraduate teaching in both hospital
and community settings is highly
regarded.
Success in recruitment and retention of international leaders during the last 5 years
has been excellent and has assisted with increasing the profile of the IfWH. Senior staff
recruited or promoted include:
Ki
Undergraduate Education
Recruitment and Retention
Relative publications
Education and Training
Excellence
UCL EGA IfWH 1st Quinquennial Review
4D Biomedical Analysis Publications in WH 2003–8
15
Overview
Overview
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
Clinical
There are numerous markers of excellence in our clinical service.
The table below summarises a range of qualitative and quantitative measures.
(a) Neonatal Medicine
Regional endometriosis centre for North Central London
Regional unit for NC London Perinatal Network
Regional urogynaecology centre for North Central London
Perinatal mortality rate below the national average
Accredited by the RCOG for 2 trainees in Reproductive Health
– 1 of only 2 centres in UK
The EPICure Study data (figure p. 22) demonstrate a
significant increase in survival of very premature babies
at UCH compared to the rest of England
Leading national centre for Paediatric Gynaecology
– strong links to GOSH
Only unit in UK providing Integrated Transitional Care service, with
multidisciplinary follow up rate 90% and neuro intensive care cots
Internationally renowned Margaret Pyke Centre and
Mortimer Market Centre
Consultant presence 12 h per day and, for complex cases, at night
Supraregional referral centre for complex
laparoscopic surgery
Healthcare Commission Quality indicator – 100%
Low central venous line infection rates
Very low readmission rates after NNU discharge
Optimal management of babies requiring relatively low levels
of care and transitional care
Parental satisfaction – high levels of trust, encouraged by staff
approachability, optimism and honesty
National Grid Training centre for neonatal medicine
Integrated service with GOSH for surgical and cardiac cases
(b) Maternal and Fetal Medicine
Patient satisfaction scores over 80%
18 week compliant across whole spectrum of gynaecology
(d) Women’s Cancer
Regional referral cancer centre for the NL Cancer Network
(6 hospitals). Larger clinical work load than any centre in
mainland Europe
Leading national and international centre for highly complex
laparoscopic surgery
Familial Cancer Clinic is the supraregional referral centre for
South East England
Accredited by the RCOG for 3 trainees – more than any other
UK centre
Peer review in 2001 and 2005 – met 97% of the Improving
Outcomes Guidance
Tertiary referral centre for North Central London Perinatal Network
Peer review team in 2005 awarded Special Merit and recognised
as outstanding example of how a network should be organised
Referral centre for complex growth restricted fetus
Clinical Negligence Scheme for Trusts (CNST) level 2 achieved
for Maternity services in 2007
New real time Maternity Information System purchased and
being introduced – one of first in UK
Dedicated consultant PA for obstetric haematology, cardiology,
anaesthetics, neurology and psychiatry
Fully compliant with guidelines of Confidential Enquiry into
Maternal and Child Health (CEMACH) report
Specific obstetric physician – one of four in UK
NEONATAL MEDICINE
Overview
UCL EGA IfWH 1st Quinquennial Review
Outperform national standards with 0% breeches for target
referrals, 99.4% patients within treatment target times and 92%
compliant with guidelines
35% reduction in surgical wound infection highlighted in the
Nationsl Audit Office (NAO) report and used as a case study
by the National Primary Care Development Team
Theatre occupancy is 100% and a Possum® scoring
system for assessment of surgical morbidity and mortality
has shown consistently low actual against expected
morbidity ratios of 0.13 : 0.42
3rd and 4th degree tear rate at 0.95%
Royal Free Hospital is the preinvasive referral centre for the
North London Cancer Network and a specialist centre for
management of vulval disease including pre-malignancy
(c) Reproductive Medicine and Benign Gynaecology
Fall in asepsis >20 rates from 10% in 2005/6 to
4.7% in 2007/8 post complex surgery
IVF conception rates in Assisted Conception Unit – best in UK
in 2008, and amongst top 3 in UK for many years
Only 1 case of MRSA in 2006/7
Intra-uterine insemination rate of 10% per cycle
Accredited for training by the RCOG and the European
Society of Gynaecologial Oncology
Human Fertilisation and Embryology Authority (HFEA)
accredited laboratory for 10 years
Embedded psychosocial support and 85% patient satisfaction
with Clinical Nurse Specialist (CNS) support
Education and Training
Women’s Health was the education focus of Quality Assurance (QA) reviews in 2007/8 and excellence of teaching and learning and the high
quality of the organisation of the clinical course was highly commended in the reports. GMC QA visits identified innovations and evidence of
good practice from Women’s Health in the context of SSC activity for Phase 1 students.
16
17
UCL EGA IfWH 1st Quinquennial Review
NEONATAL MEDICINE – CLINICAL
CLINICAL
Jane Hawdon
Janet Rennie
Angela Huertas-Ceballos
Nikki Robertson
Neil Marlow
Mark Sellwood
Judith Meek
John Wyatt
The UCH Neonatal Service is the lead
for the North Central London Perinatal
Network (NCLPN), providing the whole
spectrum of the specialist neonatal
care pathway. As part of the team
based at the EGA Wing and Great
Ormond Street Hospital for Children
(GOSH), we also manage complex
pregnancies where the baby will require
transfer for surgery or cardiology care
at GOSH. Because of the general lack
of capacity for tertiary neonatal care
we also take babies from surrounding
networks on request, producing a
diverse, busy and vibrant service.
From November 2008 we have been
housed in spacious purpose-built
accommodation with 17 intensive or
high dependency cots and 15 special
care cots, and with a busy transitional
care service integrated within the
maternity ward. Uniquely we are
equipping three intensive care cots to
provide neurointensive care, including
cotside electroencephalogram
(EEG) video-telemetry, therapeutic
hypothermia and recyclable gas
ventilators.
Our specialist practice is the product
of close crossdisciplinary working
with input from experts in fetal
medicine, paediatric surgery, speech
therapists, dieticians, physiotherapists,
occupational therapists, social workers
and pharmacists. A neonatal community
nurse and respiratory nurse specialist
also provide support for families of
infants after discharge into the local
area. We have an established followup service, focused on chronic lung
disease, neurodevelopment and an
echocardiography service. We also
provide outpatient support for infants
of drug using mothers and those
at risk of HIV or hepatitis B and C,
and clinics for babies with feeding
difficulties. Transfer of children with
developmental problems to community
services is achieved seamlessly
with developmental therapy support
provided from within the clinic setting.
18
The unit is amongst the busiest in London and operates at over 80% bed occupancy. In
2007 there were 585 admissions to the neonatal unit (13% births) and 547 to transitional
care, reflecting the high risk casemix of our maternity service. Approximately 60 infants
per year have surgical conditions and are transferred to GOSH. We are well supported
by dedicated 24-hour neonatal and paediatric transport services.
Although managed in different divisions, we work closely with the UCH paediatric
team, sharing outpatient facilities and moving more mature babies who require ongoing
hospitalisation to their care. We also contribute to the paediatric teaching faculty.
We remain very proud of our care of babies born at very low gestations and we have
published outcomes that compare favourably to other internationally respected studies in
terms of survival and developmental morbidity. Almost uniquely amongst tertiary centres
and perinatal networks we have low risk-adjusted neonatal mortality at network and unit
level in national benchmarking through Confidential Enquiry into Maternal and Child
Health (CEMACH) (see figure below).
Members of our team provide professional leadership, taking on roles within national
bodies and frequently being asked to advise outside agencies. This is a key component
of our aim to provide national leadership in the development of neonatal care.
The department has a long history of leading research in partnership with UCL.
This tradition continues, with a focus primarily on the neonatal brain and the sequelae of
perinatal events. The concept of modern neonatal care includes a move towards care
that is more responsive to individual needs and involves families closely in their child’s
care. This philosophy, which is included within the Neonatal Individualised Developmental
Assessment and Care Programme (NIDCAP), is being integrated into our routine clinical
practice. The translational nature of our research and the integration of laboratory and
clinical studies create a thriving, stimulating working and training environment for staff of
all disciplines to the advantage of the babies we care for and their families.
Network
3.5
Neonatal death rate (per 1000 live births)
NEONATAL MEDICINE
Average network neonatal death rate
95% confidence interval
3.0
2.5
2.0
1.5
1.0
0.5
0.0
0
5000
10000
15000
20000 25000
Live births
30000
35000
40000
45000
Adjusted neonatal death rate compared to the average Network neonatal death rate:
England, 2007 – NCLPN indicated by arrow (Source CEMACH Perinatal Mortality Report
2007, Feedback Report: North Central London Neonatal Network).
19
NEONATAL MEDICINE – clinical
NEONATAL MEDICINE
UCL EGA IfWH 1st Quinquennial Review
Our vision is to provide clinical leadership across the NCLPN and
enhance wellbeing and outcomes for sick newborn babies and
their families. We carry this out in a multidisciplinary setting that is
responsive to the needs of our patients.
We aim to develop a high quality neonatal service of international
repute, delivering an integrated, evidence-based symbiotic clinical
and academic service that itself is a benchmark of excellence.
Our objectives
1. Provide a comprehensive neonatal service for the local
population in partnership with other NCLPN units.
2. Develop strategies of care that incorporate evidence-based
interventions designed to optimise outcome for high-risk infants.
3. Ensure holistic care for families addressing all their needs
and aspirations through pregnancy planning, preconception
health, pregnancy, labour, delivery, the neonatal period and
subsequently, and including bereavement support.
4. Train and educate our workforce to a high level of competence,
including the wider EGA Wing workforce, for whom we provide
neonatal life support and clinical examination training.
5. Facilitate research and development in perinatal and neonatal care.
6. Support midwives in developing excellent newborn care,
promoting healthy child-rearing practices including exclusive
breast-feeding, vaccination, good diet and prevention of SIDS.
7. Support intensive care activity across London, whether
because of inadequate local tertiary service provision or for
aspects of care in which we or our associated colleagues have
specialist expertise (hypothermic neuroprotection; specialist
postnatal support at GOSH).
Achieving our objectives
4. We have active nursing and medical education programmes,
run neonatal life support (NLS) courses and contribute to
local and national training opportunities. UCH is a recognised
Training Centre for the National Grid (Royal College of
Paediatrics and Child Health (RCPCH)). We contribute to the
UCH Quality Project.
5. See Neonatal Medicine – Research.
6. We provide daily consultant level support to the postnatal
wards in order to encourage good childcare practice.
7. Of our activity 59/578 admissions in 2007 (10%) were from
outside the network and 75 babies were transferred to GOSH
for ongoing care, with 2008 data not available as yet
RESOURCES
Space and Equipment
Purpose built Neonatal Intensive Care Unit (NICU) on Level 2 of
the EGA Wing.
• 17 Intensive care stations, each permanently equipped with
monitoring, respiratory support and infusion pumps, with
paperless notes and clinical workstations to be installed;
additional equipment for High Frequency Oscillatory Ventilation
(HFOV) and inhaled nitric oxide (iNO) delivery
• three cots equipped for neurointensive care, including
two Cardinal Health Nicolet 32-channel EEG monitors with
polygraphy, video facility and central server; two Brainz twochannel aEEG recorders; two Criticool hypothermia devices;
two Tecotherm devices; ventilators with recirculation circuits for
delivering xenon (in development)
• Practice development nurses (three)
• Nursing establishment (130 (currently
16 vacancies)), staffing is not to British
Association of Perinatal Medicine
(BAPM) 2001 leve,l but provides
adequate staffing to 1996 standards
and two cubicles at 1:1 nursing with
two shift supervisors. A range of
specialist nursing roles has been
developed to encourage personal
development and career progression.
• Pharmacy (one pharmacist); other
health professional support includes
speech and language therapy (1.5
whole time equivalent (WTE)); dietetics
(1 WTE); EEG; physiotherapy (1 WTE);
occupational therapy (0.1 WTE in
Outpatients) with sessional support
from counselling and psychotherapy
and hospital social work.
Neonatal Unit Budget 2007/8
Income
£5,885,623
Expenditure
Underspend
£5,525,750
£359,873
Staffing costs
£4,404,517
Bank/agency/locum
£54,356
Equipment
£63,750
(PFI move associated with near complete refit)
• 15 Special Care cots with high dependency capacity.
Suitability
• three 4-bed bays and one 3-bed.
• stabilisation room adjacent to Theatre 2 on Labour Ward.
2. We have an ongoing guideline group in UCH and also
assimilate Network guidance. This is married to an active audit
plan and journal club; we recruit to external randomised trials
and develop our own scientific investigative portfolio to ensure
optimal practice.
• parent facility: kitchen and sitting area, private area for breast
milk expression, interview room, three en-suite bedrooms for
rooming in.
3. Holism is encouraged through multidisciplinary working with
obstetric, fetal medicine and midwifery colleagues and paediatric
specialists, informally and formally in weekly multidisciplinary
liaison, or Link, meetings. We contribute to antenatal counselling
and two consultants run a specialist neuroabnormality antenatal
counselling clinic. Within the neonatal service we engage a
range of expert allied health professionals, including dietetic
and pharmacy support, with the developmental care practices
encouraging holistic care with broad parental support (social
work, psychology and psychotherapy).
Staff
• Medical Physics laboratory on site and clinical investigation
room adjacent to reception.
• team room for meetings and IT resources.
• office space is at 250 Euston Road (NHS) and 86-96 Chenies
Mews (academic).
Mark Sellwood (Lead Clinician) and Annie Hunt (Senior Nurse)
• Eight consultants: Professor Neil Marlow, Drs Leigh Dyet,
Sian Harding, Jane Hawdon, Angela Huertas-Ceballos,
Judith Meek, Janet Rennie and Nicola Robertson.
• Walport Lecturer (1.0); SpR-level staff (including two imaging
fellows with clinical responsibility; total of nine posts);
Junior Specialty Trainees (twelve, including two Academic
Clinical Fellows)
PERFORMANCE AND MEASUREMENT OF
QUALITY OF ALL ACTIVITY
UCH is the lead centre for NCLPN with a high rate of incoming transfers (see table below).
Activity has risen from 2006-07, but 2008 data are not currently available from the Network.
14-23% admissions are transfers (IUT or NNT) and a significant workload arises from our
support of the surgical workload at GOSH.
ACTIVITY
2007
2006
UCH
%
NCLPN activity
UCH
%
NLCPN activity
Intensive care
2491 days
59%
2075 days
59%
HD care
4434 days
81%
2356 days
40%
Special care (incl TC)
7394 days
7814 days
Network transfers
48 (8% admissions)
76 (13% admissions)
Out of network transfers
34 (6% admissions)
59 (10% admissions)
Transfers to GOSH
75 (38 back transfers)
65 (39 back transfers)
Finances
• arranged as three 4-bed bays, two single cubicles and one
3-bed bay.
1. NCLPN: Jane Hawdon is current clinical lead and crossNetwork audit is reported publicly in the Annual Report. We use
a common IT platform and have excellent communication with
the other neonatal services locally. Our outpatient work ensures
a seamless transition from inpatient to community.
20
• Advanced Neonatal Nurse Practitioners
(six: one vacancy)
Space has vastly improved since the old
EGA hospital, but issues remain in terms of
quiet space for counselling and bereaved
parents, as well as functional office or
private space on the Neonatal Unit for
private conversations and telephone calls,
and a staff rest room. Furthermore, there
is little writing space due to inadequate
design of office facilities and clinical
workstations. Equipment is otherwise highly
adequate and the support is excellent.
Staffing levels at present are consistent
with those of similar sized neonatal
services, but will require expansion to meet
2001 nursing standards.
Commissioning arrangements are expected
to change with the publication of the
Neonatal Taskforce Report in June 2009.
It is unclear how the recommendations
will affect services, but is envisioned that
stronger commissioning should match
activity to remuneration better.
Activity is constant throughout the year at around 80% occupancy (including transitional
care (TC) beds; see graph below). ICU occupancy is greater, averaging >90%. Around
50% of admissions are to TC, which is a major area of activity for the service.
100
80
Percent occupancy
STRATEGY, AIMS AND OBJECTIVES
UCL EGA IfWH 1st Quinquennial Review
60
40
20
0
Jan
Feb March April
May
June
July
Aug
Sept
Oct
Nov
Dec
Occupancy 2008. Target for neonatal services – 70% (DH 2003)
Survival compares favourably with national data and other international centres of
excellence, for example, Karolinska in Sweden. We have published survival and morbidity
data (Riley K, Roth S, Sellwood M, Wyatt JS. Acta Paediatr 2008 97:159-65), a report which
prompted two leading articles (Lagercrantz/Fanaroff. Acta Paediatr 2008 97 142-3). Survival
has remained constant at 80% (74-90%) for births <29 weeks from 1998-2007. In 2008
survival was 23w: 50%; 24w: 67%; 25w: 93%; 26w: 87%; 27w: 70%.
21
NEONATAL MEDICINE – clinical
NEONATAL MEDICINE – clinical
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
Long-term outcome remains a major concern for survivors of in
particularly extreme prematurity. Angela Huertas-Ceballos heads
the NCLPN Follow-up Group as part of the South East Neonatal
Database project.
Outcome for babies born at <29 weeks in NCLPN demonstrates
close approximation to those in other reports with 43% of children
in 2003-4 showing normal outcome and only 9% with severe
impairment. (NCLPN Annual report 2007). UCH babies at 2 years
have 3% Severe disability, 18% with mild-moderate impairment and
48% free of impairment (21% lost to follow up).
100
• Leading development of European Neonatal Training
Curriculum and Assessment Framework (Neil Marlow).
CHALLENGES
• Developing a neonatal virtual learning environment (3rd
Leonardo da Vinci Fund application currently being considered
to roll this out under the aegis of ESPR and RCPCH).
Staff feedback is obtained through regular staff feedback surveys.
In 2008 we took part in a divisionwide staff survey. In 2009 we
carried out our own staff survey and results are currently being
analysed. An action plan has been based on the 2008 survey
results, which is in place, but impacts little on Neonatal Medicine.
High quality benchmarked outcomes
New EGA Wing The greatest challenge faced by the service in
2006-08 was the planned move to the new building. This was
accomplished smoothly and without incident due to exceptional
planning, clinical leadership and engagement. However, the new
accommodation requires time in which to establish protocols and
methodology. The challenge of the Private Finance Initiative (PFI)
contract has meant that these problems are not easy to solve
where infrastructure changes are required.
Quality Project
In this UCH project neonatal staff work closely with midwives and
obstetricians to identify and develop projects which will improve
quality of care and outcomes. Outputs are improved according
to mother feedback surveys and monitored with a scorecard.
The latter monitors key markers across the perinatal service,
for example, readmissions and unexpected admissions to the
postnatal wards are monitored regularly and Jane Hawdon is
currently designing an audit in response to data and issues raised.
EPICure 1 (1995)
EPICure 2 (2006)
UCH (95% CI; 2003–6)
80
User satisfaction data are collected by questionnaire from all
families after discharge. Results of discharges from the new unit
are not available. Our old unit suffered from cramped conditions
and relatively poor facilities for parents, which attracted comments
on a regular basis and should now improve. Staff are regularly
praised and rarely the subject of complaints.
60
%
40
PMET-B Trainees Survey
Neonatal trainees rate the experience they have at UCH very highly
against other areas of the Trust and other neonatal services
(http://reports.pmetb.org.uk).
20
Percentile rankings are as follows.
0
22 weeks
23 weeks
24 weeks
25 weeks
Gestational age at birth
Babies admitted for Intensive Care in England in 1995 and in 2006
compared to UCH 2003–6
Clinical audits 2008
• Management of patent ductus arteriosus (PDA): found in 57% of
infants born <29 weekd gestation, 81% received treatment, 8/36
(22%) had surgery. Action – move to prophylactic treatment.
• Abnormal abdominal X-rays (AXR): ongoing study correlating
AXR report to clinical course. When results were last reviewed,
44/48 AXR were reported to be abnormal, indicating
appropriate requests.
• Infection screens: 196/202 blood cultures negative, 4 infants had
no culture result (prompt for audit). Reasons are being explored.
• Jaundice and UTI: 0.6% of prolonged jaundice screens
showed evidence of UTI, emphasizing the rarity, but
importance of this cause.
• High serum sodium: hypernatraemia dehydration was found in
1:1000 deliveries (higher than published data). Increasing age
at presentation was associated with higher Na2+ level.
Contribution to external audit projects 2008
• National Neonatal Audit Project http://www.hqip.org.uk
• CEMACH
• NCLPN report and Standardised Electronic Neonatal Database
(SEND) project
• National Neonatal Surgical Survey (Taskforce/Royal College of
Surgeons (RCS))
22
Overall satisfaction
>75% (very good)
Clinical supervision
50-75%
Workload
<25% (i.e. very busy)
Handover
50-75%
EC working time compliant
100%
Adequacy of experience
near maximal
Educational supervision
50%
Feedback
50-75%
Induction
25%
Learning opportunities
50%
Bullying
0% (very low)
Work intensity
<25% (high)
AREAS OF EXCELLENCE
Leading the profession
• This key role is central to our practice at the Unit, hospital
network and national levels as described in other sections.
Individuals are involved in work of the RCPCH (Jane Hawdon,
Angela Huertas-Ceballos and Judith Meek), RCOG (Neil
Marlow and Janet Rennie), BAPM (Neil Marlow and Jane
Hawdon), NICE (Janet Rennie, Chair of Hyperbilirubinaemia
group, Jane Hawdon and Neil Marlow), NPSA (Neil Marlow),
NHS/DH Neonatal Taskforce (Neil Marlow), CEMACH (Neil
Marlow (Advisory Board), Jane Hawdon and Nikki Robertson).
• Janet Rennie is author of the principal UK Textbook of
Neonatology and a manual of care. Janet Rennie, Nikki
Robertson and Cornelia Hagmann have co-authored a new
textbook on Neonatal Cerebral Investigation.
• Published extremely low gestational age (ELGA) survival and
morbidity (see above)
• CEMACH data (see above)
Staffing
Unique clinical services
Nursing Recruitment and retention are key concerns within
neonatal intensive care services. Our current vacancies are
inhibiting the opening of the whole unit (we tend to have up to 5
beds closed on a daily basis). Strategies are in place to combat
this, which is a national issue, most acutely problematic in London.
Retention is improved by full staffing, which also releases nurses to
undertake personal development plans agreed at appraisal.
• Joint fetal medicine neurology clinic (Janet Rennie, Leigh Dyet
and Lyn Chitty). This is a unique service where parents are
rapidly seen by two experts following a referral in, with a ‘onestop shop’ regarding ultrasound diagnosis and counselling.
Genetic advice is usually available in the same clinic (Dr Alison
Male). If MRI is needed it is performed within a week, reported
by an expert within 24 hours and the result relayed to the
parents immediately afterwards. The service has been audited
with parent satisfaction questionnaires and comments were
highly favourable despite the difficult and emotive area. It is
the focus of a current NIHR bid to obtain accurate prognostic
information in collaboration with other neonatal neurological
services, led by UCH.
• Our multidisciplinary and holistic approach to follow-up
clinics for chronic lung disease and infant feeding, which
aims to address all aspects of need and minimise long-term
complications of premature birth. For example, feeding support
(speech and language therapy and dietetics), respiratory
therapy advice (respiratory specialist nurse) and integrated
developmental assessment and therapy.
Medical staff Consultant levels are appropriate for full cover of the
maternity and neonatal service during office hours, but increasingly
consultants are having to remain in hospital overnight or return
frequently, because of training grade staff vacancies, inexperience
of trainees, and casemix. Medical staffing is a national issue
in paediatrics and initiatives are underway to help resolve this,
although UCH is a popular destination for trainees, both for those
in National Grid Neonatal Training and for those who are not career
neonatologists. Changes in training and European Working Time
Directive (EWTD) have led to a reduction in trainee experience,
necessitating increased supervision. Strategies to improve the
experience of bedside medical support are required.
Leading clinical outcome research
• Longitudinal UCH cohort studies - the cohorts from UCH,
starting in the 1970s with the first outcome studies following
very preterm birth in the UK, whose earliest survivors are now
young adults. These studies provide valuable and unique
insight into the progress of preterm birth.
• National outcome studies of high international impact (EPICure
– two key papers cited 410 (Wood, NEJM 2000) and 272 times
(Marlow, NEJM 2005))
Developmental care
With one individual qualified NIDCAP Trainer and three more
staff in training as facilitators, we are preparing to integrate
developmental care more fully into our care bundles.
Engagement with community and global health
• Teaching and training of neonatal skills in Mulago Hospital,
Kampala, Uganda
• Published pilot of low-technology cooling for perinatal asphyxial
encephalopathy (Robertson Lancet 2008).
• Supporting perinatal charities (Best Beginnings, the Bobath
Centre (Judith Meek)
23
NEONATAL MEDICINE – clinical
NEONATAL MEDICINE – clinical
UCL EGA IfWH 1st Quinquennial Review
AHP and support staff Recruitment into these posts has not been problematical and we
have highly expert individuals in posts with specialist neonatal expertise. Receptionists are
more isolated within the new unit and higher levels of staffing are required to maintain the
entry-exit arrangements.
Funding
Commissioning the service has only recently changed to a more equitable footing compared to that in other London Neonatal Commissioning areas, but is not yet completely
competitive. The Neonatal Service should be a net ‘gainer’ from payment by results due
to high levels of activity and occupancy, but delays mean that that the introduction of
payment by results (PbR) may be delayed until after 2012. The Neonatal Taskforce Report
should result in better funding for the base service and support for data collection and
follow-up of high risk groups, but the impact of this will not be felt until 2010-11.
IMPACT AND IMPORTANCE
Neonatal care is one of the success stories of modern medicine. Over the past 25 years
neonatal mortality has decreased and survival at extremely low gestational ages is
continuing to improve. These changes are due to improvements in obstetric, as well as
neonatal care, due to improved team communication and coordination, and have been
generally evidence-based. Current practice is focused on enhancing the development of
babies admitted for neonatal care, and the family experience to ensure optimal outcomes
and minimise disability.
The Neonatal team at UCH has been at the forefront of advances in modern neonatal care.
It has pioneered therapies that have become central to the standard care of sick babies:
parenteral nutrition, ventilation strategies, fluid balance, neonatal cranial ultrasound,
transcutaneous blood gas monitoring, near-infrared spectroscopy, magnetic resonance
spectroscopy and therapeutic hypothermia.
We are continuing in the spirit that has had such significant impact on neonatal care to the
benefit of babies and their families. In addition to the two academic senior appointments
three consultants (Janet Rennie, Judith Meek and Angela Huertas-Ceballos) hold
Comprehensive Biomedical Research Centre (CBRC) PAs to encourage and protect
time for academic activity. We are currently setting up the facility to use xenon as
neuroprotection following asphyxial encephalopathy in a unique study funded by the MRC,
which will be a world first (Nikki Robertson). We have funded and are working to integrate
continuous video EEG into neonatal intensive care with the intention of trialling new
anticonvulsants and evaluating neural development (Janet Rennie and Neil Marlow). We are
evaluating the use of NIRS and single shot evoked potentials to improve understanding of
the preterm newborn’s response to noxious stimuli (Judith Meek).
24
UCL EGA IfWH 1st Quinquennial Review
Advances in MRI technologies (with the
impending introduction of a clinical and
research 3T Scanner) are being harnessed
to study longitudinal cohorts in new
neuro-developmental outcome studies
(Nikki Robertson and Neil Marlow) and to
investigate the fetal brain (Janet Rennie,
Lyn Chitty and Neil Marlow).
Furthermore, the long-term health of the
babies and their families is of paramount
importance. Much concern has been
expressed at the frequency of intellectual,
behavioural and physical problems
experienced by children born at very low
gestations. We have one of the longest
running follow-up programmes in the world,
now led by Angela Huertas-Ceballos,
and our department has made significant
contribution to the academic literature in
this area. In addition, we have organised
our care to optimise the outcomes for
these infants by assiduous attention to their
intensive care, growth and the use of the
Newborn Individualized Developmental
Care and Assessment Program (NIDCAP)
– kangaroo care to engage parents more
contructively in the care of their child.
There is robust evidence that neonatal
care produces the best outcomes when
organised hierarchically. We are providing
clinical leadership in this area at local level
(NCLPN), and nationally through BAPM
(Jane Hawdon and Neil Marlow) and the
Neonatal Taskforce (Neil Marlow). Janet
Rennie is leading the development of NICE
guidance in the management of neonatal
jaundice. Jane Hawdon has been a member
of NICE Guideline Development Groups
(GDG) for antenatal care, postnatal care,
diabetes in pregnancy and hypertension in
pregnancy, and was on the working groups
for Safer Childbirth and the CEMACH
Diabetes in Pregnancy Enquiry. Neil Marlow
is a member of working groups developing
professional guidance around termination
and fetal awareness (RCOG), following
on from the influential Nuffield Council for
Bioethics report into fetal and neonatal
practice (2007). He has contributed to
several RCOG Green-top guidelines, for
example, virus infections in pregnancy
and electronic fetal monitoring. He is also
on the Safer Neonatal Practice Board
(NPSA/RCPCH) and an investigator on the
Birthplace Project (www.NEPU.ox.ac.uk).
Neil Marlow is the current President of the
ESPR and of the IPRF and Tertiary specialty
representative at the European Academy of
Paediatrics (UEMS section of Paediatrics).
Nikki Robertson is Head of the ESPR Brain
Section.
These roles have important international developmental and service elements. In research
terms, centralising neuroprotective services should not only enhance clinical outcome, but
also allow academic study in detail utilising the state-of-the-art facilities we have at UCH.
We are also supporting the adaptation and introduction of developed world technologies,
such as neonatal life support (Mark Sellwood) and intentional hypothermia in sub-Saharan
Africa and India (Nikki Robertson and Sudhin Thayyil). We are working in partnership with
local investigators to try and translate some of the advances improving neonatal mortality
and morbidity elsewhere to places where this remains a huge issue.
FUTURE DEVELOPMENTS
Clinical
Capacity
The report of the Neonatal Taskforce will recommend further centralisation of intensive
care for extremely preterm and sick newborn babies. This has major capacity issues for
the UCH Neonatal Service, which is already working at full capacity. Careful collaboration
with commissioners, primary care and partner units within the network is critical to solving
these problems and will need to involve good fiscal planning.
Developing our Neonatal Neurology Service
We intend to develop the service based around the neuro intensive care cots. We would
seek a part-time consultant to lead and facilitate the service and give us critical mass to
do so. Such development is dependent upon adequate capacity as above. Goals of this
service would include providing a clinical investigative and diagnostic service, running
of clinical trials, identification of biomarkers for later impairments and it would be a joint
academic and NHS development.
Developing the microenvironment for the baby
Clinical practice will change as we become more facilitative and engage the baby more
as an individual. We have embraced the NIDCAP model to achieve this and have funded
training for three medical and nursing menbers of staff in addition to the one post we
have as a trainer. In the new EGA environment it is easier to develop such practices.
Organisational
Surgery
Transfer of sick small babies for neonatal
surgery is not an ideal practice. Neonatal
surgery was previously carried out at UCH
but this is a very low volume service and
maintaining anaesthetic cover proved difficult
leading to centralisation at GOSH. We wish
to repatriate this activity if at all possible,
as the care afforded babies requiring
emergency surgery would be enhanced by
on site care. Experience for the neonatal
staff would also be enhanced, both for
medical training purposes and nursing.
Combining with paediatric services, we may
be able to find a suitable solution, and we
are aware of support from both surgeons
and paediatric colleagues for this.
Administrative issues
The lack of combined office space
and separation of academic from NHS
colleagues leads to fragmentation of
all teamwork. Furthermore, there is little
resource available for NHS colleagues who
wish to undertake academic activity and
the lack of critical proximity threatens the
potential advances. Little academic space
is available in the unit, making support
of academic activity difficult. We need
to identify space to achieve appropriate
research activity.
Nursing developments
Enhanced nursing and midwifery roles are
essential if the service is to survive. Enhanced
responsibility encourages retention. Goals for
the Neonatal Service are as follows.
• Nurse-led special care
• Advance neonatal nurse practitioner
(ANNP) support for each shift to provide
continuity and training opportunities for
inexperienced medical trainees
• Midwifery-led examination of the newborn
• Achievement of Baby-friendly Status (WHO)
Medical staffing
The specialist nature of neonatal intensive
care and increasing inexperience of trainees
means that we do have to look at alternative
models of medical care. Devolving traditional
areas to nursing is a limited solution in light
of nursing recruitment difficulties. Sub- or
junior consultant grade development is being
piloted at present at Manchester Strategic
Health Authority (SHA) and is an area we will
need to evaluate.
We believe we have the talent and capacity
to remain one of the UK’s leading neonatal
services, providing leadership in professional
and research activity and developing a model
service over the next five years.
25
NEONATAL MEDICINE – clinical
NEONATAL MEDICINE – clinical
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
NEONATAL MEDICINE – RESEARCH
UCL has been at the forefront of perinatal brain research for over 30 years. In the late 1970s the team at University College Hospital
(UCH) first reported outcomes following ultrasound examination of the brain in the preterm baby, pioneering a series of highly focused
outcome studies based upon correlation with recognised patterns of ultrasound appearances, defining the risk of disability associated
with specific findings (Stuart, Arch Dis Child, 1983). This focus on the preterm then widened to include the term asphyxiated infant. In
1982 UCL clinicians and physicists acquired phosphorus-31 magnetic resonance (MR) spectra from a newborn infant, the first ever
from a human brain (Cady, Lancet, 1983; Hope, Lancet, 1984). These landmark studies contributed towards identification of the great
prognostic capability of magnetic resonance spectroscopy (MRS) (Azzopardi, Pediatr Res, 1989; Penrice, Pediatr Research, 1996),
the concept of a window following a hypoxic-ischaemic insult, during which cerebral energetics are preserved and therapy may be
possible. This led directly to the development of hypothermic neuroprotection for the newborn. Today therapeutic hypothermia is being
introduced into clinical practice and is an excellent example of laboratory-to-bedside translational research.
Our aims are currently focused around the following.
Medical Physics, UCL: Professor Roger Ordidge
• The study of hypothermic neuroprotection and other novel
neuroprotective agents that act additively with cooling in term
encephalopathy.
Department of Statistical Science, UCL: Dr Rumana Omar
• Application of neonatal neuroprotection in low and mid
resource settings, ensuring rigorous evidence base and safety.
• Automated EEG detection of seizures.
Research Areas
Research into perinatal brain injury and development, in particular using MR biomarkers,
has continued to thrive at UCL. Currently the research spans two main areas:
• in vivo models of neuroprotection (pre-clinical piglet and rodent models)
• clinical studies of the term and preterm infant, both mechanistic studies and clinical trials.
The application of MR imaging (MRI), MRS, electroencephalography (EEG) and near
infrared spectroscopy (NIRS) is common to both research areas, as per diagram below.
Preclinical focus
Clinical Focus
Xenon and hypothermia neuroprotection
Psychological outcome
Defining optimal temperature for
neuroprotection in brain injury
Image analysis and correlates
Physiological responses to pain
Role of inflammation
RCT into preterm delivery, fetal growth
restriction, SaO2 targets etc.
Melatonin and hypothermia neuroprotection
Piglet
Rodent
MRI
MRS
EEG
NIRS
Preterm brain and development
Term hypoxic-ischemic
encephalopathy and neuroprotection
Preconditioning for endogenous
neuroprotection
Inhaled Xenon trial
Pre-clinical model of seizures
Automated seizure detection
Cooling in low resource settings
Non-invasive autopsy
Two main areas of neonatal research
with projects and common techniques
Academic Leadership
Research lead for Neonatal Medicine is Dr Nikki Robertson, who is a Reader in an NHS
funded academic post. Since 2003 she has built a team of pre-clinical and clinical
researchers focused on the perinatal brain. Key group members include Drs Janet Rennie
(EEG), Judith Meek (NIRS) and Angela Huertas-Ceballos (Developmental Outcome),
each a Consultant Neonatologist with Comprehensive Biomedical Research Centre
(CBRC) funding (1 PA) (see Appendix 2.2 for further details of staff members). In 2007 a
search was made for a complementary established academic to build further the clinical
research profile at UCH. We were fortunate to attract Professor Neil Marlow, who is a senior
academic figure and a Fellow of the Academy of Medical Sciences, with an international
reputation for outcome studies in perinatal medicine, including large cohort studies and
focused explanatory neuropsychological studies, and wide collaboration in multicentre
randomised trials. He commenced in post in September 2008. He also assumes the role of
Deputy Director of the Institute for Women’s Health, working closely with Nikki Robertson as
the Research Lead.
26
Academic Neonatal Medicine was
awarded a Walport Lecturer in 2007, Dr
Giles Kendall, and two Academic Clinical
Fellow posts in 2007-08. Current research
team also includes one Lecturer in
psychology, one Senior Research Fellow,
two Research Fellows, one Neuro-imaging
Fellow, as well as a range of PhD, MSc and
other categories of students. The preclinical team comprises one Postdoctoral
Researcher and MR Laboratory Manager,
Dr Stuart Faulkner, and two neonatologists,
Drs Takenori Kato and Dorottya Kelen,
who are funded by external grants. These
members of staff are responsible for
maintaining 24-hour intensive care for the
model during experiments.
The group has produced a substantial
number of high impact clinical and
research publications and secured
significant external research funding. In
addition to the staff listed above, close
collaboration exists with Professors Donald
Peebles and Gennadij Raivich in the
Perinatal Neuroscience Research Group
in Maternal and Fetal Medicine, as well
as with a range of groups within UCL and
beyond, as specified in the section below.
STRATEGY, AIMS
AND OBJECTIVES
A critical body of expertise in the
evaluation of neonatal brain development
exists in a range of pre-clinical and clinical
settings at UCL and UCH. Against the
background of a longstanding culture of
research and enquiry and large research
programmes, the neonatal service fosters
an ethos of collaboration and facilitation for
research, supporting multicentre trials and
facilitating research with external groups
from the Institute of Child Health (ICH) and
other areas in UCL.
All India Institute of Medical Sciences: Dr Vinod Paul
Makerere University Medical School: Dr Margaret Nakakeeto
• Understanding of the relationship between preterm MRI
markers and outcomes.
2. Understanding neurocognitive outcomes for
preterm infants
• Investigating underlying psychometric deficits in relationship to
prematurity.
To determine patterns of brain injury using quantitative MRI in the
developing preterm brain and long-term consequences of these
patterns of injury.
• Developing a rational analgesic strategy in preterm babies.
• Evaluating the MRI as a postmortem tool.
OVERVIEW
Department of Biological and Environmental Sciences, University
of Helsinki: Dr Sampsa Vanhalato and Professor Kai Kaila
• Supporting outcome evaluations as part of multicentre
randomised trials of perinatal interventions.
To study the interactions between environment, genes and
outcomes in extremely and moderately preterm children.
To relate structure with function in the preterm brain and relate
these changes to perinatal risk factors.
Specific objectives
To understand the cortical processing of pain in preterm infants
and its neurological consequences.
1. Neuroprotection of term neonatal hypoxic-ischaemic encephalopathy
To measure the effects of analgesia and its potential for
neuroprotection.
To optimise hypothermic and pharmacological neuroprotection of
the newborn using our large animal pre-clinical model, currently
evaluating xenon neuroprotection and optimal temperature.
Collaborations include
To translate important advances observed in pre-clinical studies to
the clinical setting as quickly as possible.
To develop a closed-circuit neonatal ventilator delivering inhaled
xenon to babies for neuroprotection.
To develop robust MR biomarkers of outcome in term brain injury.
ICH: Professors Faraneh Varda-Khadem and David Gadian,
and Dr Michelle De Haan
UCL Centre for Medical Image Computing:
Professor David Hawkes
Department of Anatomy and Developmental Biology, UCL:
Professor Maria Fitzgerald
To develop automated seizure detection algorithms.
University of Nottingham: Dr Nicola Pitchford and Professors
Penny Gowland and Tomas Paus
To evaluate the use of hypothermia in low resource settings, such
as in Uganda, Malawi and India.
University of Warwick: Professor Dieter Wolke
NPEU, University of Oxford: Professor Peter Brocklehurst
Collaborations include
Institute of Neurology (IoN), UCL: Professors Xavier Golay,
Tarek Yousry and Francesco Scaravilli (retired)
Karolinska Institute, Sweden: Professors Hugo Lagercrantz
and Lars Olsen
University of Edinburgh: Professor Jane Norman
Queen Mary, University of London (QMUL):
Professor Kate Costeloe
University of Leicester: Professors David Field and
Elizabeth Draper
Institute of Child Health, UCL: Professor Anthony Costello
London School of Hygiene and Tropical Medicine:
Professor Diana Elbourne
Imperial College London: Professor David Edwards and
Drs Denis Azzopardi and Frances Cowan
National Perinatal Epidemiology Unit (NPEU), University of Oxford:
Dr Jennifer Kurinczuk
Industry: Air Products plc, SLE ltd, Climator Sweden AB
University College Cork: Dr Geraldine Boylan
3. The role of postmortem MRI of the fetus,
newborn and children
To compare the accuracy of whole body postmortem MR and
computed tomography (CT) imaging with those techniques
conventional in perinatal and childhood autopsy.
To study normal and abnormal fetal brain and heart development
using high field MRI at 9.4 T.
To develop MR detectable markers of hypoxic brain injury in a
postmortem setting.
Centre for Biomedical Imaging (CABI), UCL: Dr Mark Lythgoe
27
NEONATAL MEDICINE – reSEaRCH
NEONATAL MEDICINE – reSEaRCH
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
Collaborations include
Clinical MR studies
ICH: Drs Andrew Taylor, Neil Sebire, Tom Jacques and Angie Wade
We currently use a clinical 1.5T MR scanner on which we have
installed MRS. A 3 T MR scanner will be installed at UCH in 200910, jointly funded by CRBC and UCLH NHS Trust.
Heart Hospital, UCLH: Drs Perry Elliot and Petros Syrris
Department of Epidemiology and Public Health, UCL:
Professor Stephen Morris
University of Sheffield: Drs Elspeth Whitby and Marta Cohen
QMUL: Professor Susan Dilly
John Radcliffe Hospital, Oxford: Dr Waney Squire
University of Sydney: Drs Johan Duflou and Raj Puranik
4. To develop and determine childhood outcomes for perinatal clinical trials To design and run appropriate clinical trials
To support national and international multicentre trials
Clinical Studies Space
Neonatal Unit
Within the new EGA Wing Neonatal Unit we have identified three
cots for neurointensive care. EEG telemetry is currently being
installed with a server off site (Level 3). Together with the cooling
apparatus and the new recyclable gas ventilators in development,
these will form a dedicated service area to focus neurological
investigation and treatment in a unique venture. No academic
laboratory space is provided within the neonatal unit envelope.
NPEU, University of Oxford: Professor Peter Brocklehurst
University of Edinburgh: Professor Jane Norman
Office accommodation
Imperial College London: Dr Denis Azzopardi and Professors
David Edwards and Neena Modi
We are housed in Chenies Mews, which is substandard
accommodation (see Meternal and Fetal Medicine – Research for
further description and potential for change).
University of Nottingham: Professor Cris Glazebrook
International collaborators: Ikaria, Inc, Drs Lisa Askie, Martin
Offringa, Fillip Cools and Professor William Tarnow-Mordi
RESOURCES
Space and equipment
Pre-clinical model
Following closure of the old EGA Hospital in January 2009 preclinical studies were moved to the Institute of Neurology in a new
collaboration with Professors Tarek Yousry and Xavier Golay. A new
9.4T large-bore MR system has recently been installed and the
IoN have allowed us to temporarily use the laboratory and office
space in order to complete our funded studies, until an alternative
is found. We hope that longer-term collaborative links and common
funding will occur. Collaborations with IoN and National Hospital
MR physicists are likely to improve our MRI protocols.
Institue of Neurology in Queen Square
28
The pre-clinical rodent model has been used successfully
to evaluate the interaction between systemic inflammatory
responses and hypoxia ischaemia (Giles Kendall in collaboration
with Professors Peebles and Raivich). This has led to the
identification of the TNF family of cytokines as critical mediators
in the sensitisation of the neonatal brain to subsequent hypoxia
ischaemia. Additionally, Giles Kendall has studied the changes in
brain pH during and after a HI insult. These studies have led to the
assessment of potential novel neuroprotective strategies.
Outcome evaluation
clinical research evaluations take place in the setting of the routine
neonatal follow-up clinic (now sited in the ground floor outpatients
of the new EGA wing).
Collaboration with the Institute of Child Health gives access to the
neuro-psychological suite at the Wolfson centre (Professor Khadem
and Dr de Haan).
Current collaborations include
Professor Francesco Scaravilli (IoN) collaborates closely with the
group and supervises the morphology and immunohistochemistry
part of the work.
PERFORMANCE AND MEASUREMENT
OF QUALITY OF ALL ACTIVITY
1. Neuroprotection in term hypoxic-eschaemic
encephalopathy
Pre-clinical studies
Over the past five years Nikki Robertson has utilised and
developed the existing piglet model based around a new
portfolio of studies in close collaboration with Ernest Cady and
MR Physics. In particular the group has characterised the timing
and response of this model to defined hypoxic ischaemic insults
and are evaluating the effect different degrees of hypothermia.
Over the past two years we have characterised the additional
neuroprotection conferred by xenon gas inhalation in combination
with hypothermia as rescue treatment as a prelude to an already
funded clinical trial to commence in the Autumn as a collaborative
venture with Imperial College London (MRC). With the support
of a private donation, Nikki Robertson is developing a closed
circuit xenon neonatal ventilator with the close collaboration of Air
Products plc, SLE Ltd, UCL and Imperial College.
Experimental studies remain on target despite the disruption of
a laboratory move in January 2009. Nikki Robertson’s group now
utilises the new IoN 9.4T MR research facility with adjacent
space and equipment for animal preparation and care and has
developed a modified model using intermittent MR observations in
addition to other multimodal neuro-monitoring (NIRS, EEG).
The primary outcome measures for these studies of
neuroprotection are quantitative MR measures (bridging
biomarkers) and brain histopathology and immunohistochemistry.
Clinical studies
The clinical MR service runs with the support of Giles Kendall
and the neuroimaging fellow. We currently use the UCH 1.5T MR
scanner and have an allocated ½ day of scanning time. Clinical MRI
reporting is by Dr Roxanna Gunny (Pediatric Neuroradiologist). Our
main interest is in quantitative MRI (brain-water T2 relaxometry and
diffusion) and MRS. Since 2005, term encephalopathic infants who
have had quantitative clinical MRI are currently under follow-up.
Clinical service and academic development
The equipment and space for the dedicated neuro-intensive care
cots are in place. EEG telemetry is in place and remote server
connection is being made (Jannet Rennie). We have appointed a
dedicated EEG technician and are participating in an automated
seizure detection study in collaboration with University College
Cork (Wellcome Trust). Clinical reporting of EEG is through UCH
Department of Neurophysiology and Dr Ronit Pressler (ICH) is
supporting the research aspects of neurophysiology.
Global Health
The feasibility pilot RCT of therapeutic hypothermia led by Nikki
Robertson in Uganda has drawn attention to the facts that NE is
10-20 times more common in low resource settings than in the UK
and that we cannot directly translate results from the developed
world to low resource settings (Lancet, 2008). Nikki Robertson
continues to work closely with the Ugandan colleagues and Drs
Frances Cowan and Nikki Robertson will visit Uganda in May 2009
to follow up infants entered in this study. Plans for a collaboration
with Indian colleagues were formalised with Sudhin Thayyil during
a visit in April 2009, with feasibility studies starting in May 2009
at the All India Institute of Medical Science and Calicut Medical
College, Kerala.
2. Understanding neurocognitive outcomes
for preterm infants
Longitudinal study of outcome following preterm birth
Professor John Wyatt continues a close collaboration with the
Institute of Psychiatry in the adult evaluation of very preterm
survivors. This is a productive partnership continuing the work of
the late Dr Ann Stewart. Since 2005, Nikki Robertson has led the
recruitment of a cohort of approaching 100 very preterm children
who have had scans at term-equivalent age with T2 relaxometry
(Cornelia Hagman) and other quantitative MR measures; we are
currently acquiring follow-up information (Angela Huertas-Ceballos,
Neil Marlow and Sam Johnson).
The recent arrival of Neil Marlow at UCL in September 2008
has strengthened our portfolio of neurodevelopmental outcome
studies. Professor Marlow is conducting a range of studies, which
are transferring their focus to UCL, including the internationally
renowned EPICure studies of outcome following extremely preterm
birth (NEJM 2000, 2005), with papers in the top decile of ISI Web
of Science citations. EPICure has recently been recognised by the
MRC as having Programme status and will come up for renewal
in 2011. The team based at UCH has provided essential original
studies in this area and the EPICure study is an internationally
renowned study in this area which has underpinned national
guidance (BAPM 2009) and major national reports (Nuffield
Council on Bioethics 2007; Parliamentary Science and Technology
Committee report 2008) and thereby influences local and national
policy in terms of clinical practice and organisation of care.
Professor Marlow further collaborates with a team at the
University of Leicester in the NIHR funded LAMB study – a cohort
investigation of outcomes following moderately preterm birth.
Other cohorts
Neil Marlow is a PI on the National Birthplace Study – a SDO and
DH funded evaluation of the safety of different places of birth such
as home birth and midwifery led units.
Investigating outcomes for preterm children
Detailed studies of psychological development following very
preterm birth are critical to understanding the pathways of
aberrant or delayed development for which interventions have
been designed to ameliorate the developmental disadvantage
of preterm birth. Trials of postnatal intervention are ongoing
and new areas of targeting under development. Application of
neurophysiologic measurements of cortical processing will be
related to outcome and used to further develop brain-orientated
intensive care.
We have established collaborations with Professor Khadem and
Dr de Hann (ICH), who are investigating in particular the
development of hippocampal function in relation to prematurity,
and with Prof Janet Stocks in investigating respiratory outcomes
as part of the EPICure 2 study. Neil Marlow has studies of
middle childhood outcome in relation to MRI evaluation of brain
29
NEONATAL MEDICINE – reSEaRCH
NEONATAL MEDICINE – reSEaRCH
UCL EGA IfWH 1st Quinquennial Review
development still ongoing in collaborations at Nottingham. Neil
Marlow and Dr Sam Johnson are piloting new investigations of
neuro-psychological development in childhood in relation to fetal
growth restriction and MRI measures of brain development. With
Dr Johnson he will continue to develop these areas in the new
setting of UCL in collaboration with the fetal medicine department
and with Neuoropsychology (ICH). These studies complement
Professor Peebles’ studies into inflammatory markers and bacterial
16S-DNA detection, which will form the basis for a new set of
cohort studies evaluating the basis of inflammatory influences in
Brain development.
Pain Physiology
Judith Meek has an established research profile with NIRS
and close collaboration with Professor Maria Fitzgerald in the
investigation of pain physiology. Recent research includes
spatial resolution of spectroscopy signals, and the use of NIRS
in functional and optical imaging investigations. More recent
investigations include the use of NIRS and single shot evoked
potentials in assessing cortical responses to pain in preterm
babies as part of a large MRC-funded project.
3. The role of MRI in perinatal and childhood
post-mortem
Dr Sudhin Thayyil and Nikki Robertson are pursuing studies of
postmortem MR microscopy work. Over 400 cases have been
studied so far and we are confident of completing the 600 cases
stipulated by the DOH. In a tangential study, 9.4 T MR microscopy
will be used to study whole body (200 micron resolution) and fixed
brain (basal ganglia, cortex and water shed areas) and whole
heart (18 - 25 microns resolution).
4. Trials
Neil Marlow has wide experience in running and outcome
evaluation of randomised trials for example developmental
interventions (APIP, PIP) and of High Frequency Ventilation (UKOS:
NEJM 2004). Such studies require the determination of longerterm outcomes to detect effects or persistence of effects and he
has acquired significant expertise in these areas. Recent projects
include 7-year outcomes for the ORACLE Children’s Study (MRC
with University of Leicester: Lancet 2008 – two papers), teenage
outcomes of negative extra-thoracic pressure trials (Neil Marlow
PI: Lancet 2006), total body hypothermia (TOBY; MRC with Imperial
College/NPEU: revision submitted to NEJM), delivery timing in fetal
growth restriction (Neil Marlow Co-CI; MRC GRIT Outcome Study).
In addition Professor Marlow and Dr Johnson provide training and
QA for outcome evaluations for a wide number of trials. The close
collaboration with the NPEU has been particularly fruitful. Current
RCT evaluations are undertaken with a wide range of collaborators
including:
the NPEU (BOOST-II UK (Neil Marlow PI; CI: Brocklehurst), the
TOBY Follow up study (Neil Marlow PI, CI: Azzopardi Imperial
College), the TOBY register (lead Azzopardi Imperial College),
PROGRAMS (Neil Marlow PI, CI: Modi Imperial College)),
the University of Edinburgh (OPPTIMUM Neil Marlow PI, CI
Norman),
30
UCL EGA IfWH 1st Quinquennial Review
Markers of academic esteem
Clinical 3T MR system
Nicola Robertson – Honorary Secretary
Neonatal Society until 2009, Lead for
Brain and Development Section, European
Society for Pediatric Research.
The installation of a multinuclear 3T MR system at UCH is critical for the continuation of
world-class neonatal MR research at UCL. Over the last 2 years, the working group has
made progress obtaining CBRC funding for 50% of the project and is awaiting a decision
on UCLH support for the remainder.
Space
NeoPROM (first neonatal prospective IPM of oxygen saturation
target trials in USA, UK, Canada, Australia and New Zealand (CI
Lisa Askie, Sydney).
Neil Marlow – FMedSci, NIHR senior
investigator, Chair Neonatal Taskforce WG,
Past President BAPM, President ESPR,
President IPRF, Honorary Life Friend BLISS,
Chair of organising committee for Perinatal
Medicine 2008.
AREAS OF EXCELLENCE
Janet Rennie - Honorary FRCOG, Chair of
NICE guideline development committee on
neonatal jaundice.
The University of Cambridge/AMS Amsterdam (TRUFFLE Neil
Marlow PI, CI: Lees/Wolf))
Ikaris (industry-funded EUNO trial, Neil Marlow Consultancy)
University of Sydney (Australian Placental Transfusion Trial, Neil
Marlow International CI)
PreVilig (an individual patient meta-analysis (IPM) of High
Frequency Ventilation Trials (CI Martin Offringa (Antwerp)/Lisa
Askie (Sydney))
Peer reviewed journal publications
Since 2004 > 100 publications from the pre-clinical studies, clinical
brain research and neurodevelopmental follow-up studies (of
which 3 Lancet, 2 New England Journal of Medicine, 2 Annals of
Neurology, 1 Brain and 1 Radiology). Please see the Publications
Booklet for the full list and end of Neonatal Medicine – Research
section for details of the key 10 publications.
Research funding
More than £2 million has been awarded in grants related to preclinical and clinical brain research at UCL (Nikki Robertson: PI).
Professor Marlow brings a substantial number of individual (>£3.5
million) and collaborative grants related to neurodevelopmental
outcomes. Judith Meek is a co-applicant on an £800,000 MRC
grant evaluating pain in infancy and a further £75,000 in completed
projects. Janet Rennie is a co-applicant on a large Welcome Trust
grant (£580,000) shared with University College Cork (please see
Appendix 2.1 for details of all grants).
Books
Roberton’s Textbook of Neonatology, ed. Rennie JM Elsevier 2005
Neonatal Cerebral Investigation, ed. Rennie JM, Hagmann C,
Robertson NJ. Cambridge University Press 2008
A recent review concluded:
“This is a wonderful book… reflecting the academic experience
of senior neonatologists. I can think of no comparable book in the
U.S. While Volpe’s Neurology of the Newborn… is more comprehensive, it does not equal this book in its clinical approach or the
quality of the imaging or figures. Other neuroimaging texts… do
not have the clinical depth of this book.”
Doody’s Book Review Service. Jay Goldsmith.
Teaching: courses
We have run neonatal cerebral ultrasound courses annually until
2007. This was restructured and run in 2008 as Neonatal Cerebral
Investigation. The course was over-subscribed and rated as
excellent and will run annually.
Ernest Cady: FInstP, past president
European Society for Magnetic Resonance
in Neuropediatrics, Health Professions
Council Partner.
CHALLENGES
We require space adjacent to the EGA neonatal unit to facilitate neonatal neuro-assessment using developmental habituation protocols and space yet to be identified within
the Institute suitable for clinical assessments. These facilities are critical if we are to take
forward hypothesis-based outcome research and effectively study the neuropsychological
development of the newborn infant and child. The outpatient setting within the NHS is already maximally occupied. Further issues about the quality and availability of office space
are addressed under Maternal and Fetal Medicine: Research.
IMPACT AND IMPORTANCE
Fulfilment of reproductive potential with a normal, healthy baby is the desired outcome
for most women and men. We have aligned neonatal medicine with women’s health to
encourage a perinatal focus and to acknowledge the importance of the ultimate fulfilment
for a woman. Clinical proximity and dependency work hand-in-hand with research practice.
Pre-clinical MR system
The key problem faced in the last three
years has been the uncertainty about
the pre-clinical MR system. In 2006, the
15-year old 7T magnet needed essential
maintenance to reduce helium boil-off and
internal icing; an upgrade to a new Linux
based operating system was also required.
The repairs and upgrade were achieved,
however delay in re-energising the magnet,
which was only stabilised at 4.7 T, delayed
funded projects by 6 months. We made
excellent progress in 2007/8, although in
the summer of 2007 the supply of piglets
transiently stopped due to foot and mouth
disease.
In 2007 the lease by UCL of the UCH
MR laboratory space in the EGA Hospital
terminated; we negotiated an extension
until funded research was completed.
Due to the forthcoming demolition of the
old EGA Hospital we again negotiated a
further extension from UCH until December
2008 when the xenon pre-clinical
neuroprotection study was completed.
The tight deadlines meant that the team
had to work very hard to complete all the
experiments before the move.
We are very fortunate now to have
access to the IoN new 9.4T MR system,
provisionally for only 2 years, which has
necessitated a change in model (see
above).
Sir William Ramsey, discoverer of xenon
and Professor of Inorganic Chemistry at
UCL 1887–1913
Dr Faulkner next to prototype xenon
ventilator in pre-clinical piglet MR
laboratory
Asphyxia
NE occurs in 0.5 to 4.0 per 1,000 live births and accounts for a substantial proportion
of admissions for neonatal intensive care. Following this potentially catastrophic end to
pregnancy, 10-15% of cases will die in the neonatal unit and up to 40% will have other
significant severe disabilities including cerebral palsy (10-15%) blindness, deafness,
global cognitive impairment, or problems with cognition, memory, fine motor skills and
behaviour. The financial and human costs to parents, professionals and wider society are
enormous, including the cost of litigation. Research into the prevention and treatment of NE
is therefore of importance; the introduction of the first effective therapy (hypothermia) for
NE is very exciting.
31
NEONATAL MEDICINE – reSEaRCH
NEONATAL MEDICINE – reSEaRCH
UCL EGA IfWH 1st Quinquennial Review
The focus of research in Academic
Neonatal Medicine is to address this
problems working to understand and
enhance the first successful treatment
for NE. Rapid recognition and effective
treatment of symptoms may be as
important and our work on seizure
detection and eventually treatment is key
to this area. We are well placed to lead in
this area having pre-clinical and clinical
research, together with our ambition to set
aside cots specifically for treating babies
with neurological conditions.
Preterm birth is a major health problem
in the developed world, in particular in
the UK where preterm birth is increasing
in prevalence. The cost to the public
sector has been estimated at ~£3 billion.
Although 7.2% of all births are preterm,
this group incurs 10.2% of all costs which
comprises significant additional cost. In
particular the health burdens are greatest
in children born below 30 weeks (1%
births) in whom the risk of serious disability
is very high (up to 40% have learning
problems or cerebral palsy). The burden
falls not simply on the family or the health
service but also on the educational sector
as learning difficulties and behavioural
problems become more prevalent with
age. Finding interventions that may prevent
the sequelae of very preterm birth is
challenging and has proved difficult to
study in terms of developmental support.
The current focus on establishing robust
biomarkers for these later impairments to
shorten the turn around time for studies
of neonatal interventions is critical; this
is ongoing work we are carrying out.
Furthermore, Neil Marlow has led several
studies of developmental interventions,
which may provide additional targeted
benefit for very preterm babies and their
families. We also have unique expertise
in the neurophysiology of pain and
will continue to develop techniques for
quantifying cortical responses which
will lead to an understanding of the role
of pain in adverse neurodevelopmental
outcomes of prematurity and thus to
methods of minimising its impact. Smaller
more pragmatic studies into the use, for
example, of Kangaroo Care and other
developmental interventions in the neonatal
unit will allow us to continue the refine care
and thereby outcome.
Autopsy has a crucial role following
perinatal, childhood and adulthood deaths,
but its uptake has declined in recent years
following high profile adverse publicity.
32
UCL EGA IfWH 1st Quinquennial Review
In ~30% of terminations, autopsy
information can change the recurrence
risks advised to parents. Advances in
early antenatal diagnosis have increased
the number of pregnancy terminations in
the past decade and perinatal autopsy
provides important quality assurance for
such programmes. Additional findings,
unknown before death, are reported at
autopsy in up to 50% of neonatal and
paediatric deaths: in 10% of these cases
the additional diagnosis could have
prevented fatality if known earlier. this may
impact future reproductive strategies for
couples.
Only a few such facilities exist worldwide
and there are none in Europe giving the
potential for partnership with industry,
strengthening UCL translational research
and complementing the current CABI
equipment.
FUTURE
DEVELOPMENTS
Capacity for large animal research
One outstanding issue is the need for
space and financial resources to set up
a pre-clinical MR laboratory so that the
piglet work can continue. In 2008, Nikki
Robertson discussed the need for a clinical
MR system suitable for pre-clinical research
and can see an opportunity for setting this
up in collaboration with Professors Tarek
Yousry and Xavier Golay (IoN) and Andrew
Taylor (cardiovascular research, ICH).
We envisage such a system being used
to i) develop and test devices used in
angiographic interventions and assess
their impact (MR); ii) develop devices
for use in MR interventions but need
to be controlled angiographically;
iii) pharmacological neuroprotection
in term asphyxial encephalopathy and
iv) stem cell repair after hypoxic-ischaemic
injury. We would like to set up a hybrid 3 T
MR-digital subtraction angiography (DSA)
suite that mirrors the Great Ormond Street
Hospital and National Hospital facility and
is capable of holding large animals.
Development of biomarkers relevant to preterm
neurological and psychological outcome
Our dedicated neuro-cot facility at UCL is the first in the UK;
staffing will be the key challenge to overcome to enable cot
availability at all times. In parallel with this we wish to further
understand the complex causal chain of pre-disposing factors,
exposures and events which result in NE with the ultimate
translational aim of developing novel preventive or ameliorative
strategies. We are collaborating on a new study involving CEMACH
(Confidential Enquiry into Maternal and Child Health), Imperial
College and the NPEU that will be the first population based study
of NE risk factors.
This aims to shorten the time to develop new interventions and
strategies operative in the antenatal and postnatal environment.
The installation of the 3T MR system at UCH will allow the
development of prospective serial MR studies to assess brain
growth trajectories in preterm infants and outcomes. The
collaborative team we have assembled to study these areas is
well placed to lead UK research in this area.
Extension of hypothermia into less developed clinical settings
Non-invasive autopsy and the use of
MR in particular are important means of
improving the acceptability of postmortem
examinations which we are currently
evaluating.
Randomised trials are the bedrock of
evidence-based medicine. We have
facilitated many such trials and are
working to improve the quality of outcome
evaluations. Increasingly as gains from
trials become smaller, refining trials and
outcomes is key to more rapid turnaround
and successful results. We are and will
continue to be well placed to work within
this area as part of the perinatal community
to deliver the best care for our patients.
Development of a new clinical model for the provision of
neuroprotective therapies for the newborn infant
Tesla MR system at Queen Square used
in the pre-clinical work
Within the setting of multicentre RCTs in Africa and Asia, Nikki
Robertson will lead the initiative to establish whether therapeutic
hypothermia for moderate to severe NE is safe and effective.
These investigations also provide the opportunity to assess factors
associated with morbidity and mortality in infants undergoing
therapeutic hypothermia and to evaluate appropriate methodology.
Nested explanatory studies will study potentially important risk
factors such as the presence of chorioamnionitis and/or funisitis,
early sepsis determined with both conventional laboratory and
molecular methods and genetic variation in candidate genes
that encode putative mediators of brain injury associated with
altered risk of poor outcome after adverse perinatal events. NIKKI
ROBERTSON led the submission of a trial outline to the MRC to
study populations in sub-Saharan Africa and together with ST has
developed new collaborations through the All India Institute of
Medical Sciences (AIIMS) and Calicutt Medical College.
Pre-clinical research in the next
three to five years will be focused
on characterising and developing
endogenous neuroprotective strategies
such as optimising neuroprotection by
ischaemic pre-conditioning in which brief
non-lethal ischaemia episodes confer
protection against a subsequent period
of lethal ischaemia. Dr Robertson’s new
collaborators in this area are Professors
Derek Yellon and Raymond MacAllister,
who have experience of pre-conditioning
in myocardial reperfusion injury. Nikki
Robertson also aims to use the piglet
model to define anticonvulsant drug
efficacy and toxicity for neonatal seizures.
New collaborators include Dr Geraldin
Boylan (University College Cork) and
Dr Sampsa Vanhatalo (Helsinki).
Further development of the rodent model
will facilitate short and long term functional
assessment alongside MR evaluation
and histological outcome. Using these
techniques, this model will be used to
explore molecular mechanisms of perinatal
brain injury and to evaluate a variety of
neuroprotective agents both in isolation
and in combination.
Identification of specific underlying developmental
trajectories and impairments
This will facilitate the development of targeted interventions in
these areas of executive function; we have ongoing studies, which
will identify such functional impairment and experience to develop
trials of interventions. Further evaluations of the EPICure cohorts
(1995 and 2006) are planned and NM/SJ are co-applicants on a
FP7 application to study model of care and its influence on 7 year
outcomes across 10 European regions.
Neurophysiology
The continued pioneering of techniques to measure functional
evoked responses in awake infants will further increase our
understanding of these trajectories and enable us to develop and
test interventions to minimise damage due to the adverse sensory
environment of intensive care.
Neonatal seizures
Current research applications will bring close collaboration in the
field of evaluation of neonatal anticonvulsants through a range of
pre-clinical and clinical trials (EU FP7 application).
Evidence-based medicine
We already have expertise and track record in meta-analyses
(both individual patient data meta-analyses and diagnostic study
analyses). We aim to develop and expand our focus on this
important area of research. JMR is leading a current NIHR bid to
a call to study antenatal MRI and outcomes in CNS abnormalities.
Phase 2 of Less Invasive Autopsy Study
The clinical roll-out of our current autopsy work is the next phase
(Sudhin Thayyil). This will be a multicentre study evaluating
clinical benefits, cost-effectiveness and acceptability of a step
wise less invasive autopsy with whole body MR and CT imaging
and endoscopic biopsy, in cases where conventional autopsy
is refused by parents (NIHR programme grant – registration of
intention (ROI) submitted in March 2009).
Ugandan doctors performing cranial ultrasound as part of the
pilot therapeutic hypothermia project
33
NEONATAL MEDICINE – reSEaRCH
NEONATAL MEDICINE – reSEaRCH
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
TEN KEY NEONATAL MEDICINE PUBLICATIONS AT IfWH 2004–09
Kenyon S, Pike K, Jones DR, Brocklehurst P, Marlow N, Salt A,
et al. Childhood outcomes after prescription of antibiotics to
pregnant women with spontaneous preterm labour: 7-year followup of the ORACLE II trial. Lancet 2008;372(9646):1319-27.
This long-term follow-up study of children who took part in the
ORACLE II trial of antibiotics for preterm labour in the presence of
intact membranes found an unexpected increase in children with
any functional impairment who were exposed to erythromycin. A
number of pathways are suggested; this study adds weight to the
argument that we must be vigilant about interfering with systems
we poorly understand.
Marlow N, Wolke D, Bracewell M, Samara M, Group. ES.
Neurologic and developmental disability at six years of age after
extremely preterm birth. N Engl J Med 2005;352(1):9-19.
This is a unique study describing the increased level of impairment
at school age faced by extremely preterm infants born in 1995
compared to standarized norms in the United Kingdom and
Ireland.
Gluckman PD, Wyatt JS, Azzopardi D, Ballard R, Edwards AD,
Ferriero DM, Polin RA, Robertson CM, Thoresen M, Whitelaw A,
Gunn AJ. Selective head cooling with mild systemic hypothermia
after neonatal encephalopathy: Multicentre randomised trial.
Lancet. 2005;365(9460):663-70.
This was the first large randomized clinical trial of selective head
and whole body cooling for neonatal encephalopathy; the data
were particularly encouraging in infants with moderately abnormal
amplitude integrated EEG abnormalities at randomization.
Therapeutic hypothermia (whole body) is now being introduced as
standard therapy for term infants with neonatal encephalopathy.
Robertson NJ, Nakakeeto M, Hagmann C, Cowan FM, Acolet D,
Iwata O, Allen E, Elbourne D, Costello A, Jacobs I. Therapeutic
hypothermia for birth asphyxia in low-resource settings: A pilot
randomised controlled trial. The Lancet. 208; 372(9641):801-3.
This study suggested that therapeutic hypothermia with wholebody cooling, screening, informed consent and randomization
are feasible and inexpensive in a special-care baby unit in a
low-resource setting. The study also suggested that rigorous
randomized trial to determine the safety and efficacy of therapeutic
hypothermia in this context are urgently needed so that any
benefits of cooling are reached in areas of the world that might
need it.
Iwata O, Thornton J, Sellwood M, Iwata S, Sakata Y, Noone M,
et al. Depth of delayed cooling alters neuroprotection pattern
after hypoxia-ischemia. Ann Neurol 2005;58(1):75-87.2000;343(6)
(378-84).
This study suggested that different temperatures provide different
degrees of neuroprotection and that different parts of the brain
may respond best to varying levels of cooling.
34
Thayyil S, Robertson N, Scales A, Sebire N, Taylor A. Parental
consent for research and sudden infant death. Lancet.
2008;372(9640)(715).
Post-mortem research is crucial to understanding cases of
sudden, unexpected death in children, nevertheless, following
organ retention scandals and subsequent changes to Human
Tissue Authority Act, such research had virtually become nonexistant in the UK, due difficulties in obtaining parental consent.
In a bid to reverse this trend, we developed the first successful
prospective telephone consenting model in the UK, using specialist
nurses, and achieved over 90% consent rates for post-mortem
research; more importantly newly bereaved parents considered
such participation as a highly positive experience.
Hagmann C, de Vita E, Bainbridge A, Gunny R, Kapetanakis
A, Chong W, Cady EB, Gadian D, Robertson NJ. MRI T2 is an
objective measure of cerebral white matter signal abnormality in
preterm infants at term equivalent age. Radiology 2009; in press.
Robust surrogate biomarkers of outcome are needed to be able
to efficiently assess interventions in the preterm infant; this study
is a first step toward validating a quantitative biomarker of preterm
brain white matter signal abnormality on magnetic resonance
imaging.
MATERNAL AND FETAL MEDICINE
NEONATAL MEDICINE – reSEaRCH
UCL EGA IfWH 1st Quinquennial Review
Thayyil S, Cleary JO, Sebire NJ, Scott R, Chong WK, Gunny
R, Owens C, Olsen O, Offiah A, Parkes HG, Chitty L, Price AN,
Yousry T, Robertson NJ, Lythgoe MF, Taylor AM. Less Invasive
Autopsy: Initial Experience Using High-field 9.4T. Lancet in press
We acquired the first whole body “Virtual Microscopy” images
using high field post-mortem MR imaging at 9.4Tesla in human
fetuses. This technique would not only provide an accurate method
for “Less Invasive Autopsy”, but also may significantly advance
our current understanding about fetal malformations, particularly
relating to heart and brain.
Iwata O, Iwata S, Bainbridge A, De Vita E, Matsuishi T, Cady
EB, Robertson NJ. Supra- and sub-baseline phosphocreatine
recovery in developing brain after transient hypoxia-ischaemia:
Relation to baseline energetics, insult severity and outcome.
Brain. 2008;131(8):2220-6.
This paper demonstrates that baseline brain energetics may
influence tolerance to ensuing transient hypoxia-ischaemia
and describes biomarkers of outcome within a few hours of
resuscitation. This is an important concept and may have relevance
for understanding mechanisms and pathways related preconditioning, which can be detected clinically.
Marlow N, Hennessy EM, Bracewell MA, Wolke D. Motor and
executive function at 6 years of age after extremely preterm birth.
Pediatrics. 2007 Oct; 120(4):793-804.
This paper describes the motor and executive function of children
born extremely preterm at the age of 6 years.
35
UCL EGA IfWH 1st Quinquennial Review
MATERNAL AND FETAL MEDICINE – CLINICAL
MATERNAL AND FETAL MEDICINE
OVERVIEW
The maternity services at UCLH provide
high quality, safe, accessible and equitable
care to women and their families. The move
to our new state-of-the-art accommodation
has provided the opportunity to redesign,
evaluate and improve the service provided.
Current organisational
structure
Rekha Bajoria
Ratna Chatterjee
Anna David
Debbie Gould
Maternity services are led by Susan
Sinclair, Divisional Manager, Tim Mould,
Clinical Director, Debby Gould, Head of
Midwifery, Pranav Pandya, Obstetric Lead,
and Sue Beatson, Divisional Senior Nurse
(Appendix 3.1). In addition, there is a
robust statutory framework for midwifery
supervision which acts as an independent
monitor of maternity services.
STRategy, aims and
objectives
Joyce Harper
Joseph Iskaros
Pranav Pandya
Melissa Whitten
36
Patrick O’Brien
Eric Jauniaux
Donald Peebles
Gennadij Raivich
David Williams
Our aim is to be internationally recognised
as a centre of clinical and academic
excellence in maternity services. We are
committed to providing services that
are woman-focused and family-centred.
This commitment is to both high quality
midwife-led services for low risk women
and excellence in maternal and fetal
medicine for women with known risk
factors at booking or those who develop
complications in pregnancy.
The Health Care Commission (HCC)
Audit in 2007 highlighted concerns about
maternity care in London. In recent
years London’s maternity services have
experienced a rising birth rate, higher rates
of multiple births, more obese women,
an increase in social and ethnic diversity,
leading to a more complex case mix and
an increase in the number of Caesarean
section (CS). In addition, stillbirth and
perinatal mortality rates were above the
national average. In response to this report
and national targets set by the Department
of Health (DH), we have identified key
objectives to ensure high quality midwifeled services and excellence in maternal
and fetal medicine for the challenging case
mix of women we now care for.
UCLH is committed to providing good clinical and psychological outcomes for the woman
and baby and seeks to achieve this by the following.
Leadership and communication
We have created a leadership structure through the Quality Project that is unambiguous,
with clear reporting lines to ensure safety. The Quality Project was a venture supported by
McKinsey, a management consultancy firm, in order to review maternity services following
publication of the HCC report. Various areas of the maternity service were then reviewed
and processes put in place to improve the quality of care and the experience of our
patients and staff. In addition we have established the maternity leads group to ensure the
dissemination of a single vision for maternity services.
Facilitating direct access to services
The evidence suggests that early access to maternity services can improve outcome. We
will continue to promote early booking at 8 to 10 weeks gestation, which will ensure all
women have access to screening services, if they wish. However, one of the challenges
facing us is that the most vulnerable and excluded families in our society often access
services late or lose contact. We are committed to improving the health and well-being of
these families and are linking in with community projects, such as Sure Start, to develop
strategies that will enable us to identify these women and overcome barriers to access.
Providing individualised and flexible service
We have developed a service that is sensitive and responsive to women’s needs. This
has been achieved by the co-location of maternity services, extended hours of service
and service redesign to support multidisciplinary working. For example, the preterm birth
clinic provides obstetric, midwifery and ultrasound expertise in a single appointment within
the Maternal Fetal Assessment Unit to minimise number of appointments and maximise
specialist input. This is integral to our philosophy of care in maternity services.
37
MATERNAL AND FETAL MEDICINE – clinical
MATERNAL AND FETAL MEDICINE
UCL EGA IfWH 1st Quinquennial Review
Facilitating normal birth – home,
birth centre or labour ward
Increasing continuity of care
Continuity of care will be improved by
the introduction of team midwifery. It is
anticipated that by June 2009 all women
choosing UCLH will be cared for by a
midwifery team.
Advocating choice
We will ensure that all women are active
partners in their care through the provision
of choice. This will include choice in how to
access services, place of birth, analgesia
in labour, including use of immersion in
water and choice of postnatal care.
Reducing maternal and perinatal
mortality and morbidity
High risk obstetric services at UCLH have
pioneered the development of fetal and
maternal medicine at a local, national and
international level for many years. Today
we remain at the forefront of clinical and
academic excellence within this specialty
and our large multidisciplinary team
provides a comprehensive and integrated
clinical service. We offer rapid access
to multidisciplinary expertise when a
pregnancy is identified to be at increased
risk. For example, a woman with a fetus
thought to have congenital heart disease
will be assessed and counselled in our
combined cardiology clinic. In addition,
we are improving pregnancy outcome
by continuing to develop and implement
advances in maternal and fetal medicine,
for example, non-invasive prenatal diagnosis
and new treatments for medical disorders in
pregnancy.
Working in partnership
We are working in partnership with the
other maternity units in North Central
London to ensure we meet the strategy for
maternity care outlined in Maternity Matters
(DOH, 2007). This will allow supportive
working that promotes safety, strategic
working and academic research within
all of the units, which will mean that the
following benefits may be realised:
• Potential to continue to improve outcome
for women and babies across NCL.
• Potential to engage in large scale
clinical research.
• Potential to work together to ensure that
stability is maintained in each unit.
38
UCL EGA IfWH 1st Quinquennial Review
Resources
Facilities and infrastructure
The EGA Wing at University London
Hospital is a new, purpose-built, £70 million
maternity and gynaecology building,
which opened in November 2008. The
new facilities have provided a unique
opportunity for the co-location of essential
maternity services.
Level 1
The Integrated Antenatal Service
comprises of Antenatal Clinic, Fetal
Medicine Unit, Maternal Fetal Assessment
Unit and Ultrasound Screening Unit. This
is an innovative service that offers all
women a fully comprehensive package of
antenatal screening and care.
Level 2
The Labour and Delivery Unit is a modern
and spacious area for intrapartum care.
It comprises of twelve delivery suites, two
dedicated state-of-the-art operating theatres,
a four-bedded Additional Care Unit. The
adjoining neonatal unit contains 17 intensive
therapy cots and 15 special care cots.
Level 3
The Bloomsbury Birth Centre is a midwifeled unit providing a home-from-home
environment for low risk women. It features
two birthing pools and six spacious en-suite
rooms that are fully equipped for active birth.
Inpatient maternity services are co-located
with modern facilities for 39 inpatients.
Financial
The annual budget for maternity at UCLH
was £14.4 million in 2008 and the service
is expected to run within budget this year.
In addition we anticipate that our referral
base will expand as a result of recent
service developments and increase
income generated. Recent Service
developments include the Integrated
Antenatal Service and the introduction of
a one-stop clinic for the assessment of risk
for Down syndrome. This in contrast to the
traditional model, which involves waiting up
to seven days for a result.
Staff
There has been an active policy to recruit
midwives in line with the increasing
number of births. At present we are
fully established for 4,800 births and
continuing our recruitment drive to meet
increasing demand. Our midwife-to-birth
ratio is currently 1:31 and we are working
towards 1:29 in line with recommendations
of birth rate and the evidence-based
workforce planning tool for maternity
services. We currently offer 40 hours per
week Consultant labour ward cover and
will increase this to 60 hour cover later
this year in line with the Royal College of
Obstetricians and Gynaecologists (RCOG)
recommendations. Senior staffing has also
been strengthened and expanded by a
number of promotions and appointments
in the last two years, including Debbie
Gould as Head of Midwifery, Pranav
Pandya as Clinical Lead for Obstetrics,
Donald Peebles as Professor of Obstetrics,
Anna David as Senior Lecturer (new post)
and two new consultant posts, Elizabeth
Peregrine and Melissa Whitten. In addition,
we are currently recruiting a Chair of
Midwifery.
Equipment
Maternity services were privileged to have
state-of-the-art equipment purchased as
part of the move to the EGA wing. These
purchases included top-of-the-range
ultrasound machines, K2 CTG monitoring
throughout the whole unit, maternity
information system, fully equipped
Additional Care Unit, and theatres and
birthing suites designed for active birth.
We have capacity to increase births to
5,200 per annum. Since the move to the
EGA Wing demand for care has continued
to increase and the option of providing
care for more than 6,000 women has been
considered. Several options are presently
available and these include expansion of
the birth centre, increasing inpatient beds,
service redesign and implementation to
reduce admissions, such as outpatient
induction of labour and fetal fibronectin
testing. In addition to the above we
are developing partnerships with other
maternity units in North Central London
to manage the increasing demand at
UCLH without affecting patient safety and
destabilising other trusts.
The implementation of the Working
Time Directive (WTD) has resulted in a
reduction in hours for junior doctors and
more consultants are now required to
provide maternity care. This has led to the
creation of two additional posts in line with
increasing activity and this will also enable
us to increase labour ward Consultant
cover to 60 hours per week.
Recommendations are that all units
should have one whole time equivalent
(WTE) consultant midwife for every 900
low risk women. We currently have two
substantive consultant midwives: one
for normality, based in the birth centre,
and one for Public Health, focusing
particularly on mental health and postnatal
care. In addition, plans are in place to
recruit a further consultant midwife for
intrapartum care to promote normality, and
a clinical practice facilitator to support the
development of students.
Performance and
Measurement of
Quality of All
Activity
Maternity scorecard
The maternity scorecard (Appendix 3.2)
has been introduced, which is essentially
an assessment tool to identify areas
that are performing well and identify
weaknesses in the system. It is particularly
important on two levels.
1) Most of the objectives within the
scorecard are key indices of standards
set by the National Service Framework
(NSF), RCOG, and Confidential
Enquiry into Maternal and Child Health
(CEMACH). All are auditable and
action plans are made where deficits
are apparent. Where any standard
falls into the red field, the IfWH Clinical
Board is made aware of the problem.
A clear action plan is then devised to
amend the problem. Currently the high
rate of Caesarean sections is being
addressed, particularly as the EGA has
been selected as an early implementer
site for reducing the Caesarean section
rate as part of a national initiative to
develop ways in which to normalise
childbirth.
2) It enables divisionwide tracking of key
performance indicators and is reported
to clinical governance boards on a
monthly basis.
Improving safety
UCLH achieved Clinical Negligence
Scheme for Trusts (CNST) level 2 in 2007
and are working towards achieving level 3.
Health Care Commission
Review and Quality Project
The results of the HCC Audit in 2007 were
disappointing for UCLH and London as
a whole. At UCLH we were particularly
disappointed by the user feedback and
have since put considerable effort and
investment into addressing the core
areas identified. This was achieved
via the Quality Project, which enabled
various areas of the maternity service
to be reviewed and processes put in
place to improve the quality of care and
the experience of our patients and staff
(Appendix 3.3).
User satisfaction
Patient satisfaction surveys were introduced following the HCC Review and are now
embedded in all clinical areas. The results of these are collated and displayed both on the
Trust Intranet and in the clinical areas on a weekly basis. The questionnaires are specific
to each clinical area and are focused around problematic areas highlighted by the HCC.
Significant improvements have been noted since the introduction of these, which have
proved to be helpful in providing an early warning system (Appendix 3.4).
Staff feedback and satisfaction
An annual staff satisfaction survey in Women’s Health is undertaken by the Trust. Last
year concerns were raised after staff reported that they had experienced bullying or
harassment. The Trust has taken this seriously and commissioned a diversity and equality
analysis that will attempt to understand the dynamics within the unit and develop strategies
to manage unacceptable behaviour. It is anticipated that this work will also be valuable to
other divisions and will be rolled out across the Trust.
Improving access to services
Communication and access are key to delivering high quality care. A daily telephone audit
was introduced following concerns about access to services. It was initially introduced in
the Integrated Antenatal Service and is now being rolled out to the whole division. In line
with recommendations made by the National Service Framework a pathway for self-referral
has been implemented at UCLH. Details are available on the Trust website and women
can self-refer via telephone, e-mail or fax. The evidence shows that early booking can
improve outcome for woman and baby. In line with National Institute for Health and Clinical
Excellence (NICE) recommendations we have implemented booking at 8 to 10 weeks
gestation.
Fetal Medicine key performance indicators
The Integrated Test to screen for Down Syndrome has a 90% detection rate for a false
positive rate of 2.5% at UCLH, which exceeds recommendations made by the National
Screening Committee in 2007 (75% detection rate for a less than 3% false positive rate).
39
MATERNAL AND FETAL MEDICINE – clinical
MATERNAL AND FETAL MEDICINE – clinical
UCL EGA IfWH 1st Quinquennial Review
practice will reduce the risks of prenatal
diagnosis (Appendix 3.6)
Reducing complaints and serious
untoward incidents
The Women’s Health Complaints Scorecard
documents formal complaints received on
a monthly basis.
The number of serious untoward incidents
(SUI) and serious adverse incidents (SAI)
are reported on a monthly basis to the
Umbrella Governance Group and a clear
action plan is developed (Appendix 3.2).
Reduction of maternal morbidity
and mortality
Implementation of the obstetric early
warning chart, MEOWS – modified early
warning system.
40 hour Consultant cover on Labour Ward
with additional Consultant for elective
Caesarean section list three times per
week.
UCLH is fully compliant with CEMACH
organizational standards for diabetes
maternity services.
UCLH has a lower preterm delivery rate
(22% versus 36% nationally), Emergency
CS rate (12% versus 38% nationally) and
stillbirth rate (26.8 per 1,000 nationally
and 15 per 1,000 at UCLH) in women
with diabetes compared to national
performance indicators.
Educational
All staff participate in an annual personal
development review and compose a
personal development plan with their line
manager. In addition to this all midwives
are allocated a supervisor of midwives and
undergo an annual supervisory review.
Junior doctors are assessed by feedback
forms at the end of their posts. Clinical
skills, such as cardiotocograph (CTG)
interpretation and resuscitation are
assessed and audited at annual mandatory
study days. There is also the interactive K2
CTG training package available online to all
staff and an initiative is in place to ensure
all staff complete this.
40
AREAS OF EXCELLENCE
Midwifery
Caseload midwifery was introduced last year, this is an organisational model of care,
whereby a midwife is responsible for the planning and execution of midwifery care for
an agreed number of women, with that midwife being the primary provider of midwifery
care wherever the woman is. In this model midwives’ work centres around women, rather
than being attached to particular locations, which enables improved continuity of care
and communication through building a relationship of trust. UCLH established a team of
six WTE midwives to provide caseload midwifery care to women living within a specified
geographical area. 79% of women had a normal vaginal delivery and 13% of these births
took place at home, with both of these figures exceeding the national average.
Although achieving excellence, UCLH plans to move to ‘team midwifery’ to improve
continuity of care for all women as the caseload team can only manage small numbers
at present. Team midwifery is a model whereby small teams of midwives aim to provide
antenatal, intrapartum and postnatal care for women, supported by core staff on the
maternity ward and in the delivery suite and antenatal clinics. This model is based on
evidence from trials showing clear advantages for women who receive care from a team
of midwives. It is anticipated that this will commence at UCLH in June 2009. In addition
to the caseloading team’s achievement, Patient Satisfaction Forms completed by women
choosing the Bloomsbury Birth Centre demonstrated a very high level of satisfaction in all
key performance indicators.
Integrated Antenatal Service
UCLH has successfully launched the Integrated Antenatal Service (IAS) in response to
the NSF and NICE recommendations for antenatal care. This is an innovative service that
offers all women a fully comprehensive package of antenatal screening and care. For
example we have established new clinics for the management of preterm birth, prolonged
pregnancy and multiple pregnancies. Low risk midwifery and high risk obstetric services
work side by side to ensure all women and unborn babies receive a rapid and seamless
transition to senior medical or midwifery care, should the need arise. Formal complaints
have fallen from approximately three per month to less than one and patient satisfaction
with the service has increased.
Maternal Medicine Services
The maternal medicine services have risen to the challenge of our increasingly complex
caseload and many of our experts represent their specialty within national bodies, for
example, NICE and CEMACH. Our Diabetes and Endocrine team have secured a joint
funded project with CEMACH, which will feed directly into the DH Diabetes in Pregnancy
Initiative for England. This will investigate the reasons underlying poor uptake of
preconception care by women with diabetes and develop a new postpregnancy follow-up
strategy to improve the health of the nation.
Furthermore, our Maternal Medicine team have established an exemplary service for
women with cardiac disease, the single largest indirect cause of maternal death in the
UK. Multidisciplinary team work at UCH in collaboration with the Heart Hospital is aimed
to provide safe maternity care in the most appropriate environment. Its effectiveness is
demonstrated by the fact that in this very high risk group our mortality and morbidity rates
are well below the national average. This standard is maintained across all high risk clinics.
The mental health team have introduced the NICE prediction and detection questions at
booking and are one of the few maternity units in the UK to have a dedicated perinatal
psychiatrist and multidisciplinary team to care for these women.
The Fetal Medicine Unit (FMU) continues to be internationally recognised as a centre
of clinical and academic excellence. The increasing number of referrals shown below
demonstrates our success. We have fulfilled our commitment to providing a service that
offers parents holistic care by establishing close links with allied disciplines. These include
health professionals from the Neonatal Unit, Great Ormond Street Hospital for Children,
Institute of Child Health, Wolfson Institute of Preventative Medicine, North East Regional
Genetics Service, as well as referring hospitals. In addition, we have close affiliations with
patient support groups, such as Antenatal Results and Choices (ARC) and the Genetic
Interest Group (GIG).
700
600
500
400
300
200
100
0
Ma 200
rch 7
2
Ap 007
ril
20
Ma 07
y
Ju 2007
ne
20
Ju 07
ly
20
Au 07
g2
Se 007
pt
20
Ja 07
n2
0
Fe 08
b2
Ma 00
rch 8
20
Ap 08
ril
2
Ma 008
y2
Ju 008
ne
2
Ju 008
ly
2
Au 008
g2
Se 008
pt
20
Oc 08
t2
0
No 08
v2
De 008
c2
0
Ja 08
n2
0
Fe 09
b2
00
9
Implementation of non-invasive
prenatal diagnosis in routine clinical
In addition to the above, external study days are organised by various members of the
maternity team. Over the past year these have included Dilemmas in Obstetric Ultrasound,
Antenatal Screening Update, Amniocentesis Workshop, Fetal Anomaly Workshop and CTG
Interpretation.
Fetal Medicine Unit
Number of consultations
is monitored to inform prenatal counselling
(Appendix 3.5).
There are multidisciplinary teaching sessions held by each discipline of maternity services
on a weekly basis.
Fe
b
Neonatal outcome for surgical
correction of structural malformations
UCL EGA IfWH 1st Quinquennial Review
Month
Fetal Medicine Unit monthly activity. 1 February 2007 to 28 February 2009
To secure our place at the forefront of fetal medicine and build on our international
reputation we have successfully recruited Professor Kypros Nicolaides, a world leader
in the field of academic and clinical fetal medicine. Professor Nicolaides has over 900
publications in peer-reviewed journals and major clinical interests in the areas of screening
for Down syndrome, preterm labour and intrauterine growth restriction. He is a pioneer
in fetal therapy and will introduce a service for laser ablation in twin-to-twin transfusion
syndrome. In addition he will help us to establish a state-of-the-art screening service at
UCLH, which will increase the referral base for maternity services. In addition, Professor
Nicolaides will link into existing research strengths in the IfWH, developing clinical research
projects in a number of areas (see Maternal and Fetal Medicine – Research).
Quality Metrics and Aspiring to
Excellence project
UCLH developed and implemented a
maternity scorecard in February 2008 as
part of its Quality Project.
CHALLENGES
The move to Phase 2 was the biggest
challenge that maternity services have
faced in recent years. Prior to the move
there were restraints on funding for the
development of the environment and
equipment and this had an impact on
the delivery of effective maternity care.
Planning for Phase 2 was initiated over ten
years ago and during this time there have
been major changes to the provision of
maternity care. In order to accommodate
recent advances a large number of
senior managers and clinicians worked in
multidisciplinary teams to restructure the
service. The move allowed for an increase
in capacity and a change in location to
a state-of-the-art unit. It was therefore
essential in planning to ensure that there
were sufficient staff and resources to cope
with increasing demand and that staff
were familiar with the new surroundings
and equipment. In preparation for this a
large recruitment drive took place and we
carried out extensive staff familiarisation.
In addition antenatal services were
simultaneously subjected to care pathway
mapping and service development
projects to produce a new model of care fit
for the 21st century.
Caesarean section rate
The Caesarean section rate at UCLH
is currently 34%. We are committed to
increasing the number of women who
successfully have a normal vaginal birth
and reducing the number of operative
deliveries. We will achieve this by
promoting continuity of midwifery care
through teams, increasing the number of
births in the birthing centre, providing oneto-one care in labour, installing a birthing
pool on the delivery suite, encouraging
Vaginal Birth after Caesarean (VBAC) and
implementing the reducing Caesarean
section audit tool.
41
MATERNAL AND FETAL MEDICINE – clinical
MATERNAL AND FETAL MEDICINE – clinical
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
An obstacle in achieving this is the increasing demands to manage
and deliver high risk pregnancies as a result of patient choice,
assisted conception, restructuring of the neonatal network and
advances in maternal medicine.
The recent establishment of UCLH as part of an Academic Health
Science Centre, with Women’s Health as one of the themes, will
provide a mechanism for planning maternity service provision
across the partnership.
Capacity
Quality metrics and information system
The move to the new hospital has resulted in a significant increase
in demand which is greater than the capacity available at present.
This will be managed by working in partnership with hospitals
within the network and by increasing capacity within the EGA Wing.
There is a lack of clear national guidance to develop quality
metrics in maternity care, although it is likely that booking within
twelve weeks gestation, one-to-one care in established labour,
reducing the Caesarean section rate and improving the normal
birth rate (defined as spontaneous onset of labour, spontaneous
vaginal birth, no epidural, no syntocinon, no episiotomy) will be
included. Data collection has been particularly difficult at UCLH
because we do not have a Maternity Information System and there
is no formal process to collect outcome data.
Options to achieve this include expansion of the birth centre,
increasing the number of postnatal beds and reducing the number
of unnecessary admissions, for example, fetal fibronectin or
outpatient induction of labour.
UCLH already works as part of a clinical network within North
Central London, although this is primarily geared towards
neonatal referral patterns (for which UCLH is the tertiary referral
unit). However, the maternity aspects of the network are being
strengthened by improved dialogue with local units to ensure a
strategic use of capacity across the network.
The Eclipse Maternity Information System will be introduced later
this year and this should allow us to collect relevant data easily in
the future and provide outcome data for specialist units, such as
Fetal Medicine Unit.
Meeting expectations
Our final challenge is how to meet the rising expectations of
women and their families. At UCLH we are focused on accelerating
change and meeting the needs of the woman and her family,
for example, outpatient induction of labour and Down syndrome
screening.
The quality of the service provided for the half a million babies
born in England every year and their mothers has a long term
impact on the health of the nation. UCLH is a centre of clinical
and academic excellence and therefore needs to be driving the
delivery of high quality care in maternity.
Actual deliveries
Reducing maternal mortality
Actual number of bookings
We want all women at UCLH to be active participants in planning
their care and believe that choice and continuity are central to
improving pregnancy outcome. Choice begins at referral and ends
with postnatal care. We aim to offer all women a choice in how to
access maternity services, a choice in the type of antenatal care
they receive and a choice in the place of the birth. Furthermore,
continuity of care has been shown to significantly improve normal
birth rates. This finding was replicated at UCLH when 79% of our
case loading team’s women had normal births. It is anticipated that
by June 2009 we will be able to offer a team midwifery model of
care for all women and provide improved continuity of care.
Planned number of deliveries
500
400
300
UCLH has a lower preterm delivery rate, CS rate and stillbirth
rate in women with diabetes compared to national performance
indications. Our team are leaders in this field and have secured a
joint funded project with CEMACH, which will feed directly into the
DH Diabetes in Pregnancy Initiative for England.
Other leading contributors to maternal and neonatal morbidity and
mortality include preterm birth, pre-eclampsia, intrauterine growth
restriction, obesity and medical disorders in pregnancy. For
women at risk of pregnancy complications from these conditions
we offer integrated multidisciplinary clinics that provide senior
specialist input from a range of disciplines in one appointment.
This has enabled us to not only offer a service that fits around
the needs of the women, but also to provide continuity of care,
reduce hospital appointments and most importantly improve
clinical and psychological outcomes for the woman and baby.
Developing new techniques and pathways of care
Traditional prenatal diagnosis relies on the use of invasive
procedures, such as amniocentesis and chorionic villus sampling
(CVS) to obtain genetic material from the pregnancy. These
procedures are very accurate, because they involve inserting
a fine needle into the womb, but carry a risk of causing a
miscarriage. Fetal medicine services at UCLH are committed to
making prenatal diagnosis safer for women and their families and
have achieved this by the following.
•
Offering all women the Integrated Test to screen for
Down syndrome. We were the first unit in the country
to implement the Integrated Test and have achieved a
detection rate of 90% for a false positive rate of 2.5%.
•
Offering non-invasive prenatal diagnosis (NIPD) of fetal
sex from 8 weeks gestation for parents with a pregnancy
at risk of an X-linked genetic disorder or congenital
adrenal hyperplasia. This has been extremely successful
and has resulted in a 50% reduction in the number
of invasive procedures performed in this population,
reducing the number of healthy babies lost as a result of
invasive procedures.
•
Leading the country in establishing a non-interventional
study in rhesus (RhD) negative women to determine the
baby’s RhD status using NIPD. This will mean that in the
future we can identify the 40% of RhD negative women
who are carrying a RhD negative fetus and therefore do
not require anti-D immunoprophylaxis. This will decrease
demand for anti-D, avoid unnecessary exposure to
human blood products and save the NHS valuable
resources.
•
Conducting a national project funded by the National
Institute for Health Research (NIHR) to evaluate NIPD
for other indications. This will include the diagnosis of
conditions like cystic fibrosis, thalassaemia and Down
syndrome with the ultimate objective of making prenatal
diagnosis safer and more accessible
In addition, early access to maternity services has been shown
to improve clinical and psychological outcomes for the woman
and baby. The introduction of the Integrated Antenatal Service
has ensured all women have direct access to a midwife from early
pregnancy.
200
Providing specialist services for North Central London
100
t2
00
No 8
v2
00
8
De
c2
00
Ja 8
n2
00
Fe 9
b2
Ma 009
rch
20
Ap 09
ril
20
0
Ma 9
y2
00
9
Ju
ne
20
09
Ju
ly
20
0
Au 9
g2
00
9
20
08
Oc
08
pt
20
Se
08
20
Au
g
00
8
Ju
ly
00
8
e2
Ju
n
ril
Ap
Number of bookings and deliveries
Ma
y2
08
20
08
08
20
20
rch
Ma
20
08
Fe
b
Ja
n
7
00
7
00
c2
De
t2
Oc
No
v2
00
7
0
42
Disadvantaged and minority groups have a worse outcome.
Maternity services need to address this issue by providing high
quality care, such as promoting early access, flexible clinic times,
encouraging father’s participation, interagency working and
linking with Community services, for example, Sure Start. This
is a challenge at UCLH, because 70% of the women booked
for confinement live outside of our catchment area. This makes
establishing continuity and links with the local community more
difficult. In addition to the above we want to increase breastfeeding
uptake rates to 90% and increase referral for smoking cessation to
5% by birth, both of which require continuity.
IMPACT AND IMPORTANCE
Predicted number of deliveries based bookings (assuming from Nov 2008
85% of bookings translate into deliveries in 7 months time)
600
Disadvantaged and minority groups
Pre-existing diabetes occurs in 1 in 250 pregnancies in England,
Wales and Northern Ireland and the prevalence of both type 1
and type 2 diabetes is increasing. Women with diabetes are at an
increased risk of losing a baby or having a baby with a congenital
anomaly. Good periconceptual glycaemic control reduces the risk
of these adverse outcomes.
43
MATERNAL AND FETAL MEDICINE – clinical
MATERNAL AND FETAL MEDICINE – clinical
UCL EGA IfWH 1st Quinquennial Review
Training national leaders
UCLH has successfully trained a number of subspecialists in
maternal and fetal medicine who are internationally recognised as
leaders in the field, for example, seven current Professors of Fetal
Medicine were trained at UCLH. In addition, we have an ongoing
commitment to training and are the only centre in the UK to have
three recognised posts for subspecialty training in maternal and
fetal medicine.
In addition to training, senior staff perceive an important part
of their contribution to be in shaping and informing national
developments in maternity care. Some notable examples are
Maggie Blott who is Vice President of the RCOG, and Jo Modder
who is Obstetric Lead for the Confidential Enquiry into Maternal
and Child Health.
UCL EGA IfWH 1st Quinquennial Review
FUTURE DEVELOPMENTS
Maternity services will be committed to providing effective,
personal and safe care to improve the health of the nation.
This will involve getting the basics right first time every time and
having services that are sensitive and responsive to needs of
the woman and her family. In the future we will provide a service
that is continuously improving quality of care and will implement
measures that allow for regular audit, service user feedback and
evaluation in order to achieve this.
Partnership between health professionals and organisations will
be required to ensure equitable provision of high quality, effective
maternity care. These partnerships should extend to universities
and industry in order to secure implementation of clinical and
academic excellence.
The implementation of midwifery teams nationally will improve
continuity of care for all women and facilitate an increase in the
normal birth rate and a reduction in the Caesarean section rate.
Women and their families will have greater confidence in their
midwife and see them as an expert in normal pregnancy and
birth. This is likely to increase the level of job satisfaction within
the profession.
Maternity services at UCLH should remain at the forefront of
developing and implementing clinically effective innovations.
These include:
• screening and prevention of
preterm birth
• screening and treatment for intrauterine growth restriction
and pre-eclampsia
• expanding clinical applications for
Non-invasive Prenatal Diagnosis (NIPD)
• evaluating the role of gene therapy
• introduction of preconception clinics for maternal disease,
which could be developed in collaboration with
the Margaret Pyke Centre
• introduction of fetal surgery
MATERNAL AND FETAL MEDICINE – RESEARCH
OVERVIEW
Lead – Dr Lyn Chitty
The UCL Research Department of Maternal and Fetal Medicine,
lead since January 2008 by Professor Donald Peebles, is one of
four research departments in the Institute for Women’s Health.
Obstetric research has a long established track record at UCL
and until recently was under the leadership of Professor Charles
Rodeck, who retired in September 2007. Currently research activity
is centred on six groups, which encompass many of the major
causes of UK maternal and perinatal mortality and morbidity.
One reader and two research midwives. Collaborative research
involving a much larger multinational group with broad interests
in aetiology of congenital abnormality and psychosocial and
technical aspects of prenatal diagnosis, with a particular emphasis
on the development and clinical implementation of novel methods
of non-invasive prenatal diagnosis (PND).
Maternal Medicine
Research groups
Lead – Dr David Williams
UCL Centre for Preimplantation Genetic Diagnosis
Group consists of one consultant and senior lecturer and two PhD
students. They conduct clinical research into the role of angiogenic
factors and vascular function in pre-eclampsia. Parallel studies
assess the prognostic value of pregnancy outcome in determining
later cardiovascular health.
Research Lead – Dr Joyce Harper,
Clinical Lead – Professor Joy Delhanty
The Centre consists of one Emeritus professor, one reader, one
non-clinical lecturer, one research nurse and nine PhD students.
They provide a clinical preimplantation genetic diagnosis
service for patients receiving in vitro fertilisation (IVF), mainly in
collaboration with the Assisted Conception Unit (ACU) at UCLH,
conduct research into preimplantation genetics and run the
MSc and Postgraduate Diploma in Prenatal Genetics and Fetal
Medicine. Group activity is included in the Department of Maternal
and Fetal Medicine. Donald Peebles is line manager for Joyce
Harper and Sioban SenGupta. The laboratories are located in
Chenies Mews and Fetal Medicine provides a major input into the
MSc, but also in the Reproductive Health Department, which has
close research links with ACU.
Perinatal Neuroscience
Lead – Professor Gennadij Raivich
Comprises of two professors, one clinical lecturer, one non-clinical
lecturer, two research assistants and two PhD students. This is a
multidisciplinary group including basic neuroscience and clinical
obstetrics and neonatology. Their aim is to identify mechanisms
contributing to inflammation-associated injury to developing brain
and devise therapeutic interventions to reduce the incidence of
long-term neurodisability in infants born prematurely or following
peripartum hypoxia-ischaemia.
Placental Development
Lead – Professor Eric Jauniaux
Group consists of one professor, one lecturer who has just left
and two PhD students. The aim is to investigate the molecular
mechanisms of early placental development and their role in the
pathophysiology of placental-related complications of pregnancy.
Perinatal Gene and Cellular Therapy
Lead – Dr Anna David
Group consists of one professor, one senior lecturer, one research
assistant and two PhD students. The research aims are to develop
prenatal treatment of severe and life-threatening disorders using
gene and cellular therapy and to investigate the efficacy, safety and
ethical issues of such treatment.
44
Prenatal Diagnosis
Research links and collaborations
An important factor that supports this translational research
activity is the integrated nature of the relationship between senior
academic and clinical staff in obstetrics. Professor Peebles
combines his role as Head of the Research Department with
a clinical role as Consultant in Maternal and Fetal Medicine,
as well as Lead for the Women’s Health Theme within the UCL
Biomedical Research Centre. Four research groups were included
in the Women’s Health theme in the successful UCL/UCLH
Comprehensive Biomedical Research Centre (CBRC) bid in 2007
and the three consultants, David Williams, Donald Peebles and
Lyn Chitty, receive funding for translational research from the
CRBC. Professor Peebles works closely with the Clinical Lead
for Obstetrics to ensure a coherent joint strategy for clinical and
academic appointments and identification of clinical and research
priorities.
These research groups are supported by important links across
UCL and nationally, for example, Professor Raivich has a joint
appointment with the UCL Department of Anatomy, Dr Lyn Chitty
is also a senior lecturer at the Institute of Child Health (ICH), and
significant collaborations, enabled by jointly held or submitted
grants, exist with ICH, Cardiology, Neuroscience and Health
Services Research at UCL, as well as Imperial College and
Cambridge University.
Translational research
Research spans the full spectrum from basic to translational and
clinical research, for example, the Neuroscience group investigate
the mechanisms that make developing white matter vulnerable
to infection and inflammation, using transgenic mouse models.
Dr David uses a large animal model, in this case fetal sheep, to
investigate the use of viral vector-delivered Vascular Endothelial
Growth Factor (VEGF) to improve uterine blood flow in complicated
pregnancies. At the more clinical end Dr Chitty leads a national
study into the use of non-invasive diagnosis to customise treatment
of Rh-negative mothers during pregnancy.
45
MATERNAL AND FETAL MEDICINE – reSEaRCH
MATERNAL AND FETAL MEDICINE – clinical
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
RESOURCES
• Build core strengths in relevant basic science, and at the same
time, in order to achieve critical mass and ensure long-term
sustainability of research output, aim to appoint scientists who
can link with groups within UCL and IfWH
Space
• Consider development of research infrastructure and
collaborations to improve success rate of clinical research,
such as statisticians and health services researchers (HSR)
• Maintain core laboratory facilities within Women’s Health,
co-located with office space to foster team work and identity
Research funding
Prenatal Cell and Gene Therapy group comprises clinical academics and scientists working together to treat genetic diseases
affecting the fetus
Theme management
All research group leads meet on a monthly basis at meetings
chaired by Professor Peebles. They are appraised annually by the
Clinical Lead if they are funded jointly by the Higher Education
Funding Council for England (HEFCE) and NHS, or CBC and NHS
and by Professor Peebles if HEFCE funded.
STRATEGY, AIMS AND OBJECTIVES
Aims
• to perform research that leads to a demonstrable improvement in
maternal and neonatal outcomes of pregnancy
• to train and enthuse scientists and clinicians in women’s health
at the undergraduate and postgraduate stages, with the longterm aim of building research and clinical capacity in women’s
health.
• to be identified as the leading centre in Europe for obstetric
research on the basis of research excellence, indicated by
publications and impact on women’s health
Strategy
We propose to achieve these ambitious aims using a number of
strategies to finance and shape the nature of obstetric research
over the next five years. The strategy for the Department is not
developed in isolation, but as part of an Institutional strategy, with
the IfWH Strategic Planning Board and CBC Theme Management
Board (Donald Peebles being a member of both) playing an
important role in shaping research and clinical goals.
46
Recruitment strategy
Recruitment of individuals of high calibre at both senior and junior
levels is essential to build research capacity in the Department.
This requires funding and occurs against a national background of
shrinking expertise and personnel involved in obstetric research.
However, the increasing profile of the IfWH and UCL, as well as
enormous strengths in biomedical research at UCL, as indicated
by the recent outstanding performance of our returned unit, UoA4,
in the recent Research Assessment Exercise (RAE), are positive
factors. We have recently recruited Professors Kypros Nicolaides
and Neil Marlow to Neonatal Medicine, but also with important
benefits for Maternal and Fetal Medicine, both of whom have an
international track record for high quality research.
Research capacity
Obstetrics already has a very significant input to the training of
clinical academics in the specialty: two Walport Academic Clinical
Fellows (ACF) and one Walport Clinical Lecturer (CL), with another
clinical lecturer to be appointed in spring 2009, and an academic
Foundation Year entry to do obstetric research. In addition there
is input into the Masters programme, both in terms of teaching
and providing MSc projects, and 14 current PhD students. We
propose to maximise these training opportunities, as well as the
calibre of candidates who apply, by ensuring ACFs and CLs apply
successfully for Research Training Fellowships and enthusing
potential academics through Special Study Module (SSM) in
Obstetrics early in their medical career.
Research strategy
The Department of Maternal and Fetal Medicine at UCL has been,
and continues to be, a highly productive research organisation.
However, new sources of funding, vacancies arising and UCL/
UCLH initiatives, such as the Comprehensive Biomedical Research
Centre and UCL Partners, provide the opportunity to make
changes to enhance research productivity and its clinical impact.
Guiding principles are oulined below.
• To map research activity to areas of clinical excellence and
nationally identified priorities, and aim to have each aspect of
clinical care underpinned by research
• To identify unique aspects and areas where IfWH can develop a
niche, supported by strengths elsewhere in the Institute and at
UCL, for example, use of polymerase chain reaction (PCR) based
methods to identify role of placental bacterial infection in preterm
birth and brain injury (work by Professors Peebles and Klein, the
latter based at ICH) and use of gene therapy to increase uterine
perfusion (Dr David, Cardiovascular Medicine at UCL)
In addition, Chenies Mews contains 220 m2 of office space, shared
with Neonatal Medicine, as well as a recently refurbished seminar
room (Theobald Seminar Room), which seats 50 people and has a
large staff room adjacent to it. This useful facility is extensively used
for meetings, lectures, audit days, as well as running the MSc course.
Financial
Departmental expenditure for the last five years is shown in the
figure below. The HEFCE component includes salaries, as well as
other HEFCE funding for teaching and research.
4.0
HEFCE
3.5
EU Other
EU Government Bodies
3.0
£m pa Funding
Dr Williams is clinical lead for a Medical Research Council (MRC)
funded randomised controlled trial (RCT) into the use of statins to
prevent pre-eclampsia, whilst Dr Harper’s group has been the first
to provide preimplantation genetic diagnosis for couples affected
by a number of genetic disorders.
A major challenge for the Department is to increase the amount
of grant funding. This is central to ongoing success and is a top
priority. In addition, there is an issue of core funding to maintain
essential posts. Laboratory equipment would be of enormous
benefit. It is hoped that the Institute Charity, Health of Women,
combined with recent investment into the establishment of a
fundraising initiative will make a contribution along the lines of
current Women’s Cancer funding from Eve Appeal.
Research is mainly centred around three laboratories
(Preimplanatation Genetic Diagnosis, Perinatal Neuroscience and
Placentation) in the Department of Obstetrics in Chenies Mews. These
occupy approximately 250 m2 and there is additional laboratory and
office space on the ground floor, currently occupied by the Perinatal
Haemoglobinopathy service, now a part of clinical Haematology
and due to move shortly. The laboratories are equipped to provide a
full range of immunohistochemical, PCR, molecular biology and cell
culture techniques. In addition, the UCL Centre for Preimplantation
Genetic Diagnosis provides a clinical diagnostic service and are
seeking Clinical Pathology Accreditation (CPA) of their premises.
Animal studies are performed in the UCL Biological Services
laboratories in the Cruciform Building (full range of housing, theatre
and functional testing services for rodent research, with large number
transgenic mouse colonies), as well as a long-standing, successful
collaboration with the Royal Veterinary College in Camden (chronic
experiments in pregnant sheep with implanted telemetric monitoring
of maternal and fetal blood flow and pressure). Full use is also
made of centralised genomic and proteomic facilities in the IfWH
laboratories in the Paul O’Gorman building, confocal and electron
microsocopy in UCL and vascular biology facilities in the Department
of Cardiology.
UK based Charities
Research Councils
2.5
2.0
1.5
1.0
0.5
0
2003–4
2004–5
2005–6
2006–7
2007–8
UCL IfWH Obstetrics Funding 2003–2008
47
MATERNAL AND FETAL MEDICINE – reSEaRCH
MATERNAL AND FETAL MEDICINE – reSEaRCH
UCL EGA IfWH 1st Quinquennial Review
Staff
For a full list of staff, their roles and funding, see Appendix 4.1.
Obstetric research is supported by three professors, two readers
and a recently appointed ‘new blood’ senior lecturer Dr David,
who is funded by the Department of Health (DH) and was one of
only two in the UK awarded this funding in Obstetrics. In addition,
there are two HEFCE funded non-clinical lecturers and two
clinical lecturers, who are combining 50% research time with 50%
subspecialty level clinical training. The senior faculty has been
strengthened by recent recruitments and promotion. In the last
18 months Professor Nicolaides has been recruited to a Chair of
Fetal Medicine (50% time), having commenced this employment
in April 2009. Professor Peebles was recruited internally to head
the Department, in addition to Dr David being appointed to a
new senior lectureship. Dr Williams, lead of Maternal Medicine
Research, is one of a small number of physicians in the UK
specialising in obstetric medicine. He was recruited from Imperial
College London as an NHS consultant, but with a significant
research component (four PAs, CBC funding). A new post
for Professor of Nursing or Midwifery has also been recently
advertised, for the future postholder to work with Professor Linda
Franck in the Centre for Patient Care Research and Innovation
(PCRIC) at ICH. In addition, Dr Lyn Chitty holds her main academic
contract at ICH (6), but has clinical PAs (3) and some CBC funded
research time (1 PA) within UCLH. As her research predominantly
relates to fetal medicine, her research group is included in the
Department structure. Approximately 15 PhD students and research
fellows are employed on external grant funding at any one time.
PERFORMANCE AND
MEASUREMENT OF QUALITY AND
AREAS OF EXCELLENCE
The main key performance indicators for research excellence are
number and impact of published papers and the grant income
generated. These are detailed fully in the Publications booklet and
Appendices 1.2 and 4.2. All data are from 2004 onwards. In total,
the Departmental return includes 175 original papers, 58 review
articles, 45 book chapters and 5 books. Over the same time period
Professor Nicolaides, our most recent recruit, has published over
230 papers. Members of the Department have been applicants
on successful applications for approximately £9 million. Of this,
however, only £2.2 million has been held by the UCL Department,
and £330,000 by UCLH R&D. This research activity is summarised
below with reference to other important outcomes, such as the
number of students achieving higher degrees, and mention of the
wider roles played by academic personnel in research, patient
care and education locally and nationally.
UCL Centre for Preimplantation
Genetic Diagnosis
Notable research activity
This group provides a clinical service, is active in resaerch and
has a major role in education. Professor Delhanty (Emeritus
Professor of Human Genetics) runs the clinical service providing
48
UCL EGA IfWH 1st Quinquennial Review
preimplantation genetic diagnosis for monogenic disorders,
patients carrying chromosome abnormalities (for example,
known translocations), embryo sexing for X-linked disease, and
aneuploidy screening of embryos for patients with infertility. They
have been the first to perform preimplantation genetic diagnosis for
a number of diseases, including type 1 diabetes mellitus, Crouzon
syndrome, Connexin 26 and, most recently, with a great deal of
media coverage, BRCA1. In 2008 they counselled 110 couples
and managed 36 treatment cycles resulting in 12 pregnancies.
Dr Joyce Harper leads the research arm of the group. Ongoing
avenues of research include investigating genomic instability
in embryos destined to show chaotic mosaicism, use of whole
genome amplification techniques in early stage embryos to assess
gene expression and a study of DNA checkpoint genes. Joyce
Harper has also run an MSc and Postgraduate (PG) Diploma
in Prenatal Genetics and Fetal Medicine since 1996. This is an
internationally recognised course of huge popularity. As a result a
new MSc and PG Diploma in Reproductive Science and Women’s
Health has been established, due to start in 2009. Both courses
will run together and share four out of eight modules.
• Investigating the endogenous repair mechanisms leading to
CNS regeneration following a variety of interventions including
axotomy, infection and hypoxia-ischaemia
• Clinical studies using novel PCR-based techniques to identify
and quantify bacteria in membranes and fetal blood, in
collaboration with Professor Klein at ICH, to define the role of
bacteria in preterm labour, fetal inflammation and long-term
neurological outcome
Particular areas of success
• Experiments led by Donald Peebles were the first to show that
even nanograms of bacterial endotoxin injected into the fetal
circulation during a gestational ‘window of vulnerability’ led to
extensive necrosis within the developing white matter. Exciting
recent research has resulted in identification of unusual bacterial
species in a large proportion of samples of placental membrane
from preterm labours, which was carried out using an optimised
PCR technique. This will allow the true role of bacterial infection
in preterm brain injury to be defined.
Publications
There have been 23 peer-reviewed papers over the same time
period including journals, such as Neuron, Neuroscience, National
Medicine, and Proceedings of the National Academy of Sciences.
In addition there are eight review articles and a book.
MD and PhD students
Five students have obtained higher degrees – three MD and two
PhD degrees, and a further four are currently at various stages of
preparation.
Markers of esteem
Donald Peebles is a recent Editor of BJOG, ex-member of the
Royal College of Obstetricians and Gynaecologists (RCOG)
Scientific Advisory Committee, member of scientific advisory
boards of two charities (Wellbeing and SPARKS), member of two
RCOG working parties and one national guideline preparation
group, member of executive committees of British Association
Perinatal Medicine (recently co-wrote a national guideline
on management of in utero transfers), Fetal and Neonatal
Physiological Society (FNPS) and an external examiner for
Nottingham Medical School. Gennadij Raivich is Editor for NeuronGlia-Biology and Cell and Tissue Research.
Since 2004 the group has received approximately £110,000 in
peer-reviewed grant funding, as well as PhD studentship support
amounting to £346,000.
• Gennadij Raivich has an international reputation for his research
into the role of inflammatory molecules in promoting and inhibiting
endogenous CNS repair following various forms of trauma. Of
particular note has been his work describing the central role
played by C-jun in neuronal regeneration (Neuron, 2004).
Publications
Grant income
Research activity
They have published 65 papers and two editions of a widely
recognised textbook on preimplantation genetic diagnosis.
Donald Peebles and Gennadij Raivich have been principal
investigators (PIs) on grants bringing an income of over £1.8 million
since 2004.
Professor Jauniaux leads this group, which was supported until
March 2009 by Shanti Muttukrishna, non-clinical lecturer. The group
has two main research streams:
Grant funding
Placental Development
MD and PhD
There are currently nine PhD students and five students have been
awarded degrees in the last five years.
Markers of esteem
Dr Harper has a high international profile, having chaired a PGD
consortium for the European Society for Human Reproduction and
Ethics, as well has having been a member of a number of their
committees. She is a current board member of the International
Society of Prenatal Diagnosis and led the PGD International
Society (PGDIS) Organising Committee until 2005.
Perinatal Neuroscience
Research activity
This multidisciplinary group brings together basic neuroscience
and clinical perinatology. Areas of overlap and collaboration with
brain research in Neonatal Medicine, led by Nikki Robertson,
include a joint interest in the development of neuroprotective
strategies and the neurological consequences of perinatal
exposure to potentially neurotoxic factors, such as infection, with
this work being being led by Professor Marlow. Main areas of
research activity are set out below.
• Identification of the molecular signals associated with
neuronal and glial cell death following hypoxia-ischaemia or
infection, using transgenic mice and with the aim of identifying
pharmacological interventions to reduce cell loss
Examining vessel contractility using an organ bath
49
MATERNAL AND FETAL MEDICINE – reSEaRCH
MATERNAL AND FETAL MEDICINE – reSEaRCH
UCL EGA IfWH 1st Quinquennial Review
• understanding the role of oxygen and endogenous anti-oxidants
in early placentation using human tissue, cell culture and animal
experiments
• identification of biomarkers for early detection of pre-eclampsia.
Particular area of contribution
Eric Jauniaux has a long-standing and successful collaboration
with Professor Burton in Cambridge. Research conducted over
the last ten years has had a profound impact on understanding
the processes underlying early placentation. In particular he
has shown that the placenta pre-12 weeks of gestation has
limited expression of anti-oxidants and is particularly vulnerable
to excessive blood supply, rather than hypoperfusion, as was
originally thought. This concept led to a number of international
trials to assess the role of exogenous anti-oxidants to prevent early
pregnancy failure and is fundamental to current understanding
of conditions such as pre-eclampsia and miscarriage. His
publications on this topic have been cited over 1,000 times and are
internationally renowned.
Publications
The group has published 46 papers in the last five years. Those
with the highest impact factor (IF) include American Journal of
Pathology (5.5), Journal of Clinical Endocrinology and Metabolism
(5.5), Fertility and Sterility (3.7) and Human Reproduction Update
(7.2). Professor Jauniaux in addition has published eight chapters
and review articles and has been a co-editor of two textbooks. Dr
Muttukrishna was the first to publish an observation that inhibin and
activin are elevated as early as 15 weeks in pregnancies destined
to develop pre-eclamptic toxemia (PET).
Grant income
Eric Jauniaux has been co-applicant on two Wellcome Trust
programmes (just over £2 million, although held in Cambridge);
other grant funding since 2004 totals £100,000.
MD and PhD students
Three MD students have completed in the last four years.
Markers of esteem
Eric Jauniaux was Laureate of the International Prize for
Exceptional Achievement in Research in Placentology of the
International Placental Federations Association (IPFA) in 2002, and
is an editor of Prenatal Diagnosis and Reproductive Biomedicine
Online.
Perinatal Gene and Cellular Therapy
Research activity
This is a relatively new group, initiated in 2000 by Professor Rodeck
in collaboration with Professor Coutelle (Gene Therapy) at Imperial
College London, funded by an MRC programme grant. Anna David
was the first PhD student employed on this grant and now leads
the group with support from Donald Peebles.
The group has three main current areas of research as follows.
• the use of Ad.VEGF vectors to improve placental perfusion
with the long-term goal of treating severe clinical fetal growth
50
UCL EGA IfWH 1st Quinquennial Review
Markers of esteem
restriction (in collaboration with Professors Martin and Zachary
in Cardiovascular Medicine, UCL)
Dr Chitty is a member of the Down Syndrome Screening
and Ultrasound Screening groups of the National Screening
Committee, a member of the research advisory board of BDF
Newlife and co-convenor of an RCOG study group on reproductive
genetics. She recently led the SAFE European Consortium and is a
frequently invited speaker on this topic around the world.
• isolating haemopoietic stem cells (and possibly mesenchymal in
the future) from amniotic fluid to correct thalassaemia in utero,
first in a mouse model and then possibly in human studies in
collaboration with Dr Paolo De Coppi at ICH
• correction of monogenic disorders using gene therapy in utero;
initial studies have focused on cystic fibrosis and factor IX
deficiency in collaboration Drs Waddington and Nathwani, UCL
Haematology
Maternal Medicine
In collaboration with Clinical Pharmacology at UCL and with the
Department of Epidemiology at London School of Hygiene and
Tropical Medicine (LSHTN), Dr Williams has established two areas
of research:
Particular areas of success
Babies born severely growth-restricted are at increased risk of
perinatal death and morbidity and there are currently no effective
therapies. This group have developed a novel technique involving
injection of an adenoviral vector expressing VEGF into the uterine
artery, leading to over expression of VEGF in the uteroplacental
circulation and a sustained increase in uterine blood flow in an
animal model. Recent grant funding will support research to
determine whether this results in accelerated fetal growth. The
vector is patented and the research has attracted significant
research and financial support from industry (Ark Therapeutics), as
well as winning prizes at recent international meetings.
• assessing the association between pregnancy outcome, for
example, pre-eclampsia and gestational diabetes on women’s
future health
• establishing the contribution of maternal, paternal and placental
factors towards the aetiology of pre-eclampsia
Grant income
Scanning a fetus in the Fetal Medicine Unit at UCH
Grant income
Research is funded by a collaborative industrial grant with Ark
Therapeutics (£430,000 until 2010), project grant funding from
Action Medical Research (£147,000) and two PhD studentships
(Dorothy Hodgkin, £90,000 and Taiwanese Government
scholarship, £66000).
Publications
The research has resulted in eight papers (IF of Gene Therapy
– 4.8) and eleven chapters and review articles. Five abstracts
have been awarded prizes including two Presidents awards at the
Society of Gynecologic Investigation (SGI) meeting in USA.
MD and PhD students
One PhD student has successfully completed, two more are in the
middle of their research.
Markers of esteem
Dr David was awarded a ‘new blood’ DH senior lecturer award on
the basis of this research. Anna David is also a member of the
RCOG Guideline Committee, ex-RCOG Academic Committee and
Secretary of the Blair Bell Research Society.
Prenatal Diagnosis
Research tradition
Prenatal diagnosis and therapy has been a mainstay of obstetric
research at UCL since 1990 with the appointment of Professor
Rodeck, who had an international reputation for his pioneering
work developing ultrasound-guided invasive procedures, such
as fetal blood transfusion. More recently he led the Serum Urine
and Ultrasound Screening Study (SURUSS), assessing novel
methods of Down syndrome screening, some of which are now
incorporated into NICE recommended protocols.
Current research
Dr Chitty now leads this research theme. She has played a major
role in establishing the clinical significance of initial research
showing that up to 5% of the cell-free DNA in maternal blood
derives from the fetus, probably trophoblast. As a consequence,
UCLH have been amongst the first in the world to use this
technique for fetal sexing where there is a risk of inheriting an
X-linked condition, as well as determining fetal Rh genotype where
the mother is allo-immunised. Dr Chitty has recently obtained major
National Institute for Health Research (NIHR) funding to extend
these studies. Existing expertise at UCL will also allow basic
research into the use of ‘deep sequencing’ techniques on her
extensive bank of samples to karyotype the fetus.
David Williams is clinical lead on a national MRC funded RCT to
investigate whether statins can be used to ameliorate early onset
pre-eclampsia (£550,000). He is also an applicant on a further
£240,000 grant funding application.
Publications
Since joining UCLH in 2005, the group has produced 5 peerreviewed papers and 19 book chapters and reviews. The highest
impact factor publication is in the British Medical Journal (BMJ):
Pre-eclampsia and the risk of cardiovascular disease and cancer
in later life: a systematic review and meta-analysis.
MD and PhD students
David Williams is supervising two PhD students, including one
newly appointed and funded by UCL CBRC to investigate the
paternal phenotype of men who father pregnancies affected by
pre-eclampsia and fetal growth restriction. One PhD student has
successfully completed.
Grant income
Lyn Chitty is PI on peer-reviewed grants totalling more than £3.3
million and is a co-applicant on a further £800,000. These include
two NIHR grants, one for £247,162, which is entitled ‘Antenatal
determination of fetal rhesus status using cell-free fetal DNA in
the maternal circulation before 20 weeks: is routine application
practical and beneficial?’, and a programme for £1,999,840 to
assess non-invasive PND.
MD and PhD students
One student has recently submitted.
Publications
The group has published 41 papers, 9 book chapters
and 14 reviews.
Markers of esteem
Dr Williams is a member of the NICE guideline development group
for hypertension and ex-president of the UK Obstetric Medicine
Society.
Education
Members of the Department have a major commitment to
educational activity, discussed in more detail in the Education
theme. In addition to running the MSc in Prenatal Genetics and
Fetal Medicine, staff are heavily involved in starting a new MSc
in Reproductive Science and Women’s Health. Professor Peebles
also manages the MSc in Haemoglobinopathies, led by Dr Ratna
Chatterjee.
51
MATERNAL AND FETAL MEDICINE – reSEaRCH
MATERNAL AND FETAL MEDICINE – reSEaRCH
UCL EGA IfWH 1st Quinquennial Review
The Department hosts a very successful module of the Physiology
BSc dedicated to Fetal and Neonatal Physiology, lead by Dr Ray
Noble, contributes to the Women’s Health Module in Year 4 of the
Undergraduate course (Donald Peebles sits on the Undergraduate
Committee), and also provides research projects for BSc and
MSc students. Professor Peebles is the Academic member of the
Specialist Training Committee of the London Deanery and also sits
on the Board of the London School of Obstetrics and Gynaecology.
Anna David and Melissa Whitten set up the UK Network of
Academic Trainees in Obstetrics and Gynaecology, now run
through the RCOG Academic Committee, to improve recruitment
and retention of academic trainees in clinical academia.
CHALLENGES
Facilities
The Chenies Mews site presents two major challenges.
• It is old, has not been redecorated for over 20 years and is
isolated from other centres of IfWH activity
• Recent recruitments, including David Williams and Kypros
Nicolaides, and prospective recruitment of Chair of Midwifery
and Neonatology, have highlighted the shortage of office and
suitable laboratory space.
Possible options include:
• splitting the Department up to take advantage of any space
that becomes available in more modern buildings and to locate
teams with other researchers with shared interests, for example,
new IfWH laboratories in Cancer Institute. Disadvantages of
this approach would be loss of Departmental identity and team
spirit, and absorption of women’s cancer research into other
groups.
• demolition of the Chenies Mews site and adjacent vacant former
Department of Haematology with rebuild of an ‘Institute for
Women’s Health’ combining laboratory and office space. This
has the great advantage of providing a single, modern centre for
women’s health research activity, but would involve identifying a
very significant capital outlay and may not be large enough.
• identifying existing premises on the UCL/UCLH campus that is
vacant and large enough to accommodate women’s health with
only minor upgrades. This would be more affordable than the
second option above, and therefore more realistic, but require a
suitable site. There are potential candidates, but none has been
definitively allocated at present.
Grant funding
The figure on funding provided above highlights several problems
with the funding of obstetric research. Firstly, the Department is
overly dependent on HEFCE funding, leading to inconsistencies
with other research departments in the IfWH, which receive less
and secondly, grant income is insufficient and in particular does
not include enough from research councils and other prestigious
funding agencies who make a significant contribution to overheads.
52
UCL EGA IfWH 1st Quinquennial Review
Potential solutions include:
• refocusing on the importance of submitting grant applications,
as some groups have only written one or two applications in the
last four years.
• making the applications more competitive by introducing internal
peer review and mentorship for more junior researchers
• increasing the size and quality of core reproductive science
activity in obstetrics through collaboration, particularly within
UCL, and recruitment
• increasing applications to NIHR for Benefit funding, which
will require broadening research remit to include relevant
professionals, for example, statisticians, health services
researchers, nurses, midwives and user groups. Recent
developments supporting this approach include the recruitment
of Professor Nicolaides (who has extensive track record of
effective clinical research and has demonstrated ability to
recruit to large studies), the advertised Chair of Midwifery,
recent successful applications by Lyn Chitty for Research for
Patient Benefit (RfPB) and Programme funding from NIHR and
collaborations with Professor Rosalind Raine, a successful health
services researcher and NIHR Panel member.
Research remit
Six research groups and additional increases in the scope of
maternity research pose challenges relating to lack of critical mass
and lack of focus. Compared with other departments in IfWH, such
as Gynaecological Oncology, that have a central, disease focused
theme, it could be argued that obstetrics, which has grown in an
organic fashion based on recruitment of personal excellence rather
than research compatibility, is spread too thinly to achieve research
excellence.
Balancing clinical service provision and research: a particular
challenge for the UCL Centre for PGD is that a single group, based
entirely within UCL, provides a clinical service whilst no one has
a primary clinical contract with UCLH, except the genetic nurse
specialist, but is also an active research group. Almost all PhD
students come with their own funding and the clinical PGD funds
some posts. Problems arising from this dichotomy are that there
is insufficient time or focus to apply for grant funding, and clinical
achievements are not recognised in university appraisal, making it
difficult for staff to successfully apply for promotion. This can only
be addressed by aligning and integrating the clinical service with
UCLH strategy, as well as strengthening research activity through
recruitment.
IMPACT AND IMPORTANCE
Obstetric research at UCL is focused on conditions that lead to
maternal and perinatal mortality and morbidity in the UK and the
developing world alike. Each year over 200 million women suffer
life-threatening complications of pregnancy, while half a million die
in childbirth, with over 99% of these in developing countries. The
single largest cause of maternal death worldwide is postpartum
haemorrhage (see misoprostol initiative in Uganda in the Global
Health section). Three million babies die in the first week of life
and a similar number are stillborn. Preterm labour and delivery
are still poorly understood and efforts at prediction, prevention
and treatment are woefully inadequate. It is the major cause of
cerebral palsy and mental handicap, the prevalence of which
have not changed or even slightly increased in the last 40 years
(see Perinatal Neuroscience above). The lifetime costs of care
for one child affected by cerebral palsy may exceed £4 million
and the Department of Health has reported that approximately
60% of the entire NHS litigation costs each year are accounted
for by brain injury at birth, a sum exceeding £200 million per year.
Pre-eclampsia, a hypertensive syndrome peculiar to pregnancy
is another important cause of fetal and maternal morbidity and
mortality. Its cause and successful treatment remain elusive (see
Maternal Medicine and Placental Development).
Local challenges identified by the London Maternity Services
Improvement Board include an increasing birth rate from 104,000
in 2001 to 121,000 in 2006 with particular increases in women from
ethnic minorities (by 23%) and women over 40 years old (by 33%),
both groups being at an increased risk of perinatal and maternal
mortality (see Future Developments below). Prenatal screening for
fetal aneuploidy is offered to the majority of pregnant women in the
UK. Unwanted consequences of this policy are loss of unaffected
fetuses as a consequence of invasive karyotyping (200 per year)
and increased levels of parental anxiety (see non-invasive PND
above).
FUTURE DEVELOPMENTS
There are a number of national and local developments that will
impact obstetric research over the next two to three years.
• widely predicted falls in research funding from HEFCE and
medical research charities
• potential benefits for increased research scope related to UCL
Partners bid to become a DH recognized Academic Health
Science Sentre
• establishment of the UK Centre for Research and Medical
Innovation on the St Pancras site
• recruitment of Professor Nicolaides
Making use of the opportunities these developments provide in
line with strategy outlined in Strategy, Aims and Objectives, we will
build on the areas described below.
pre-eclampsia. Appointing Kypros Nicolaides provides a realistic
opportunity to establish the clinical relevance of some of the more
basic scientific research described above.
Health services research in Maternity
In order to maximise the potential to apply successfully for RfPB
funding, but more importantly to tackle local issues such as a high
perinatal mortality rate, inequalities in access to healthcare and
the difficulties raised by providing high quality maternity care to
an inner city population, it will be necessary to build on existing
expertise in health services research. An initial NIHR programme
bid entitled ‘Changing practice to improve perinatal outcomes in a
socially and ethnically diverse population’ with Professor Rosalind
Raine, Division of Public Health, was unsuccessful, but provides
the catalyst for further attempts. Important contributors to this
research stream would be Dr Jo Modder, Obstetric Lead for the
Confidential Enquiry into Maternal and Child Health (CEMACH)
and an NHS Consultant at UCLH, and Dr Imelda Balchin, a Walport
ACF with an impressive track record in perinatal epidemiology.
Midwifery research
Closely related to the maternity challenges outlined above is the
need to develop midwifery research at UCL. This is also an aim
that is consistent with the vision for the IfWH, which envisages a
broader approach to improving women’ health than is currently
provided by a principally medical and biomedical paradigm.
Professor Linda Franck from the Centre for Patient Care Research
and Innovation at the ICH has obtained CBC funding for a Chair
in Midwifery and/or Gynaecologicall Nursing that will be key to
developing midwifery research education and career development,
specialising in clinical, patient-focused research.
Epigenetics
The role of epigenetic regulation of gene expression in early
placental development, fetal growth and pre-eclampsia is likely
to be of extreme importance to pregnancy success and is also
under-researched. Bringing together existing expertise within
the IfWH (Epigenetics group led by Dr Widschwendter) and ICH
(Professor Gudrun Moore, Molecular Genetics) to assess imprinting
of candidate genes in first trimester villi (chorionic villus sampling
(CVS) from UCLH FMU and Professor Nicolaides, Fetal Medicine
Foundation) has already started, is funded by a grant held jointly
by Professors Moore and Peebles and Dr Chitty) and will be
developed further.
Increased translational research
An immediate priority is to establish collaborations between the
UCL Department of Maternal and Fetal Medicine and Professor
Nicolaides’ outstanding research. His proven ability to recruit large
numbers of women to trials and observational studies, as well
as his expertise as one of the leading academic fetal medicine
specialists in the world are both unique advantages. Shared
areas of interest include preterm labour, prenatal diagnosis, fetal
growth restriction and early identification of women at risk of
53
MATERNAL AND FETAL MEDICINE – reSEaRCH
MATERNAL AND FETAL MEDICINE – reSEaRCH
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
TEN KEY MATERNAL AND FETAL MEDICINE PUBLICATIONS AT IfWH 2004–09
Reduction in diagnostic and therapeutic interventions by noninvasive determination of fetal sex in early pregnancy. Hyett JA,
Gardiner G, Stojilkovic-Mikic T, Finning KM, Martin PG, Rodeck CH,
Chitty LS. Prenatal Diagnosis 2005; 25(12):1111-6
This paper is one of the first to describe the use of non-invasive
prenatal diagnosis in a clinical setting and to demonstrate that
this technology can reliably be used to reduce the rate of invasive
prenatal diagnosis in high risk women. (19 citations)
Fetal nuchal translucency scan and early prenatal diagnosis
of chromosomal abnormalities by rapid aneuploidy screening:
observational study. Chitty LS, Kagan KO, Waters JJ, Nicolaides KH.
Br Med J 2006;332:452-4
Data showed that a policy of qf-PCR for all samples and karyotyping
only if the fetal NT thickness is increased would reduce the economic
costs, provide rapid delivery of results, and identify 99% of the
clinically significant chromosomal abnormalities. These data informed
the National Screening Committee guidelines on Down syndrome
screening.
Relationships between TGFbeta proteins and oxygen concentrations
inside the first trimester human gestational sac. Muttukrishna S, Suri
S, Groome N, Jauniaux E. PLoS ONE. 2008 Jun 4;3(6):e2302.
The first study to indicate a direct relationship between the early
intrauterine PaO(2) in vivo and inhibin A and sFLT-1 concentrations
confirming our hypothesis that specific placental proteins are
regulated by intrauterine O(2) tension.
Type 2 diabetes mellitus after gestational diabetes: a systematic
review and meta-analysis. Bellamy L, Casas JP, Hingorani AD,
Williams DJ. Lancet 2009; 373: (in press)
The increasing incidence of diabetes has highlighted the importance
of causative mechanisms. This study shows a clear link between
gestational diabetes and the increased risk of developing Type 2
diabetes in later life.
Pre-eclampsia and risk of cardiovascular disease and cancer in
later life: systematic review and meta-analysis. Bellamy L, Casas JP,
Hingorani AD, Williams DJ. BMJ 2007; 335: 974-79.
This meta-analysis showed that women who have had pre-eclampsia
have an increased risk of cardiovascular disease in later life. This
association might reflect a common cause for pre-eclampsia and
cardiovascular disease, or an effect of pre-eclampsia on disease
development, or both.
Widespread and efficient marker gene expression in the
airway epithelia of fetal sheep after minimally invasive
tracheal application of recombinant adenovirus in utero.
Peebles D, Gregory LG, David A, Themis M, Waddington
SN, Knapton HJ, Miah M, Cook T, Lawrence L, Nivsarkar M,
Rodeck C, Coutelle C. Gene Therapy 2004;11:70-8.
For treatment of cystic fibrosis, we developed a minimally
invasive ultrasound-guided method of injecting the fetal sheep
trachea in mid to late gestation. We showed for the first time,
that therapeutic levels of gene transfer to the fetal airways that
would be sufficient for prenatal therapy for cystic fibrosis, were
achievable.
Monocyte MHC Class II Expression in Term and Preterm
Labor. Lloyd J, Allen M, Azizia M, Klein N, Peebles D.
Obstet Gynecol; 2007, 110: 1335-1342
Demonstrated that monocytes from women in either term or
preterm labour are in a hyporesponsive state as a result of
previous inflammatory activation. This observation may have
major consequences in terms of vulnerability to puerpeural
sepsis.
Essential role of the AP-1 transcription factor c-jun in axonal
regeneration. Raivich G, Bohatschek M, Clive DaCosta C,
Iwata O, Galiano M, Hristova M, Wolfer DP, Lipp HP, Aguzzi A,
Wagner EF, Behrens A. Neuron 2004, 43:57-67
For many decades, neuronal injury has been known to cause
incisive metabolic changes that were suggested to play a
critical role in mediating repair. However, the actual drivers
of this repair in the living organism were unknown. The study
shows for a first time that neuronal transcription factor c-Jun is
such a master switch in allowing regeneration to occur.
Activation and deactivation of periventricular white matter
phagocytes during postnatal mouse development.
Hristova M, Cuthill D, Zbarsky V, Acosta-Saltos A, Wallace AS,
Blight K, Buckley SM, Peebles DM, Heuer H, Waddington SN,
Raivich G. GLIA, 2009, (in press)
This study showing that phagocytes are particularly numerous
and active in the developing white matter suggests another
reason why this area of the brain is so vulnerable to damage at
specific gestations and provides new avenues for developing
therapy to prevent cerebral palsy.
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY
MATERNAL AND FETAL MEDICINE – reSEaRCH
UCL EGA IfWH 1st Quinquennial Review
Local delivery of VEGF adenovirus to the uterine artery increases
vasorelaxation and uterine blood flow in the pregnant sheep. A L
David, B Torondel, I Zachary, V Wigley, K Abi Nader, V Mehta, SMK
Buckley, T Cook, M Boyd, CH Rodeck, J Martin, DM Peebles. Gene
Therapy 2008;15:1344-50.
Novel, exciting study describing a potential therapy for severe fetal
growth restriction using a viral vector to achieve local over-expression of
VEGF in the uteroplacental circulation in pregnant sheep. This resulted
in sustained increases in uterine artery blood flow.
54
55
UCL EGA IfWH 1st Quinquennial Review
REPRODUCTIVE HEALTH AND
BENIGN GYNAECOLOGY
REPRODUCTIVE HEALTH AND
BENIGN GYNAECOLOGY – CLINICAL
OVERVIEW
Benign Gynaecology and Reproductive Health incorporates several
key services within the division of women’s health. The clinical
director Tim Mould has overall responsibility for these services, as
well as the divisional manager Susan Sinclair and gynaecology
lead clinician Naaila Aslam.
These services consist of the following:
Gynaecology Diagnostic and Outpatient
Treatment Unit (GDOTU)
Rina Agrawal
Naaila Aslam
Gulam Bahadur
Rekha Bajoria
The unit provides a diagnostic service as well as outpatient
treatment for women with a wide range of both elective and
emergency gynaecological problems. The unit has a director
Davor Jurkovic and two consultant gynaecologists Naaila Aslam,
Rehan Salim. The consultants work closely with other members of
the team including four research fellows, one clinical fellow, nursing
and administrative staff.
Ertan Saridogan, consultant gynaecologist, leads the outpatient
hysteroscopy service within the GDOTU.
Paediatric and Adolescent Gynaecology (PAG)
Service
This service consists of two aspects:
Ratna Chatterjee
Paul Hardiman
Sarah Creighton
Joyce Harper
Suzy Elneil
Joseph Iskaros
Greg FitzHarris
Rehan Salim
Gynaecological problems in children and adolescents.This is led
by Sarah Creighton ,consultant gynaecologist, and takes place
both within UCH and Great Ormond Street Hospital (GOSH).
Other team members include a dedicated clinical nurse specialist
and clinical psychologist. The surgical aspects of the service are
supported by Alfred Cutner and ultrasound diagnosis by Naaila
Aslam. An African Women’s clinic has been incorporated into the
service dedicated to the care of young women affected by female
genital mutilation.
Multidisciplinary service for disorders of sex development
(DSD) in children, adolescents and adults. Together with GOSH
UCLH provides the largest and most comprehensive service
both nationally and internationally for individuals affected by
this condition. The team includes a gynaecologist, psychologist,
endocrinologists, urologists, genetics team and radiologists.
UCLH Endometriosis Service
This service is provided by a dynamic multidisciplinary team and
consists of high quality, evidence based care that aims to assess
and treat women with all grades of endometriosis.
Ertan Saridogan
56
Judith Stephenson
Alfred Cutner, Consultant Gynaecologist, is currently the service
lead. The team consists of three further gynaecologists; Ertan
Saridogan, Davor Jurkovic and Naaila Aslam. Mr Jurkovic and
Miss Aslam provide ultrasound assessment of these women and
medium level laparoscopic surgery. Mr Cutner and Mr Saridogan
provide high level laparoscopic surgery. There are two dedicated
clinical nurse specialists, Elsa Palmer and Sarah Parker and a
minimal access surgery fellow. In addition the team includes
two colorectal surgeons, one functional gastroenterologist, two
urologists, one radiologist and two pain management consultants.
Urogynaecology Unit
The unit consists of three consultant urogynaecologists – Suzy
Elneil, Alfred Cutner and Arvind Vashisht (locum), one physician
for the elderly, Adrian Wagg and a clinical nurse specialist, Mary
Remy. In addition there are two dedicated physiotherapists, a
continence nurse advisor and an HCA in continence, as well
as a clinical fellow. The unit works in close affiliation with the
departments of urology, functional gastroenterology and colorectal
surgery. Furthermore the unit closely interacts with the department
of uro-neurology at the National Hospital for Neurology and
Neurosurgery. Combined clinics with Professor Clare Fowler and
Dr Suzy Elneil take place within this setting. Patients are seen
by a neuro-physiologist, a urogynaecologist and a neurologist if
necessary. This service is unique within the UK and patients are
referred both locally and nationally.
57
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – clinical
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY
UCL EGA IfWH 1st Quinquennial Review
In addition the unit offers a dedicated postnatal urogynaecology
service, which is supported by a consultant midwife and two
consultant obstetricians.
Dr Adrian Wagg assists in providing care for elderly incontinent
patients, in particular those with multiple medical problems and
patients on complex pharmacotherapy. The provision of this
service within an urogynaecology setting enables senior patients
to be seen and treated in a single visit.
Reproductive Medicine Unit (RMU)
The RMU runs a dedicated service with the aim of providing a
multidisciplinary, patient-centred approach for the investigation
and treatment of couples with subfertility, and for women with
disorders of reproductive endocrinology, menopause and
premenstrual syndrome. The RMU is licensed by the Human
Fertility and Embryology Authority (HFEA) to carry out donor
insemination of sperm, intrauterine insemination and sperm
storage.
The RMU lead is Ertan Saridogan and the unit consists of two
other consultant gynaecologists: Melanie Davies and Rehan Salim,
Dr Gerry Conway is the consultant endocrinologist based within
the unit and Dr Elphis Christopher is a consultant in psychosexual
medicine. Dr Ratna Chatterjee is the senior lecturer within RMU
and Dr Francoise Shenfield is the clinical lecturer. In addition there
is an associate specialist, clinical psychologist, clinical scientist
and three clinical nurse specialists. There are two sub-speciality
trainees in post at present.
Assisted Conception Unit (ACU)
The ACU is a privately operated unit with a strong working
relationship with the Institute for Women’s Health. The unit offers a
comprehensive range of treatments including in vitro fertilization
(IVF) and intracytoplasmic sperm injection (ICSI ), and preimplantation diagnosis. The ACU lead is Mr Paul Serhal and the
unit has fifty members of staff. The clinical staff comprises of six
clinicians, seven embryologists and ten nurses.
The ACU has a leading national and international reputation in the
field of infertility and preimplantation genetic diagnosis. The ACU
is consistently one of the leading IVF units in the UK with a live
birth rate of 65% in woman less than 35 years of age per cycle of
IVF treatment. The unit works very closely with RMU and has for
the last year been treating NHS patients jointly with the RMU.
STRATEGY, AIMS AND OBJECTIVES
GDOTU
The aim of the unit is to provide a comprehensive clinical service
to women with both urgent and non-urgent gynaecological
problems in a single visit where possible. By employing
experienced staff and providing state of the art diagnostic
equipment, outpatient care is effective and results in a decrease
in the number of follow up visits and a significant reduction in the
number of invasive diagnostic operative procedures. This leads
to shorter waiting times and more effective utilisation of operating
theatre time.
58
UCL EGA IfWH 1st Quinquennial Review
PAG service
UCLH is the only hospital in the UK to offer such a comprehensive
and multidisciplinary service for complex congenital anomalies
and is recognised as a National and International Model of Care.
The primary aims are to improve transition from paediatric to adult
services, to expand laparoscopic reconstructive surgery, educate
clinicians and conduct research. To this end a multidisciplinary
adolescent Disorders of Sex Development (DSD) clinic has
been established. UCLH is the only unit within the UK to offer all
aspects of laparoscopic paediatric and adolescent gynaecology.
There is an established website for this service (www.uclh.nhs.uk/
middlesexcentre) providing information on the conditions treated.
A vast amount of research has been undertaken within this service
over the last ten years on gynaecological and sexual outcomes in
DSD.
UCLH Endometriosis Service
This service aims to provide state of the art, high quality, evidence
based and patient-centred treatment for the management of all
grades of endometriosis. A multidisciplinary team is in place
to provide this service. Patients are referred both locally and
nationally. There is an established website for this service (www.
theendometriosiscentre.co.uk) providing details of the condition
and management.
Urogynaecology Unit
The main strategy over the past few years has been to develop the
multidisciplinary team fully. This has involved recruiting nursing
and dedicated physiotherapy staff. The physiotherapists roles
are currently being developed into those of Expanded Scope
Practitioners. We are in the process of recruiting a substantive
consultant to join the team. The aim of the unit is to provide a
fully integrated multidisciplinary service for problems affecting
the pelvic floor and its associated organs. In addition it aims to
provide a nationally recognised postnatal urogynaecology service,
a specialist service for management of complicated pelvic
organ prolapse and urinary incontinence as well as neurological
dysfunction of the pelvic floor. Finally it is to provide a nationally
accredited centre of excellence in training, education and research
in women with urogynaecology problems. Recently a one-stop
clinic facility has been set up – allowing patients to be seen by the
physiotherapists, clinical nurse specialists and urogynaecologists
in a single visit.
RMU
As well as offering general fertility services, the RMU offers
a number of specialist services. These include recurrent
miscarriage, premature ovarian failure, late effects clinic and the
fertility preservation service run by Melanie Davies. In addition
Ertan Saridogan offers advanced minimal access surgery for
condition such as endometriosis and tubal surgery. Rehan Salim
runs the menopause and premenstrual syndrome (PMS) service.
Gerry Conway leads the polycystic ovarian syndrome clinic and the
ovulation induction programme. Ratna Chatterjee runs a specialist
clinic in the reproductive health of women with chronic disease.
Francoise Shenfield has been running the donor insemination unit
and is responsible for the clinical co-ordination of this programme.
Counselling is an integral part of the service and is provided
by a clinical psychologist and Dr Christopher runs a weekly
psychosexual medicine clinic.
The IUI and ovulation induction services are supported by the
fertility clinical nurse specialists (CNS). RMU is currently providing
a small number of NHS IVF cycles as a satellite unit in collaboration
with the Assisted Conception Unit (ACU). Our aim is to set up an
NHS IVF service over the next year by collaborating with ACU.
ACU
In addition to providing IVF services both for private and NHS
patients, the Assisted Conception Unit (ACU) has a leading role
in the clinical application of scientific development in the field
of preimplantation genetic diagnosis (PGD). This includes the
prevention of genetically inherited cancers. In all its activities
the unit seeks to be a bridge between scientific endeavour and
clinical excellence. Optimising embryo culture is central to our
strategy and currently this is the subject of ongoing research
involving dynamic embryo culture and metabolomic. The unit has
been at the forefront of the introduction of vitrification as a means
of cryopreservation of eggs and embryos. The ultimate aim is to
establish the UK’s first egg bank of vitrified eggs. Other research
includes optimisation of drug regimes for ovarian stimulation in
poor responders and the introduction of 3D ultrasound imaging in
the investigation and treatment of infertile couples.
UCLH Endometriosis Service
The clinical nurse specialists see women initially at UCLH and
act as a point of contact. Women are scanned at their first visit
and a management plan is made by one of the gynaecologists.
There is a website available for the service, which details patient
management (www.theendometriosiscentre.co.uk). Surgery
takes place on one of three operating lists depending on the
severity of the disease. There is a monthly joint operating list with
the colorectal surgeons for cases where bowel surgery will be
required. Two consultant urologists are also involved in cases as
necessary. There is now a national database to collect outcome
data from these women.
There are two dedicated pain management consultants who offer
chronic pain management for women affected by this condition.
The unit at UCLH is one of twelve units within the UK offering
integrated endometriosis care.
Due to the large number of women referred with severe disease
further support in manpower is required to support advanced
laparoscopic surgery. In addition there is inadequate administrative
support for this service. The clinical nurse specialists spend a
considerable amount of time ensuring clinics are appropriately
booked.
Urogynaecology Unit
The Trust has provided adequate space, staffing and equipment,
which has enabled the unit to reach its objectives within 12
months of establishing this new service. The outpatient theatre is
fully functional and there are adequate recovery and counselling
facilities.
This comprises four dedicated rooms in the EGA building: an
urodynamics room, two physiotherapy rooms and an uroflowmetry
room. All the other clinical rooms are shared with colleagues in
the Breast, general gynaecology and RMU services. The unit
is financed solely by UCLH. With regards to staff the following
substantive appointments need to occur in order to maintain
current activity levels: nurse continence advisor, consultant in
urogynaecology (locum in post at present) and sub-speciality
trainee in urogynaecology. New equipment has been recently
installed to support this service. However, in the future more
equipment would need to be purchased if the service were to
expand.
PAG Service
RMU
The clinics take place within the GDOTU. This has led to a dramatic
improvement in access to good quality pelvic ultrasound. The
waiting times for clinics are between 10 to 12 weeks and as a result
extra clinics have been taking place to try and meet the demand.
However, the number of clinic rooms available is limited due to high
demand from other areas. There is appropriate access to theatre
space as required.
The RMU has recently moved into the basement of the new EGA
wing. There are four clinical rooms available and three additional
rooms for consultation only. The space is limited – two of the
clinical rooms are small and cramped. The air conditioning system
is noisy and this is particularly noticeable in the smaller rooms.
The waiting facilities are inadequate – the chairs are arranged
along the corridor, with space that lacks privacy and for only eight
couples in total.
RESOURCES
GDOTU
The service is supported financially by the Trust and all the
equipment is new and of a high standard.
Junior doctors need to be timetabled to attend these activities in
order to improve their training. There is one dedicated SpR and a
clinical nurse specialist. This service has inadequate secretarial
and administrative support – there are no dedicated personnel.
This means that the clinical nurse specialist spends a significant
amount of time ensuring notes are present and preparations
adequate for the clinic.
There is a new laboratory adjacent to the RMU, which is
responsible for seminology and sperm storage. The laboratory
currently stores samples from over 2000 men who were diagnosed
and treated for cancer. The fertility laboratory fulfils all the
requirements expected from such a laboratory, and has been
designed to a high specification.
There is the potential to co-locate the current RMU and ACU within
the new EGA wing, so that these two entities would combine to
form a fully comprehensive reproductive medicine centre.
59
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – clinical
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – clinical
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
ACU
PAG Service
The ACU is currently based at the Eastman Dental Hospital. The
unit has grown for the last few years and consequently is seeking
larger premises particularly to accommodate the potential increase
in the number of NHS patients.
This is a leading national and international centre for complex
congenital anomalies. This service is recognised as the National
and International Model of Care. Patients are referred from across
the UK and Eire. In 2007, over 60 specialised reconstructive
procedures were performed.
PERFORMANCE AND MEASUREMENT
OF QUALITY OF ALL ACTIVITY
Over 400 patients were seen within the service last year. On
average the initial consultation for patients with DSD lasts
between one to two hours.
GDOTU
Trainees and consultants visit regularly from around the UK. We
provide the PAG module for RCOG subspecialty trainees from all
London regions and Oxford. In 2004 the service was recognized
as the most comprehensive multidisciplinary joint intersex service
by the Royal College of Paediatrics and Child Health (RCPCH).
See Publications booklet for list of publications.
The Gynaecology Diagnostic and Outpatient Treatment Unit have
implemented striking changes in the service. Over 10,500 patients
were seen within the last year. An audit of activity over the first year
has shown a significant change in the ratio of new to follow-up
elective Gynaecology appointments from 1:6 to 10:1. This is largely
due to improved diagnostics within the one-stop clinics.
The waiting time for the initial appointment has been reduced
from 20-40 weeks. There has been a 30% reduction in the number
of diagnostic hysteroscopies and waiting times for outpatient
hysteroscopy have been reduced from two months to two weeks.
The efficacy of diagnosis in early pregnancy has also been
improved, with a 30% reduction in the number of non-diagnostic
ultrasound findings. The number of women managed expectantly
has risen to 70% in cases of miscarriages and to 30% in cases of
ectopic pregnancies. The number of emergency gynaecological
admissions has decreased by 40% despite the increase in
numbers of women seen within the acute diagnostic service.
The unit is a major training centre. Currently there are six
gynaecology consultants and senior SpRs from other hospitals
attending for ultrasound training. We have three senior
trainees undertaking the Royal College of Obstetricians and
Gynaecologists (RCOG) advanced training skills module in Early
Pregnancy and Acute Gynaecology.
The outpatient hysteroscopy service has treated over 1,100
patients from 2001 to 2007. Hysteroscopic examination was
successfully completed in 96% of women and the majority of
women seen were amenable to a see and treat approach. This has
obvious benefits for patients, employers and society. It obviates
the need for general anaesthesia and theatre time. Outpatient
hysteroscopy has been shown to have significant cost savings.
UCLH Endometriosis Service
This is one of approximately 12 units across the UK offering
integrated endometriosis care for women with severe disease.
Our service is both nationally and internationally recognised, with
the majority of patients being referred for laparoscopic surgical
management. We have seen a continued increase in the number
of patients referred into the service.
177 women underwent fertility-sparing laparoscopic excision
of deeply infiltrating endometriosis over a two year period
between 2006 and 2007. Almost one quarter of these cases were
performed jointly with the colorectal surgeons and greater than
40% of women overall required some form of bowel surgery. The
short-term complication rate was low (3.4%).
An advanced endometriosis and laparoscopic surgery course
has been running for the past two years. In addition Alfred Cutner
and Ertan Saridogan run a yearly advanced laparoscopy course
in Hamburg.
We have a minimal access surgery fellow undergoing a two year
training programme in advanced laparoscopic surgery. This
follows the RCOG advanced training skills module. Research has
mainly involved outcomes of surgical management of severe
endometriosis (see Publications Booklet).
Urogynaecology Unit
This is a tertiary referral unit offering a comprehensive range of
medical and surgical services. Alfred Cutner offers advanced
laparoscopic surgery for prolapse and patients are referred
nationally. This is the only unit within the UK that offers uterine
preservation prolapse surgery. The urogynaecology unit is one of
only two laparoscopically-accredited centres for urogynaecology.
Alfred Cutner provides a training facility for colleagues and
trainees to observe and learn this type of surgery.
Suzy Elneil offers complex vaginal surgery and in particular
fistula surgery. This unit is one of only two within the UK offering
a vaginal approach for genital tract fistulas, which is associated
with a lower morbidity compared to abdominal surgery. Patients
are referred nationally to this service.
60
Finally the unit runs a multidisciplinary postpartum service
offering specialist care to women following childbirth. The team
consists of functional gastroenterologists, colorectal surgeons,
physiotherapists, continence nurses, midwives and obstetricians as
well as urogynaecologists. Initially the clinic reviewed ten patients
per month. This has now increased to eleven patients per week.
Women are referred from both UCLH and surrounding hospitals.
Combined clinics at the National Hospital for Neurology and
Neurosurgery (NHNN) offer cutting-edge treatments, such as
botulinum toxin therapy to the bladder and sacral neuromodulation.
The unit at the NHNN is the national training centre for both
procedures.
There is also a dedicated integrated urogenital pain service offered
at the pain management centre at the NHNN. Patients with complex
regional pain syndromes of the bladder, pelvis and perineum
are seen by a multi-disciplinary team. Most patients are referred
nationally for this service and are seen and treated at a single visit.
With regards to training the unit has a sub-speciality trainee and
a clinical fellow. In the last year we were joined by an honorary
clinical fellow from Europe training in urogynaecology.
RMU
As a tertiary referral centre, the RMU provides care for a large
number of women with cancer, genetic disease and chronic
diseases offering reproductive health support. The RMU is a
nationally recognised centre for reproductive surgery and fertility
preservation. There are approximately 1500 new referrals to the
RMU per annum.
Over 6,500 patients were seen last year. See Appendix 5.1 for RMU
success rates over the past three years.
Patient satisfaction surveys are conducted regularly within RMU.
The previous three surveys have shown a broad level of high
satisfaction (greater than 85%) with the service. Earlier surveys
revealed inadequate psychological support – this was addressed
and has shown a 15% improvement in scores. The remaining area
of weakness is the waiting time for appointments. This is being
addressed by the introduction of one-stop fertility clinics.
ACU
Key performance criteria include laboratory and clinical outcomes,
patient satisfaction as well as academic publications. The unit has
had one of the highest live birth rates in the country and the patient
satisfaction surveys have been very satisfactory. The number of
patients being treated has increased steadily as a reflection of our
favourable results.
The whole of Gynaecology is 18 weeks compliant, i.e. patients
are seen within 18 weeks from the time of referral to the start of
treatment.
AREAS OF EXCELLENCE
GDOTU
This is one of the few comprehensive diagnostic units within the
UK. Davor Jurkovic is recognised as one of the leading world
experts in early pregnancy and gynaecology ultrasound.
Davor Jurkovic is Chair of the RCOG Early Pregnancy Study Group
– which is part of the National Reproductive Research Network.
PAG Service
The multidisciplinary service offered with Great Ormond Street
Hospital is recognised as the national and international model of
care. Sarah Creighton is the Chairwoman and founding member
of the British Paediatric and Adolescent Gynaecology Society. This
service has developed innovative laparoscopic procedures e.g. the
world’s first report of laparoscopic treatment for cervical agenesis.
UCLH Endometriosis Service
This is a nationally and internationally recognised service. Alfred
Cutner is the President of the British Society of Gynaecological
Endoscopy and has developed the RCOG ATSM in advanced
laparoscopic surgery. Alfred Cutner is due to go on a one year
secondment from April to assist in setting up an endometriosis
service in Cornwall.
Urogynaecology Unit
The training opportunities offered by our unit are unique, and many
trainees from around the UK attend the unit both at UCLH and
NHNN to learn about the specialized treatments available. The joint
services offered at the NHNN are recognised nationally.
Members of the unit are regularly invited to speak at local, national
and international meetings. The urogynaecology team regularly run
workshops at the International Continence Society meetings, the
International Urogynaecology Association, the British Society of
Gynaecological Endoscopy and the UK Continence Society. The
unit runs a monthly North London Multidisciplinary Team (MDT)
Network Meeting.
RMU
This is the regional centre for preservation of male fertility (sperm
storage). Melanie Davies sits on the Human Fertilisation and
Embryology Authority (HFEA) advisor body and RCOG working
party for National Donor Screening. Francoise Shenfield is a UK
member of the European Society of Human Reproduction and
Embryology (ESHRE) executive. Ertan Saridogan is a member of
ESHRE endometriosis special interest group working party and
board member of the International Society of Fallopian Tubes.
ACU
The Assisted Conception Unit is consistently one of the leading IVF
Units in the UK with a live birth rate per cycle of treatment of 65%
in women under 35.
Research led by the Assisted Conception Unit has contributed to
outstanding success rates in IVF. Collaboration with the Prenatal
Genetic Diagnosis Group (Joyce Harper) has led to several
‘world firsts’ including the first BRCA1 tested PGD baby delivered
in December 2008. The same technology has been applied
successfully for patients with familial adenomatous polyposis (FAP),
retinoblastoma (RB) and neurofibromatosis (NF1). ACU has led the
field and has become the major centre offering pre implantation for
all cancer predisposing genes.
61
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – clinical
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – clinical
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
CHALLENGES
ACU
Urogynaecology Unit
PAG Service
GDOTU
The major challenge for ACU is to acquire appropriate new
premises and to maintain its current position as a leading IVF
provider.
Urogynaecology conditions may affect women throughout their
life cycle. The Patients seen range from teenagers with recurrent
urinary infections, to women in their reproductive years with
postpartum problems, and finally postmenopausal women with
prolapse and urinary incontinence. The unit offers a streamlined
multidisciplinary service for all women, of all ages. A one-stop
clinic is in development. The unit is nationally recognised for
developing laparoscopic and complex vaginal surgical techniques
and offers training and education in these areas. The clinical
service and training offered in uro-neurology, urogenital pain and
neuro-gynaecology is also nationally recognised.
The service is moving away from surgical and condition based
research to holistic assessment of long-term well being of
individuals with DSD. An increase in the number of referrals is
expected as general gynaecologists and urologists are less able to
deal with complex problems. There will be increased emphasis on
psychological interventions and increased involvement of patient
groups. Finally we expect to see increasing expectations of young
patients, who now have a good life expectancy and the same
reproductive and sexual aspirations as their peers.
The unit has only been operational for twelve months. There have
been a number of minor problems, which were expected to occur
before the unit becomes fully established and operational. The
added difficulty was the recent move of the service after being in
place for ten months. We are now settling into the new space. The
amount of clinic space is sufficient. However, the waiting facilities
are poor and this is a continuous source of distress to patients and
staff. There are 27 chairs in total in the waiting area.
There are no facilities provided for leaflets / magazines for patients
while they wait. There is no dedicated space available for children.
The facilities are currently being reviewed and a patient satisfaction
survey is in progress. The clinic is located in the basement, without
any natural light, which causes problems for some members of
staff who spend their entire working week in the clinic.
PAG Service
There is a lack of administrative and secretarial support for this
service. The outpatient clinic space is limited and there is a lack of
recognition by managers of this highly specialised labour intensive
service due to perceived low activity.
There has been a lack of administrative support available for
research in the past. This will hopefully be improved by the recent
appointment of a joint UCL/UCLH research co-ordinator.
IMPACT AND IMPORTANCE
GDOTU
This service offers easily accessible, high quality patientcentred care for women. Our early pregnancy service
ensures that all women are given rapid clinical and ultrasound
assessment, combined with clear management advice. There is
a robust follow up structure in place and counselling support.
Many women receive supportive non-interventional care, which
minimises the impact of their condition on their social and
psychological well-being.
The gynaecology service has been transformed with the
introduction of one-stop clinics – this is reflected in the ratio of
new to follow-up appointments. This has enabled us to become
18 weeks compliant.
Women with suspected gynaecological cancers are seen
within two weeks. The majority of women with benign disease
are reassured, whilst a minority with cancer are referred to the
gynaecology oncology clinics without delay.
PAG Service
UCLH Endometriosis Service
There is inadequate administrative support for this service.
Furthermore there is inadequate medical staffing to support the
increased clinical referral base. This is particularly true for surgical
capacity for advanced cases. This has been addressed, with an
additional substantive consultant due to be recruited soon.
Urogynaecology Unit
Nursing and medical staffing levels continue to be a cause of
concern. This has been partly addressed by recruitment of a
new substantive consultant colleague within the next few months.
There are ongoing discussions regarding permanent positions for
nursing staff. A dedicated urogynaecology office space within the
unit would act as a good focal and academic point as well as a
research space. There is currently no space available.
In the past, this group of women have been poorly treated
by the medical profession. A policy of non-disclosure of the
diagnosis to the patient and their families has been widespread.
Other controversial areas include the role of feminising genital
surgery particularly in children who cannot consent. Our
multidisciplinary clinic treats patients with respect, dignity
and honesty. There is a policy of complete openness and of
disclosure of all medical information to patients in a supportive
environment. There is a paucity of long-term objective outcome
information on psychosexual, gynaecological and psychosocial
outcome in DSD. Many of our patients are involved in research
studies and Sarah Creighton has published extensively in this
field. Research undertaken in this service is informing debate
around the world and has already changed paediatric surgical
practice.
UCLH Endometriosis Service
RMU
The RMU aims to become a fully comprehensive reproductive
medicine service and a national centre of excellence. Achievement
of this aim is hampered by the lack of a NHS IVF service. This
leads to women being referred to other units for IVF treatment. In
addition the lack of IVF is preventing RMU from providing cutting
edge services to women who require preimplantation genetic
diagnosis (PGD) or egg/embryo freezing prior to cancer treatment.
Literature suggests a prevalence of endometriosis of between
3 and 10% of the general population. The prevalence of severe
disease within this group ranges from between 5 to 30% and
can be debilitating. There is a demand for this service and as
a result of the varied clinical manifestations a multidisciplinary
team approach is essential. We offer a truly integrated service
for patients ranging from expectant and surgical management to
chronic pain management and we are a tertiary referral centre.
Members of the unit sit on various national and international
committees for the development of new pharmacotherapies,
development of laparoscopic services and techniques, promoting
sacral neuromodulation and overcoming fistulas around the world.
The unit is actively involved in raising the public awareness of
urogynaecological problems and their solutions by talking at
GP surgeries, annual Wellbeing of Women Fair, the European
Parliament and at the House of Lords.
RMU
The unit is nationally renowned for reproductive endocrinology,
reproductive surgery and late effects services.
ACU
The unit has contributed to outstanding success in IVF. It has an
international reputation and has had several world firsts including
the first BRCA1 tested. PGD baby delivered in December 2008.
The same technology has been applied successfully for patients
with familial adenomatous polyposis (FAP), retinoblastoma (RB)
and neurofibromatosis (NF1). This has resulted in favourable and
extensive international media coverage. The ACU has led the
field and has become the major centre offering preimplantation
diagnosis for all cancer predisposing genes.
FUTURE DEVELOPMENTS
GDOTU
We expect that the number of patients attending the unit will
continue to increase, which will require a regular review of staffing
and facilities. We have recently established operative outpatient
treatment of miscarriages, which we will expect to have a
significant impact on the number of patients admitted for inpatient
treatment.
UCLH Endometriosis Service
With the increasing number of referrals it is imperative to increase
our medical staff and in fact we are due to recruit a new consultant
to the service in the near future. We are planning to expand the
role of the clinical nurse specialists. We will continue research into
advanced endometriosis and ultrasound diagnosis.
Urogynaecology Unit
The immediate aims are to complete the move of the
urogynaecology unit to the new EGA wing and to ensure the 18
week targets continue to be met by maintaining staffing levels. We
aim to introduce one-stop clinics by the end of the year.
We aim to promote the monthly North London MDT Network
Meetings and become involved in research collaborations across
the network.
We hope to develop a research base at UCLH, with dedicated
sessions for an academic consultant within urogynaecology.
Finally we would aim to continue to develop and run specialist
courses such as the UCLH perineal trauma course, laparoscopic
urogynaecology study day and urogynaecology for continence
nurses.
RMU
The main objective is to develop a NHS IVF service within UCLH.
This would lead to provision of a comprehensive PGD and fertility
preservation service.
UCL has a nationally recognised PGD team, who are currently
working with the privately funded ACU.
The ACU is one of the most successful fertility clinics in the UK and
the potential of a merger of RMU and ACU into a fully functional
reproductive medicine centre is exciting. This would inevitably lead
to an increase in research output in this area.
We are planning to expand the diagnostic service by establishing
recurrent miscarriage clinics and outpatient invasive tests of tubal
patency in women with subfertility.
We are planning to increase our research activity by initiating and
participating in multicentre clinical trials in early pregnancy and
gynaecology.
The current RMU space is limited and this needs to be addressed
if the service is to expand.
62
63
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – clinical
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – clinical
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
REPRODUCTIVE HEALTH AND
BENIGN GYNAECOLOGY – RESEARCH
OVERVIEW
Research in reproductive health is managed/led by a recently
established UCL Research Department of Reproductive Health
(HoD: Professor Judith Stephenson) with extensive academic
and NHS collaborations. Clinicians and scientists work across the
spectrum of basic science through clinical research to populationbased research and randomised trials. Basic science research in
oocyte physiology and chromosomal disorders is linked closely
with the Division of Biosciences in the Faculty of Life Sciences;
clinical research is integrated with gynaecology services across
UCH, Royal Free Hospital (RFH), the Whittington Hospital, the
Institute of Neurology and Great Ormond Street (GOSH), while
sexual health research is integrated with community-based
services. Study of cardiovascular morbidity associated with
polycystic ovarian syndrome links basic science and clinical
research with an epidemiological ‘lifecourse’ approach to women’s
health, through the MRC Unit for Lifelong Health and Ageing.
The scope of reproductive health research is broad in terms of
disease focus as well as methodology. It encompasses paediatric
and adolescent gynaecology, including rare disorders of sexual
development, subfertility, use of gynaecology ultrasound to
improve diagnostics and patient management (e.g. in ectopic
pregnancy, ovarian tumours), reproductive health in chronic
disease, and prevention-related research into major public health
issues, including obesity and risk of diabetes associated with
polycystic ovarian syndrome, sexual health, teenage pregnancy,
abortion and sexually transmitted infections (STI). UCL has
established a UK Clinical Research Network of communitybased services to conduct investigator-led trials in sexual and
reproductive health.
Three themes are led by full time NHS clinical consultants:
Research in paediatric and adolescent gynaecology is led by
Sarah Creighton
Research into long term outcomes of disorders of sexual
development is led by Gerard Conway
Research in use of gynaecology ultrasound to improve
diagnostics and patient management is led by Davor Jurkovic,
recruited to IfWH in 2008.
Three themes are led by UCL clinical academics:
Oocyte/embryo research is led by Hayden Homer
Research into polycystic ovarian syndrome is led by Paul Hardiman
Research in sexual and reproductive health is led by
Judith Stephenson.
In addition, clinical research in subfertility is conducted by Paul
Serhal (Director of the Assisted Conception Unit), with contribution
from NHS consultants Melanie Davies, Rehan Salim and Ertan
Saridogan. Research into fertility preservation in cancer patients is
led by Gulam Bahadur and Paul Serhal with UCH/RF clinicians,
64
subsequent live birth rates through assisted conception. The
objectives of the basic research are to describe the molecular
regulation of chromosome segregation during female mammalian
first meiotic division; to study mechanisms of spindle assembly
and spindle microtubule dynamics, and fundamental aspects of
early mammalian embryo development. Owing to limited access
to human oocytes, current strategy is to use a mouse model for
basic understanding of cellular control mechanisms in oocytes and
embryos and, in particular, to develop experimental approaches
that can be applied to single cells. This will enable us to extend
our research from mouse to human oocytes and embryos. Another
strand of research aims to improve fertility preservation in cancer
patients through understanding and reducing the gonadotoxic
effects of chemotherapy. The objectives of clinical research
at the ACU are to improve the diagnosis and management of
patients with poor ovarian reserve through development of 3D
ultrasound assessment of follicle count and size and investigation
of responses to various stimulatory drug regimens; to identify
novel, non-invasive tests such as metabolomics, proteomics and
genomics in order to improve the embryo selection process; to
improve blastocyst survival rates e.g. by minimising cryo-injury
from vitrification (ultra-rapid freezing); to optimise oocyte freezing
using vitrification in order to establish the first egg bank that will
optimise management of cancer patients and egg recipients;
and to improve the in vitro environment that influences blastocyst
conversion rate and embryo quality, using a novel dynamic
culture technique. The strategy is to align these innovative clinical
approaches more closely to the oocyte / embryo research to
improve pregnancy and birth outcomes.
Polycystic ovarian syndrome (PCOS)
Margaret Pyke Centre
and research into reproductive health in chronic disease
(e.g. haemoglobinopathy, cancer and renal disease) is led by
Ratna Chatterjee who is currently running the first distance
learning MSc course in haemoglobinopathy.
The overarching aim of our research is to improve the reproductive
and sexual health of women by conducting internationally competitive
translational research. Our strategy is to focus on a few key areas
in which the IfWH can make a major contribution to the field.
STRATEGY, AIMS AND OBJECTIVES
Infertility and oocyte and embryo research
The aim of this theme is to develop and evaluate new approaches
to improve the treatment of subfertility and preservation of fertility.
Basic oocyte / embryo research aims to describe the molecular
regulation of mammalian oocyte and embryo development in order
to understand the mechanisms underlying human reproductive
problems, while clinical research aims to improve pregnancy and
The aim of this theme is to describe the mechanisms responsible
for increased risk of diabetes, cancer and coronary heart disease
in women with PCOS and to evaluate interventions to improve
clinical outcomes in these women. The objectives are to identify
mechanisms leading to viscoelastic and endothelial abnormalities;
to describe the molecular abnormalities of the endometrium in
relation to neoplasia and implantation; to explore the epigenetic
effects of prenatal androgen in babies born to women with
PCOS and to evaluate an intervention to reduce the maternal and
neonatal morbidity associated with this syndrome. The strategy has
been to build up effective collaborations within and outside IfWH
in order to obtain further grant income in pursuit of these aims and
objectives.
Sexual and reproductive health
The aim of this theme is to improve sexual health by reducing rates
of unintended pregnancy, abortion and STI. Although control of
fertility is essential to women’s health, the academic leadership,
research capacity and infrastructure needed to support high
quality contraceptive research is lacking. UCL has the only
senior clinical academic post for contraceptive research in the
UK. Our strategy has been to establish a UK research network
of community based services to enable high quality multicentre
studies with an initial focus on contraceptive research. The
research objectives are to help women choose contraceptive
methods that suit their needs and respect their values, and
to evaluate interventions that lead to more effective use of
contraception and prevent unintended pregnancy.
Currently underway is a multi-centre trial to compare standard use
of the combined pill with a new form of extended use of the same
pill. Projects starting in 2009 include a placebo-controlled trial of
local analgesia for insertion of intrauterine contraception, a study
of spontaneous clearance and response to treatment of genital
Chlamydia infection, and the prevalence of Mycoplasma genitalium
in women at risk of STIs.
Disorder of sexual development and paediatric
and adolescent gynaecology
Together with GOSH, UCH provides the UK’s largest and most
comprehensive service for individuals with disorders of sex
development (DSD). We are world leaders in clinical care and
research. The aim is to improve the gynaecological, psychological
and psychosexual outcomes in those diagnosed with a DSD
in childhood. We are the first group to publish objective longterm results for this group of adolescents and young women.
Our results have shown a high incidence of gynaecological and
sexual difficulties and have led to a world wide re-evaluation of
paediatric surgical policy. We have also developed innovative
surgical techniques for treatment of complex mullerian anomalies
such as laparoscopic vaginal reconstruction. Parallel research
into the reproductive endocrinology and genetic aetiology of DSD
aims to improve long term medical outcomes. Currently funded
projects include heterozygosity mapping of consanguineous
families with ovarian dysgenesis and characterisation of well being
in older women with Turner Syndrome. The Adult Turner Syndrome
service is a reference population for mapping the natural history
of this condition which is the major contributor to NIH guidelines
on management. This cohort is also the basis of a European
collaboration on cardiovascular management.
Improving gynaecological diagnosis and
management
Following the establishment of a world-class gynaecology
diagnostic and outpatient treatment unit, a research strategy is
being developed to strengthen the evidence base for transforming
gynaecology outpatient care. The aim is to provide a modern and
effective service that minimises the need for follow up visits and
reduces the number of operative diagnostic procedures.
The current research themes include:
Use of gynaecological ultrasound for diagnosis of
ovarian abnormalities
Diagnosis and management of endometriosis
Diagnosis and clinical significance of adenomyosis
Management of early pregnancy complications
RESOURCES
In general, reproductive health research has been spread across
several sites and campuses, including UCH (old EGA hospital),
Margaret Pyke Centre (contraceptive service in Charlotte St),
Eastman Dental Institute (Assisted Conception Unit, privately
managed, Grays Inn Road), Gower Street (Oocyte / Embryos Labs
shared with the Department of Cell and Developmental Biology),
and the Royal Free. New space is provided in the EGA wing for
65
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – RESEARCH
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – RESEARCH
UCL EGA IfWH 1st Quinquennial Review
clinical services in reproductive medicine, with discussion in
progress about building up an NHS IVF service. Shared research
space could only improve prospects for more collaborative
research in reproductive health.
Space
The oocyte and embryo research laboratory is based in the
Research Department of Cell and Developmental Biology in the
Division of Biosciences. There is sufficient space to accommodate
ten researchers at any one time. The laboratory is well supplied
with microscopes and imaging rigs for fluorescence studies
in single oocytes. The group have access to two confocal
microscopes immediately opposite the main laboratory. We have
recently established a new molecular biology and biochemistry
laboratory. The Assisted Conception Unit has 50 staff and is fully
equipped for clinical procedures and laboratory research including
ultrasound imaging. It is currently located at the Eastman Dental
Hospital, Grays Inn Road, but plans for the establishment of an IVF
Unit in the new EGA Hospital are in progress.
Staff and finances
Hayden Homer has a Wellcome Trust Clinical Fellowship (£680,000)
and one post-doc research associate. Greg FitzHarris is a Lecturer
and MRC New Investigator, funded by an MRC grant (£400,000)
has one post-doc research associate and one PhD student. John
Carroll has funding from MRC (£1.2 million), which supports two
post-docs, one research technician and three PhD students.
PCOS research is based at the Royal Free. Staff and finances:
Paul Hardiman, theme lead, is HEFCE funded. The team comprises
Rina Agrawal (locum consultant and honorary senior lecturer),
Anne Marie Galagher, a fertility nurse specialist and Jackie Doyle,
a clinical psychologist, funded by RF Trust.
Research in sexual and reproductive health is located in the
Margaret Pyke Centre.
Space
Three small offices (rent paid by Margaret Pyke Trust).
Staff and finances
Judith Stephenson (theme lead) funded by UCLH and Camden
PCT. Heidi Chandler, PA/research administrator, part-funded by
Camden Primary Care Trust (PCT). Sue Mann, SpR in public
health, funded by Deanery. Sabeena Panicker (clinical research
associate) and Jill Shawe (research nurse) are fully grant funded.
PhD and MSc students are registered with UCL Division Population
Health. New grant income awarded to Judith Stephenson as PI in
2007–8 is over £800,000
In Paediatric and Adolescent Gynaecology, research is carried out
within the confines of NHS clinical practice. Staff include Sarah
Creighton (theme lead), a senior psychologist and occasional
research fellow. NHS staff have no research sessions and no
academic or administrative support. Grant funding: £200,000 since
2000. Long term outcomes of DSD: Gerard Conway (theme lead);
Margaret Band (research nurse) funded by Birth Defects;
Dr La Rosa (Research Fellow) funded by Child Growth Foundation.
Pilot projects are developed with visiting research fellows – two per
year recently from Greece, Italy, Hong Kong and Spain.
66
UCL EGA IfWH 1st Quinquennial Review
PERFORMANCE AND MEASUREMENT
OF QUALITY OF ALL ACTIVITY
Long term outcomes of disorders of sexual development
The clinical resource of Turner Syndrome, PCOS, Ovarian Failure
and Adrenal Hyperplasia are the largest ever developed and have
become source material for wide research collaborations and
UCLH based projects. In addition, the model of care has been
used for new services in Europe Japan and Australia as we were
the first to focus on long term outcomes of paediatric conditions.
This area is now sought after by visiting research fellows to develop
clinical expertise that can be applied to their home centres.
Publication output is substantial relative to the size of the
department, with over 270 publications since 2004. Grant income
is relatively low. See appendices for full list of publications and
grants. For research that has had a demonstrable impact on health
care or health policy see section Impact and Importance.
Other markers of esteem such as prizes and national research
leadership roles:
Gynaecology Diagnostic and Outpatient Treatment Unit
First Walport Lecturer across all specialties in the UK to attain
Clinician Scientist status (Homer); RCOG, Harold Malkin Prize
and Blair Bell Society Prize (Hayden Homer)
Davor Jurkovic, GDOTU Director, has a strong research record in
the field of diagnostic ultrasound in gynaecology and management
of early pregnancy complications. Recently (Lancet Oncol 2008)
his group showed a measurable effect of improved quality of
ultrasonography on the management of patients with suspected
ovarian cancer in a tertiary gynaecology cancer centre, resulting in
a significant decrease in the number of major staging procedures
and length of inpatient hospital stay.
Millennium prize for innovation for G-Test for assessment of
women ovarian reserve
CHALLENGES
The Academy of Medical Sciences/RCP Young Investigator
Award (Hayden Homer)
British Fertility Society Best Young Clinician Prize
(Hayden Homer)
CLRN Lead for Central and East London Priority Group in
Reproductive Health and Childbirth (Paul Hardiman)
Mouse egg with large polar body. Chromosomes (green)
are perfectly aligned at the equator of the spindle (red)
Chair of the National Specialty Group in Health Services
Research (Judith Stephenson)
Chair of the British Society for Paediatric and Adolescent
Gynaecology (Sarah Creighton).
NIH working party on the Management of Turner Syndrome
(Gerrard Conway).
Chair of the RCOG Early Pregnancy Clinical Study Group
(Davor Jurkovic)
Member of National Chlamydia Screening Programme (NCSP)
R&D Committee and Advisor to National Audit Office on
Value-for-Money Review of the NCSP (Judith Stephenson)
National and International Management Guidelines,
including Consensus on Management of Intersex Disorders
and Guidelines from the British Association of Paediatric
Surgeons have been informed by the work of the Paediatric
and Adolescent Gynaegology Group (Sarah Creighton and
Gerrard Conway)
Member of working group of Thalassaemia Clinical Research
Network (Ratna Chatterjee)
Consultant for Thalassaemia International Federation
(TIF) and WHO on maternal and reproductive health in
haemoglobinopathies (Ratna Chatterjee and Rekha Bajoria)
AREAS OF EXCELLENCE
The oocyte and embryo research programme has an
international reputation for excellence in research into the
mechanisms of oocyte maturation, fertilization and early embryo
development. This work is led by Greg Fitzharris, Hayden Homer
and John Carroll. The Assisted Conception Unit is consistently one
of the leading IVF Units in the UK, with a live birth rate per cycle
of treatment in women under 35 years of 65%. This combination
has enormous potential to develop new and exciting translational
outcomes in treatment options for assisted conception, for measuring
oocyte and embryo quality and for improving IVF outcome.
Early research into sperm preservation before gonadotoxic
treatment was conducted by Gulam Bahadur and is now
established clinical practice. Although the first human ovarian
cryopreservation was performed at UCL/UCLH, management of
patients at risk of infertility remains a key challenge in this field.
Research at the Assisted Conception Unit has contributed
to outstanding success rates in IVF. Collaboration with the Prenatal
Genetic Diagnosis Group (Joyce Harper) has led to several
‘world firsts’ including the first BRCA1 tested preimplantation
genetic diagnosis (PGD) baby delivered in December 2008. The
same technology has been applied successfully for patients with
familial adenomatous polyposis (FAP), retinoblastoma (RB) and
neurofibromatosis (NF1). ACU has led the field and has become
the major centre offering pre implantation diagnosis for all cancer
predisposing genes.
In sexual and reproductive health, UCL has the only clinical
academic chair in the UK for contraceptive research. This has
enabled a new UK community-based research network to be
established, providing a unique opportunity for investigator-led,
multicentre trials in contraception. This builds on long-established
international strength at UCL (Division of Population Health) in
sexual health research, including evaluation of sex education,
teenage pregnancy and sexually transmitted infections.
Paediatric and Adolescent Gynaecology (PAG) at the IfWH
is internationally recognized as a centre for research into the long
term impact on sexual and reproductive function of congenital
anomalies of the reproductive system. Key areas include sexual
function in adult women who have had feminizing surgery for
ambiguous genitalia in childhood and the optimization of oestrogen
replacement both for induction of puberty and maintenance
treatment in adolescent girls with hypogonadism. Together,
Sarah Creighton and Alfred Cutner’s groups have developed and
published innovative laparoscopic procedures for complex mullerian
anomies. It is the only unit in the UK to offer these techniques.
In general terms, it is a major challenge to bring about the
necessary shift in thinking and practice from the ‘old research
world’ to the new research landscape of the NIHR. Part of the
challenge lies in communicating these radical changes to those
who would conduct research in the NHS. A particular challenge
for the Department of Reproductive Health is to bring together
clinicians and academics whose research has grown along
separate paths and who do not necessarily feel confident or
sufficiently supported to collaborate across disciplines. Such
changes in thinking and working practices will be necessary to
exploit the unprecedented levels of research funding that are
potentially available to us.
The Department of Reproductive Health is a small department
with very few UCL employees. A significant amount of research
is conducted by NHS clinicians whose job description does not
require them to conduct research (e.g. they have no research PAs).
People are also split across multiple sites, and there is no obvious
‘home’ for reproductive health. This may improve as women’ health
services have moved into the new EGA wing (Phase II) and there
are plans to develop an assisted conception service in the new
building. Initial enthusiasm to move part of the Margaret Pyke
(contraceptive) service into the EGA may not be sustained as
there are other plans for integrating contraceptive and GU services
elsewhere in the community. There are particular difficulties for
the oocyte and embryo research in having poor access to human
oocytes, compounded by the lack of an NHS IVF service, and
the distance between physiology lab (Gower St) and the Assisted
Conception Unit (Grays Inn Road). In Paediatric and Adolescent
Gynaecology, it has been hard to obtain research funding for such
a complex but small area. Ideally long term funding is needed to
follow-up patients from childhood to adult life. Lack of administrative
support hampers practical issues with regard to grant applications.
To foster greater collaboration, monthly research seminars were
held throughout 2007. These were helpful in terms of enabling
colleagues to understand more about each others’ research, but
attempts to hold meetings to develop a more strategic approach to
research development have had limited success. Current strategy
is therefore to focus on a few areas with sufficient strength and
potential for the IfWH to become a leader in the field and to make
a major contribution to women’s health.
67
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – RESEARCH
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – RESEARCH
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
First demonstration that female fetuses in PCOS pregnancies
are exposed to male levels of androgens. Data from animal
studies show that such exposure has major lasting effects on
offspring, predisposing to diabetes and coronary heart disease
and influencing brain development / behaviour in adult life.
Blastocyst embryos showing spindles (red) and chromasomes (blue)
IMPACT AND IMPORTANCE
The infertility and oocyte and embryo research underlies an area
of key importance to women’s reproductive health. For IVF, the
single most important determinant of success is arguably oocyte
quality which is in turn crucial for embryo quality. By understanding
what makes a ‘good egg’ this research theme will determine how
to evaluate egg quality and manipulate it to improve IVF outcomes.
In vitro maturation (IVM) is the process of producing a mature
fertilisable egg capable of supporting embryogenesis from an
immature precursor. Clinical application of IVM is currently limited
due to low success rates. Here again, by better understanding the
molecular requirements of oocyte development, our research will
significantly improve the success of IVM and its use in preservation
of fertility. Fertility preservation is of paramount concern to women
whose fertility is threatened, for example, by cancer treatment.
Oocyte freezing is one option for preserving fertility, but mature
oocytes are vulnerable to spindle damage from freezing. An
alternative is to freeze immature oocytes which lack spindles but
the subsequent use of such oocytes would depend on reliable IVM
which is currently a major stumbling block.
Prevention of the inheritance of cancer predisposing genes is
of paramount importance to couples at risk. ACU has pioneered
PGD techniques and established the first clinical centre for the
screening and treatment of patients at risk.
PCOS affects around 1 million women in the UK and is associated
with major morbidity, including subertility, diabetes, cardiovascular
disease, cancer, pregnancy complications and neonatal morbidity.
It is the commonest cause of anovulatory infertility, although there
are 53,000 births each year in E&W to women with PCOS. Rates of
pre-eclampsia and incidence of gestational diabetes and perinatal
mortality are all raised in PCOS. Babies born to mothers with
PCOS are exposed to an abnormal (hyperandrogenic) intrauterine
environment which is believed to increase the risk of developing
cardiovascular disease and diabetes in adult life.
Examples of work that has made an important contribution to
women’s health in the last 5 years include:
Demonstration that endothelial abnormality in PCOS depends
on elevated ADMA (asymmetric dimethyl arginine), offering
prospect of new approaches to improve vascular function, and
reduce maternal, neonatal and longterm morbidity.
Identification of genes that are dysregulated in the endometrium
of women with PCOS that will help elucidate mechanisms
responsible for neoplasia and infertility / miscarriage and allow
development of novel treatments for these clinical problems.
68
FUTURE DEVELOPMENTS
PCOS research
Oocyte and embryo research
Better understanding of mechanisms responsible for abnormal
follicular development in PCOS that will lead to development of
more effective therapies to restore ovulation in these women.
Improved understanding of the molecular regulation of
meiosis in mammalian oocytes
Control of fertility is essential to women’s health and an issue
of human rights. Family planning is unique among medical
interventions in the breadth of its potential benefits: reducing
poverty, hunger, maternal and infant mortality, improving prospects
for universal education and adaptation to climate change. Voluntary
family planning could reduce maternal mortality by 30% by
addressing the unmet need for contraception among 150 million
couples (mostly in Africa)
There have been major advances in understanding how meiosis is
regulated in lower eukaryotes, but understanding of mammalian
meiotic regulation is far less complete and virtually non-existent for
human oocytes. This lack of progress reflects lack of human oocyte
availability as well as technical difficulties. With the approaches that
our group has developed and continues to refine, we expect to see
our group lead the field within five years, making major advances in
our understanding of female mammalian meiotic regulation.
The huge success of family planning in the second half of the 20th
century led to a halving of global fertility (from 5.5 in 1950 to 2.55
in 2005). Since then there has been a disastrous disinvestment in
family planning for reasons that include a premature sense that
fertility rates are no longer a problem; diversion of funds away from
family planning and into HIV/AIDS programmes, and the legacy of
previous inept and sometimes coercive programmes (e.g. in China
and India).
IVM and allied technologies
The IfWH contributed to a UCL-Lancet Commission on the Health
Impact of Climate Change (due to report 2009) by asserting the
importance of bringing the sensitive issue of population growth
into discussion about climate change. We highlighted the key
role of family planning in determining whether global population
reaches 7 9 or 11 billion by 2050, and the importance of meeting
the huge global unmet need for contraception as a issue of human
rights, as well as a means of reducing the vulnerability of the
poorest communities to the effects of climate change.
Results of an MRC-funded long-term trial of sex education
(Stephenson et al Lancet 2004; Stephenson et al PloS Medicine,
2008) led to the intervention (RIPPLE) being included in a DH
short list of sex and relationship programmes recommended to
accelerate the Teenage Pregnancy Strategy.
A systematic review of the effectiveness of screening for genital
Chlamydia (Low et al 2009) contributed to NICE Guidance on STI
prevention in young people (NICE 2007)
Establishment of a UK community-based clinical research network
in sexual and reproductive health, co-ordinated at Margaret Pyke
Centre, UCL, has given leadership and infrastructure to support
high quality investigator-led research.
Disorders of sexual development, and paediatric and adolescent
gynaecology
Our series of papers from 2001 to 2008 confirmed that clitoral
surgery as an infant is detrimental to adult female sexual function.
The role of feminising genital surgery in the management of
children with ambiguous genitalia has been challenged and clitoral
reduction is no longer standard practice.
UCLH is perfectly positioned to develop specialist services
for women with unusual forms of infertility. The work on Turner
Syndrome and Adrenal Hyperplasia have become international
reference material for adult care. With respect to congenital adrenal
hyperplasia, we have converted a fertility rate of 10% to 90% using
novel combined endocrine and fertility approaches.
Greater ability to promote oocyte maturation by co-ordinating the
progression of meiosis with cytoplasmic maturation during in vitro
culture is expected to accompany the advances described above.
This will lead to increased capacity for female fertility preservation
based on enhanced ability to derive mature fertilisable eggs from
frozen immature oocytes.
Manipulating oocyte quality
Armed with improved knowledge about the cellular elements that
make up a ‘good egg’, we would expect to be able to supplement
poorer quality oocytes with essential molecules or activate specific
signalling pathways to increase the chance of successful in vitro
maturation and production of viable embryos. Currently, there
are no proven techniques of manipulating oocyte quality and our
systematic approaches would subvert the need for untested and
potentially risky techniques such as cytoplasmic /nuclear transfer.
Clinical correlates for oocyte quality and IVF success
At present there is no clinical measure of oocyte quality. Given that
our research framework intimately involves the clinical management
of IVF patients and the molecular analysis of their eggs, we have
an unrivalled opportunity to map for the very first time, clinically
measurable parameters that could be used as surrogate markers
for oocyte quality. Given that total ovarian reserve along with
oocyte quality are the major predictors of IVF success, new clinical
measures of oocyte quality will go a long way towards more
accurately defining a couple’s chance at successful IVF.
Dynamic embryo culture system
The introduction of more physiological culture media over the last
decade has resulted in improved embryo development in vitro. In
vivo embryos develop in a chemically and mechanically dynamic
micro environment. The objective of this research is to investigate
the effect of dynamic embryo culture on embryo development
using a computer controlled tilting /rotating embryo culture device
placed within the incubator. If initial research with mouse embryos
is successful in improving blastocyst formation, the next phase will
be to apply this innovative technology to human embryos.
Fertility preservation research
Establishing the first egg bank in the UK to optimize the
management of egg recipients and cancer patients.
Investigation of the long term impact of chemotherapy on
ovarian reserve.
Investigation of assisted laser shrinkage and vitrification of human
embryo in order to minimize cyroinjury to the cell.
Development of on vitro maturation of oocytes prior to IVF/ICSI
to avoid the risks of ovarian hyperstimulation syndrome (PCOS
women are at particular risk).
Specific interventions to induce weight loss in the 30% of
PCOS women who are obese. These interventions may be non
pharmacological, such as the programme of cognitive behavioural
therapy that we are currently evaluating.
Drug therapy to reduce the excess maternal and neonatal
morbidity associated with PCOS.
Increased use of preventative therapy in PCOS women to reduce
long term morbidity/mortality from diabetes, heart disease and
endometrial cancer.
Sexual and reproductive health
Development and evaluation of family planning interventions
in India and Africa in collaboration with a major programme of
maternal and child health interventions (Director A Costello)
Consolidating new links with Marie Stopes International, a major
global provider of family planning. We have evaluated MSI’s global
training programmes and plan to evaluate the impact of their highly
innovative tubal ligation (sterilisation) outreach programme.
Build on the newly–established UK research network of
community-based S&RH services to conduct high quality
investigator-led research that helps women choose and continue
to use effective contraceptive methods to prevent unintended
pregnancy.
Build on international strength in STI research and improve
diagnosis of pelvic inflammatory disease – an essential prerequisite to evaluate the effectiveness of the National Chlamydia
Screening Programme (NCSP).
We have the opportunity to incorporate sexual and reproductive
health care within the new EGA hospital, demonstrating that control
of fertility is essential to women’s health, and providing a seamless
women’s health service of primary, secondary and tertiary care
from puberty to beyond the menopause.
Disorders of sexual development and
paediatric and adolescent gynaecology
Focus on transition of adolescents with DSD and increasing
involvement of patient groups and the expert patient.
Move away from surgical and condition based research to holistic
assessment of long term well being of individuals with DSD.
Increasing emphasis on psychological interventions as an
alternative to genital surgery.
Join international collaborations using the cohorts built over
the past five years, including Genetics of Ovarian Failure,
GH replacement in older women with Turner Syndrome and
cardiovascular management of Turner Syndrome.
69
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – RESEARCH
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – RESEARCH
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
TEN KEY REPRODUCTIVE MEDICINE AND BENIGN GYNAECOLOGY
PUBLICATIONS AT IfWH 2004-09
Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, Friel S,
Groce N, Johnson A, Kett M, Lee M, Levy C, Maslin M, McCoy D,
McGuire B, Montgomery H, Napier D, Pagel C, Patel J, de Oliveira
JA, Redclift N, Rees H, Rogger D, Scott J, Stephenson J, Twigg
J, Wolff J, Patterson C. Managing the health effects of climate
change: Lancet and University College London Institute for
Global Health Commission. Lancet 2009;373:1693-733
Major Lancet-UCL Commission Report showing that climate
change is the biggest global threat of the 21st century.
(Stephenson is one of 28 multidisciplinary co-authors). Included is
the fundamental role of population growth and family planning in
mitigation and adaptation responses to climate change.
Wilkinson P, French R, Kane R, Lachowycz K, Stephenson
J, Grundy C, Jacklin P, Kingori P, Stevens M, Wellings K.
Teenage conceptions, abortions, and births in england, 19942003, and the national teenage pregnancy strategy. Lancet
2006;368(9550):1879-86.
First independent academic publication describing teenage
conception, abortion and birth rates in England before and after
introduction of the National Teenage Pregnancy Strategy, with
interpretation of falling rates.
Wilkinson P, French R, Kane R, Lachowycz K, Stephenson
J, Grundy C, Jacklin P, Kingori P, Stevens M, Wellings K.
Teenage conceptions, abortions, and births in england, 19942003, and the national teenage pregnancy strategy. Lancet
2006;368(9550):1879-86.
First independent academic publication describing teenage
conception, abortion and birth rates in England before and after
introduction of the National Teenage Pregnancy Strategy, with
interpretation of falling rates.
Stephenson J, Strange V, Allen E, Copas A, Johnson A, Bonell C,
Babiker A, Oakley A, Brodala A, Charleston S, Flux A, Hambidge
S, Johnston G, Monteiro H, Petruckevitch A. The long-term
effects of a peer-led sex education programme (RIPPLE): A
cluster randomised trial in schools in England. PLoS Medicine.
2008;5(11):1579-90.
Long-term cluster randomised trial of sex education in schools
in England showing that peer-led sex education (RIPPLE) was
preferred by pupils, and associated with delayed first sexual
intercourse (Stephenson et al, Lancet 2004) and possibly fewer
conceptions in girls.
Low N, Bender N, Nartey L, Shang A, Stephenson JM.
Effectiveness of chlamydia screening: systematic review. Int J
Epidemiol 2009;38:435-448
FitzHarris G, Marangos P, Carroll J. Changes in endoplasmic
reticulum structure during mouse oocyte maturation are
controlled by the cytoskeleton and cytoplasmic dynein.
Developmental Biology 2007;305(1):133-144
Demonstration that cytoskeletal components and cytoplasmic
dynein are required for reorganising the cytoplasm of the
mammalian oocyte in readiness for fertilisation.
Mantzouratou A, Mania A, Fragouli E, Xanthopoulou L, Tashkandi
S, Fordham K et al. Variable aneuploidy mechanisms in embryos
from couples with poor reproductive histories undergoing
preimplantation genetic screening. Human Reproduction
2007;22(7):1844-1853
WOMEN’S CANCER
REPRODUCTIVE HEALTH AND BENIGN GYNAECOLOGY – RESEARCH
UCL EGA IfWH 1st Quinquennial Review
Pillay OC, Te Fong LF, Crow JC, Benjamin E, Mould T, Atiomo W,
Menon PA, Leonard AJ, Hardiman P. The association between
polycystic ovaries and endometrial cancer. Human Reproduction
2005;21(4):924-929
First published study of the prevalence and prognosis of
endometrial cancer in women with polycystic ovaries.
Bahadur G, Ozturk O, Muneer A, Wafa R, Ashraf A, Jaman N et
al. Semen quality before and after gonadotoxic treatment. Human
Reproduction 2005;20(3):774-781
Unique large-size study providing data on the quality of semen
before and after gonadotoxic treatment over a period of 26 years.
The paper also provides information on post-treatment recovery
potential and the impact of treatment on the quality of life of the
male cancer patient, which can be utilised in patient counselling.
Casteràs A, De Silva P, Rumsby G, Conway GS. Reassessing
fecundity in women with classical congenital adrenal hyperplasia
(CAH): normal pregnancy rate but reduced fertility rate. Clin
Endocrinol (Oxf). 2009 Jun;70(6):833-7.
Improvement in pregnancy rate from the previous 10-30% per
patient to 90% using a new combined endocrine and fertility
protocol, which was a hot topic at ENDO 09 Washington DC, June
2009.
Koulouri O, Conway GS. A systematic review of commonly used
medical treatments for hirsutism in women. Clin Endocrinol
2008;68(5):800-805
The first systematic review of treatments for hirsutism. This paper
led on to a request for a Clinical Review for the BMJ published in
March 2009.
Systematic review for NICE of the effectiveness of different
approaches to screening for Chlamydia infection, showing
mismatch between the evidence base and current policy and
practice in the National Chlamydia Screening Programme.
70
71
UCL EGA IfWH 1st Quinquennial Review
WOMEN’S CANCER
WOMEN’S CANCER – clinical
OVERVIEW
The Gynaecological Cancer Centre (GCC) at University College
London Hospitals (UCLH) NHS Foundation Trust supports a
multidisciplinary team (MDT) that aims to provide complete care for
women with gynaecological cancers.
The clinical lead for gynaecological cancer is Miss Adeola Olaitan
and the academic lead is Professor Ian Jacobs (see Appendix 6.1
for details of other members of the core MDT).
Simon Gayther
Sue Gessler
Ian Jacobs
Christopher Jones
The GCC MDT provides comprehensive care for women
suffering from gynaecological cancer within the North London
Gynaecological Cancer Network (NLGCN). Referrals are received
from five unit hospitals, each of which has a lead gynaecologist
for cancer (Appendix 6.1), who liaises closely with the centre
MDT about patient care. Referral guidelines, based on the Clinical
Outcomes Group (COG) guidelines (1999) were agreed by the
Gynaecological Tumour Board in 2001.
In addition, the UCLH cancer centre serves as the unit hospital for
its local population and direct referrals from General Practitioners
are assessed at a weekly Rapid Access Clinic.
The catchment population is approximately 1.5 million women and
a total of 477 cancers were treated in 2007, of which 312 were
new cancer diagnoses.
Anne Lanceley
Jonathan Ledermann
Usha Menon
Tim Mould
The Breast Service at UCLH is part of the North London Cancer
Network (NLCN), and is linked closely to St Bartholomew’s
Hospital (Bart’s) to the east. Breast services occur at three levels –
screening, diagnostics and cancer treatment.
Screening services for the sector are located at Bart’s. UCLH
provides diagnostic services for the local population plus
oncoplastic surgery and oncology treatments for women with
cancer.
Adeola Olaitan
John Timms
72
Susan Ramus
Jayant Vaidya
Adam Rosenthal
Martin Widschwendter
Andy Ryan
Alexey Zaikin
At present, the service is undergoing a major reconfiguration. The
diagnostic services are being redesigned and the surgical input is
changing from a service led by UCL clinical academics to one led
by trust-funded surgeons. It is expected that referral numbers will
increase with this development, and also that clinical research will
continue.
There are sophisticated video-link facilities with unit hospitals
so that cross-site discussions can occur in real time. There are
evidence-based centre protocols for the management of all
gynaecological cancers but each patient’s care is individualised
following MDM discussion. Psychological support is offered by the
Clinical Nurse Specialist (CNS) network and integral psychology
team. We have built up close working relationships with all major
associated specialties as listed in Appendix 6.1 – Extended MDT
External Links
Colposcopy and Rapid Access Clinics (RAC)
The Colposcopy Service is integrated within the Gynaecology
Oncology Service and has recently undergone a successful quality
assurance (QA) visit. Patients referred by their GPs with suspected
cancer are seen in a weekly RAC. If cancer is diagnosed, they
are managed through the JOC and MDT. The introduction of the
gynaecological diagnostic unit, has transformed the RAC to a truly
one-stop service.
Familial Clinic
This clinic, led by Dr Menon, provides information, risk assessment
and management and support to women at high risk of ovarian or
endometrial cancer due to a family history of the disease. The main
strategies involve prophylactic surgery and screening.
Morbidity
The Reproductive Medicine Unit provides in vitro fertilisation
(IVF) and ovum or ovarian cryopreservation for young patients
about to undergo cancer treatment expected to result in loss of
reproductive function. Treatment-related morbidity can present as
genital tract stenosis, prolapse or incontinence and these patients
are managed with the uro-gynae team. Women are referred for
symptomatic relief of menopausal symptoms and a range of
complementary therapies to the Royal Homeopathic Hospital.
Education and Training
Links with the medical school, national and international units
help to raise the profile of UCLH woman’s health department
locally and worldwide and ensure excellent care for women with
gynaecological malignancies into the future.
STRATEGY, AIMS AND OBJECTIVES
Undergraduate
Student firms rotate through gynaecological oncology.
The GCC aims to provide comprehensive care to women during
cancer treatment and beyond, within the core MDT and by
strategic links to other important services. The strategy for the
breast unit is a complete reconfiguration to a modern lean service
linked with our partners within the sector.
Postgraduate
UCLH GCC has two accredited sub-specialty training posts in
gynaecological oncology and is one of the few centres that can
offer a combined clinical and academic training. The Royal College
of Obstetricians and Gynaecologists (RCOG) awarded training
recognition in 2002. The posts received accreditation for European
training in 2007.
The weekly joint oncology clinic (JOC) and the Multidisciplinary
meeting (MDM), both attended by the core MDT, are the main
focus of patient care in the GCC. All new referrals are seen at the
JOC. There were a total of 4,090 outpatient appointments in 2007.
Patient care is supported by MDM discussion.
Breast
UCLH wishes to keep screening at Bart’s while we will provide
rapid one-stop diagnostics for women with breast lumps and
73
WOMEN’S CANCER – clinical
WOMEN’S CANCER
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
positive screening tests, and provide high quality surgical
treatments and oncology treatments. To address the relatively
small numbers of cancer, treatments and protocols will be linked
with other members of the NLCN, and with Bart’s, to provide a
cancer partnership in which numbers of cases can be pooled.
This will provide a critical mass of cases for data presentation. The
sector will take advantage of the UCL Academic Health Sciences
Partnership (UCLP) to drive forward these changes and to embed
clinical research across the units in the sector.
Administrative
Surgical wound surveillance
We do not meet the trust guideline that recommends that letters
are received by the GP within five days of the consultation. A fulltime data manager was appointed in November 2008 increasing
administrative support at the centre. The duty of the data manager
is to collect good quality network wide data in order to fulfil cancer
plan standards.
Started at UCLH in May 2000, using a grant from the Special
Trustees and is now funded by the Surgical and Women’s Health
Divisions. The audit data have shown a fall in asepsis >20 rates
from 10% in 2005/6 to 4.7% in 2007/8 on T13, where the majority
of patients undergoing complex surgery are under the care of
gynaecological oncologists. The rates for gynaecological surgery
were less than 2% in 2007/8.
RESOURCES
A business case has been approved by the trust to redesign the
MDTs of the breast service. This includes: Two new radiologists
for the diagnostic team, 2.5 substantive surgical posts for the
diagnostic and oncology MDTs. At present the surgical support
comes from colleagues at Bart’s on a temporary contract basis.
The team already has breast CNS support, specialist cytology,
histopathology and three oncology consultants providing high
quality input to the teams.
Inpatients
Ten surgical beds are available on the gynaecology and breast
ward, T13 for gynaecological cancer surgery, which is adequate
for our needs. The Trust has 40 Intensive Care Unit (ICU) and
High Dependency Unit (HDU) beds and a Patient Emergency
Response Team (PERT) system, which meets the recommendation
of the Comprehensive Critical Care Review (2000). The planned
development of a 24 hour recovery should reduce the (low)
surgical cancellation due to lack of Intensive Therapy Unit (ITU)
beds. There are still delays with accepting inpatients from units.
Approximately one patient is transferred per month and the mean
waiting time is 2.5 days, which we aim to reduce to 24 hours,
and need beds to accommodate this. There is a move towards
more efficient patient care and the enhanced recovery program
will ensure more rapid patient turnover and should increase the
availability of beds.
Outpatients
The JOC is temporarily located in a clinic space converted from
a ward. The waiting area is inadequate for the large number of
patients and their relatives and consulting space for the CNSs
and research nurses is limited. The Cancer Centre, due to be
completed in 2012, will provide excellent facilities, but there is
an urgent need to address the clinic situation in the short term.
We have been in consultation with the Outpatients Manager to
ensure she prioritises improving the JOC environment. In addition,
we are piloting innovations such as nurse-led toxicity-scoring for
chemotherapy patients to increase the efficiency of the clinic and
reduce waiting times for patients.
Staff
Surgical
The Gynaecology Network Site Specific Group (NSSG)
recommends 3.5 whole-time equivalent (WTE) gynaecological
oncologists per million population, and that adequate consultant
staffing should be included as a measurable standard for the peer
review process (Nordin A, Belfast 2007). UCLH GCC has 3 WTE,
adequate for demands.
Psychology
Many of the innovative interventions are run using trainees and
volunteers. The peer support service is funded entirely by research
grants. Current funding ends in March 2009. Other initiatives
include the use of graduate mental health workers to deliver
psychological interventions to patients within the community and
the use of screening methods such as the ‘distress thermometer’
to identify which patients need increased intervention.
74
Breast
Facilities
One-stop diagnostic clinics have been created in the new EGA
Wing, Level -1. State-of-the-art mammography and stereotactic
biopsy equipment has been purchased. This is co-located with
the latest ultrasound (US) machines. The service has cytology and
radiology reporting facilities in the clinic. The inpatient beds are colocated with gynaecology beds in T13 south ward. All of the beds
in this ward are managed by Women’s Health. Breast surgery has
four theatre lists. There are two SpRs who have combined breast
and endocrine jobs to support the service.
PERFORMANCE AND MEASUREMENT
OF QUALITY OF ALL ACTIVITY
Clinical
External assessment
Administration
The Gynaecological Oncology coordinator post at UCLH has been
highlighted by the NHS Modernisation Agency as a case study
in support of having an MDT Co-ordinator in all tumour sites. A
poster highlighting the difference in service between having and
not having a co-ordinator was on show at the 2003 Modernisation
Conference (winning 2nd prize) and later at UCLH.
Patient satisfaction
Nurse-led clinic survey
A structured survey in 2007 showed that 62% of women reported
being seen within a month of their referral to the nurse led clinic.
Women reported that they felt they were offered significant time to
discuss issues important to them.
Same day pre-assessment survey
This showed that 90% of women attending this clinic considered
pre-assessment to be a standard procedure and 70% thought it was
a good idea. 40% were happy to be offered appointments the same
day and 20% highlighted the advantage of fewer visits to the centre.
Patients’ views on a centralised service
In 2002, women’s attitudes towards service centralisation for the
treatment of gynaecological malignancies were evaluated by an
independent researcher using a paper-based questionnaire.
77% of respondents indicated a preference for the centralised
clinic. Travel costs and proximity of the clinic were given low priority
in contrast to the unanimous importance placed on expertise,
reputation and availability of appointments (Hackman N, et al
Abstract 740 International Journal of Gynaecological Cancer 2004
Volume 14, suppl 1:205).
Patient information
85% of patients surveyed said they received sufficient information
about their diagnosis, treatment and other services, but only 36 of
70 women surveyed said they had received appropriate information
at their unit hospital before coming to the cancer centre. This issue
is being addressed by the cross-site CNSs. Yvonne Tapper and
Emma Elliott came runner-ups in the poster prize competition in the
UCLH Partners in Practice Conference, presenting their work on
the nurse-led clinic patient satisfaction survey results.
Survival
The GCC has prioritised the need for accurate survival data and
these will be available in the 1st quarter of 2009.
Research
UCL is the lead centre for two national screening trials in ovarian
cancer and three national studies in ovarian cancer cervix
cancer treatment. In addition to clinical trials, there is a strong
laboratory research programme. A full account of research within
gynaecological oncology is provided elsewhere in the submission.
In Clinical Psychology, Nancy Pistrang, Senior Lecturer and joint
Research Director in Clinical Psychology UCL, and Sue Gessler
have been awarded a Cancer Research UK (CRUK) Proof of
Principle Grant to develop their innovative Peer Support Service.
This qualitative and quantitative study will test the hypothesis that
patients can provide appropriate and effective psychological
support for each other. Other projects include a study to examine
factors contributing to the psychological resilience of older women
undergoing radical treatment, and a ward-based study to examine
expressive writing as a psychological intervention to improve
recovery from surgery. Dr Gessler is able to advise on appropriate
psychological measures for research studies throughout the GCC.
The GCC was externally assessed by the Peer review teams
in 2001 and 2005 and meets 97% of the Improving Outcomes
Guidance Cancer Manual standards. The service outperforms
national standards with 0% breeches for target referral
appointments, 99.4% cancer patients within treatment target times
and 92% of cases in the network compliant with guidelines. There
is embedded psychosocial support and 85% patient satisfaction
with CNS support.
Communication
In 2007, GPs across the network were surveyed for their views
on the quality of patient-related information they received from
the GCC. 86% said they received good, satisfactory or excellent
communication from the GCC (GP Links May 2008). An annual
report ensures network-wide communication.
Surgical outcomes
Theatre occupancy is 100%. A Possum® scoring system for
assessment of surgical morbidity and mortality used by the
gynaecological oncology surgeons has shown consistently low
actual against expected morbidity, with a ratio of 0.2.
75
WOMEN’S CANCER – clinical
WOMEN’S CANCER – clinical
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
Breast
Research
• Anne Lanceley was awarded a Senior Lecturer post in 2008.
• Target cancer referrals in diagnostic clinics: 100%
Cancer Research UK and UCL Cancer Trials Centre (CTC) is a
National Cancer Research Institute (NCRI) accredited national
trials centre with responsibility for national and local trials in
gynaecological cancer. Professor Ledermann, who is the Director,
is leading three national and international trials in ovarian cancer,
and Dr McCormack is the lead for a national cervical cancer
study. The centre will run the PORTEC-3 intergroup study in the
UK, which is a randomised Phase III trial, comparing concurrent
chemoradiation and adjuvant chemotherapy with pelvic radiation
alone in high risk and advanced stage endometrial carcinoma.
The Centre also has two further ovarian cancer trials, in set-up
or development, in mucinous ovarian cancer and intraperitoneal
therapy of ovarian cancer. The CTC provides a resource to develop
local translational studies in gynaecological cancers.
• Professor Ledermann is Chair of the NCRI Ovarian Cancer
subgroup, a member of the NCRI Gynaecological Cancer
Studies Group and the executive board of the Gynaecological
Cancer Intergroup.
• Cancer waiting time targets for diagnosed cancer: 100%
• Cancer manual 1* standards in external peer review: 77%
• User satisfaction survey: 94% described care as good or excellent
AREAS OF EXCELLENCE
Education
Undergraduate
In 2006-07, Miss Olaitan received the medical school recognition
award for educational excellence. Mr Silverstone and Mr Mould
received the award in 2007-08.
Postgraduate
Three training fellowships, ESGO, BSCCP and IGCS were awarded
in 2008. In addition, gynaecological oncologists from other
centres within the UK attend our surgical lists to learn the highly
specialised techniques we offer at UCLH.
Clinical Psychology
Dr Gessler is an accredited trainer for the Department of Health’s
Advanced Communications Skills Training. She has set up a
training placement for the London doctoral training in Clinical
Psychology. The team has links to the Marie Curie Research Unit
(Behavioural Sciences) in the Medical School and the Department
of Clinical Health Psychology at UCL.
Clinical pathways
The NLGCN management pathways and guidelines were reviewed
in 2007 and ratified by the Tumour Board. This document was
picked out by the Peer Review team of 2005 for special merit and
displayed on the Peer Review website as an outstanding example
of how a network should be organised.
The GCC was selected as a test site for the NHS Improvements
Survivorship pilot in 2008. The CNS team has been selected as
a test site to pilot the national patient information prescriptions.
These projects derive from the objectives set by the Cancer Reform
Strategy and the team will assist in influencing the development of
this nationally in the near future.
UCLH is a centre of expertise for minimal access surgery
nationally and all laparoscopic procedures for gynaecological
cancer are offered.
Nurse development
At UCL, despite the absence of a school of nursing, nurse-led
patient care research, with a focus on gynaecological cancer,
driven by Dr Anne Lanceley, has developed within the Institutes
of Child Health and Women’s Health. The award of UCLH/UCL
Comprehensive Biomedical Research Centre (CBRC) funding of
£0.5 million for a new, nurse-led Centre for Patient Care Research
and Innovation (PCRIC) will allow for a more coordinated approach
to research. Nurse-led research within gynaecological oncology
has allowed the development of methodologies that explore
the patient’s experience of care and measure patient benefit
outcomes. There have, in addition, been innovations in patient/
public involvement in research.
76
Immunotherapy Ovarian Cancer This is a collaboration between the
Cancer Institute and Department of Immunology, Windeyer Institute
(Professors Chain and Collins). The group has recently received
funding from Ovarian Cancer Action for further studies in patients.
This will be conducted jointly at UCLH Gynaecological Cancer
Centre and the Royal Marsden Hospital, London.
• Sue Gessler chairs the North London Cancer Network
Psychosocial group. She is on the panel of the ‘Ask-the-Expert’
sessions at the Chai Cancer Centre. She has spoken at the
International Psychosocial Oncology Society Conference both in
2006 and 2007, as well as at national meetings on psychological
assessment and screening of patients with cancer.
Breast
The one-stop diagnostic clinics fulfil the ultimate standards in
modern breast diagnostics. Oncoplastic surgery is state-of-the-art
in breast surgery. Oncologist services in both clinical and medical
oncology are outstanding.
CHALLENGES
Gynaecology
Other
Chemotherapy on wards to reduce waits
All Consultants are invited as experts to speak at local, national
and international meetings.
With input from the oncology team, the ward sister on the
gynaecology ward devised a protocol whereby post-operative
patients could receive chemotherapy on T13 under supervision
by trained staff from the oncology ward. This has obviated the
need for patients to travel back to the centre for their next dose of
chemotherapy shortly after leaving the surgical ward.
• Ian Jacobs was President of the British Gynaecological Cancer
Society 2003-05 and President of the European Society of
Gynaecological Oncology 2005-07.
• Adeola Olaitan is a lead assessor on GMC peer review and
undertakes comprehensive assessments when the practice of a
doctor within the specialty is called into question.
• Adeola Olaitan is a spokesperson for the NHS Cervical
Screening Programme and gives expert opinion to the media.
• Adeola Olaitan and Tim Mould are sub-editors of the RCOG
flagship publication ‘The Obstetrician and Gynaecologist.’
• The German Obstetrics and Gynaecology Society awarded
Martin Widschwendter the prestigious Schmidt Matthiesen Prize
at its annual conference in Hamburg in September 2008.
• Emma Elliott, lead CNS, is the president for the National Forum
of Gynaecological Oncology Nurses. She sits on the national
nursing advisory board for Glaxo Smith Kline, manufacturers of
Hyacamtin chemotherapy for advanced ovarian cancer.
One-stop service
Four slots have been made available in the pre-assessment clinic
so that patients can be seen and assessed on the same day as
they attend the JOC if surgery is planned, as patients often travel
in from a long distance. A survey of patient views (see outcome
criteria) has shown good satisfaction rates with this service.
Timely review of radiology and pathology
A courier service has been employed (April 2009) so that patient
radiology and pathology can be collected from unit hospitals in a
timely and predictable fashion, allowing decisions about treatment
to be made without delay.
Rehabilitation pathways
but the collection of cancer waiting times has reduced the time
available for admin staff to collect data. In November 2008, the
GCC appointed a full time data manager, Oscar Riches, whose
sole duty is to collect good quality data network wide.
Breast
The transformation of the breast service from a low cancer number
unit run by UCL clinical academics with a poor grant income and
limited research output, into a trust led service linked into a clinical
breast cancer network.
The linkage of the clinical units into a single coherent network with
clinical and translational research embedded throughout as part
of UCLP.
IMPACT AND IMPORTANCE
Gynaecology
The care of women with gynaecological cancers has been
restructured over the last ten years in the UK. UCLH is a successful
example of how care structure can be effectively changed with
the creation of a cancer network with a single site Gynaecological
Cancer Centre. This has allowed the creation of a specialist
multi-disciplinary team at the cancer centre. Women presenting
to any of the unit hospitals in the network are transferred to the
specialist team at the Cancer centre to allow them access to the
best possible care. Areas in which impact has been greatest are
as follows:
Psychosocial
Dr Gessler, consultant psychologist, has created an integrated
and responsive psychology team that has developed over the
last four years to strongly influence all aspects of clinical work,
teaching and training, and research in gynaecological oncology.
Dr Gessler has had an important input to patient leaflets on fertility,
menopause and sexuality after treatment. She is an investigator
on the Genetic Cancer Prediction through Population Screening
(GCaPPS) study, a randomised controlled trial (RCT) looking at
the feasibility of offering breast cancer susceptibility (BRCA)
gene testing to at risk communities, with a major emphasis on
psychological outcome measures. The peer support study is
reaching the end of its CRUK funding, but has been reported on
at the International Psycho-Oncology Society (IPOS) Congress
(London 2007) and will seek further funding.
To ensure that rehabilitation after surgery or non-surgical
oncological intervention is provided close to the patient’s home,
liaisons have been established between palliative care consultants
at unit hospitals. Emma Elliott won the Nursing poster prize at the
IfWH conference in November 2007 for a poster relating to her work
in establishing the North London Cancer Network rehabilitation
pathway and is the lead for rehabilitation within the NLCN, now a
peer review requirement.
In 2008, two pilot studies were completed with doctoral
trainees. Dr Gessler also contributes to studies with the General
Clinical Research Centres (GCRC), notably Dr Anne Lanceley’s
randomised controlled study of nurse-led follow-up in ovarian
cancer, and Penny Allen’s study of symptoms of women who
subsequently develop ovarian cancer.
Outreach Services
A psychological screening tool, the ‘Distress Thermometer’ (DT),
is being piloted in the oncology clinic. Having identified individuals
at risk or in need of help, they are reviewed at the psychosocial
MDM and discussed at the clinical MDM with other members of
the team, and a variety of interventions offered. The validation of
the Distress Thermometer has led to links with Marie Curie and
plans are underway to develop an outcome study with Marie Curie
funding to measure impact of the DT in clinical practice.
Patients referred from Harlow have difficulty travelling to the centre
for chemotherapy and in 2009 we agreed a joint protocol to allow
eligible patients to receive chemotherapy locally.
Data collection
The business plan for the development of the GCC included the
provision of a data manager to prospectively collect survival data,
Distress Thermometer
77
WOMEN’S CANCER – clinical
WOMEN’S CANCER – clinical
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
CNS Network
FUTURE DEVELOPMENTS
The NLCN was the first to appoint CNSs in joint posts between
the Unit and the centre and this provides an excellent example of
seamless care. Other networks are adopting this model.
Gynaecology
Nurse-led clinics
These were developed at the GCC by the lead Clinical Nurse
Specialist in 2004. Since then parallel clinics have been
developed at three unit hospitals. The total number of patients
seen at UCH has increased from 51 in 2004 to 112 in 2007.
Audit
The Gynaecological Oncology Department has participated
actively in the women’s health audit program and presents audit
data at an annual gynaecology oncology audit day. This presents
an opportunity for doctors in training to carry out an audit on
a subject that interests them (Yu C et al, Delayed Diagnosis
of Cervical Cancer in Young Women, Journal of Obstetrics
and Gynaecology, 2005; 25(4): 367 – 370; Yu C K et al. Total
laparoscopic hysterectomy as a primary surgical treatment
for endometrial cancer in morbidly obese women. BJOG
2005(112):1150-117)).
Patient information
The importance of accurate and complete patient information
has been highlighted in the new Cancer Reform Strategy (2008).
Re-formatted North London Gynaecological Cancer Network
information leaflets were distributed throughout the Network in
2006.
Lymphoedema Information
A new patient information booklet, ‘Advice for prevention
of lymphoedema’, has been produced by Kay Eaton, Lead
Oncology Nurse for the Trust.
Jan Simmons, Macmillan Lymphoedema project lead for the Trust,
has produced a patient ‘bookmark’ or card which women can
carry in the postoperative phase and which includes pathways to
follow in case of symptoms of oedema or infection, and how to
find a lymphoedema clinic. There are also information posters for
clinical areas.
Familial Ovarian Cancer Clinic
This is a tertiary service for women at increased risk of ovarian
or endometrial cancer due to a family history of the disease.
Referrals are received from the Clinical Genetics Services at
Guys and St Thomas, Royal Marsden Hospital North East Thames
Genetic Services and the Kennedy Galton centre and North West
Thames Genetic services, in addition to GPs and gynaecologists
from all over the South East. The team also supports the BRCA
carrier clinic at Guys and St Thomas NHS trust.
WOMEN’S CANCER – RESEARCH
Communication
Improved communication with patients is a focus of the new
cancer reform strategy and training for Senior Health Professionals
in Advanced Communication Skills is mandatory and will be
assessed in peer review. Dr Sue Gessler is an accredited trainer
and the aim is for all Consultants to have completed the course in
the next three years.
Training
Whilst surgical gynaecological oncologists undergo a formal
subspecialist training programme, recognised by the GMC, formal
subspecialist gynaecological oncology training programmes do
not exist for the other core specialties within the multidisciplinary
teams. The GCC is developing a post-FRCR (Fellowship of the
Royal College of Radiologists) training fellowship for clinical
oncologists wishing to specialise in gynaecology, exposing
them to relevant surgical and specialist oncological procedures.
Establishing such a post before it becomes mandatory will again
strengthen our position as a leading cancer centre.
Nurse development
We expect an appointment of Chair of Nursing in Women’s
Health in the near future to strengthen nurse-led research within
gynaecological oncology. The UK Clinical Research Collaboration
(UKCRC) plans for building the nurse research workforce will be
implemented and at UCL/UCLH the building block of advanced
nursing research education will be firmly in place with a new MRes
programme starting September 2008. This will help build nurse
research profile in women’s health and generally.
OVERVIEW
This theme, led by Professor Ian Jacobs, has been developed over
20 years through a stepwise progression of cumulative advances
in grant funding, research staff recruitment, technological
expertise, space and equipment. For diagram of organisational
structure, please see Appendix 7.1. The research focus is on the
following areas.
Gynaecological Cancer Research Unit (GCRU)
Lead – Dr Usha Menon
A multidisciplinary group of 35 academic and clinical staff and
students working in teams to oversee and coordinate four large
multicentre trials focused on screening and early detection of
ovarian cancer and a multitude of smaller related projects, and
run the familial gynaecological cancer clinical services at UCLH.
•
risk prediction and prevention
•
screening and early detection
Genomics
•
molecular carcinogenesis
Lead – Dr Simon Gayther
•
disease management.
This laboratory team comprises three senior postdoctoral
scientists, three research assistants and eight PhD students.
The main aims of the research programme are to establish the
underlying genetic and epidemiological basis of susceptibility
to epithelial ovarian cancer and the molecular basis of ovarian
cancer development.
Four well-established research groups (first four below) form the
core. The nursing research group together with recent recruitment
of experts in breast cancer, systems medicine and clinical cancer
genetics brings together other core specialties working in these
research areas. A weekly group leaders’ meeting and a research
seminar series nurture cross-fertilisation of ideas and commitment
to a shared vision and strategic approach amongst approximately
55 researchers. Close integration of clinical and basic science
expertise is a key strength, with eight joint appointments between
UCL and UCLH.
Epigenomics
Lead – Dr Martin Widschwendter
The focus of this group, comprising a postdoctoral scientist,
a technician and three PhD and MD students, is the role of
epigenetics in carcinogenesis and development of DNA
methylation biomarkers for the detection and characterisation of
cancers.
Cancer Proteomics
Diagnostics
Lead – Dr John Timms
The increased tendency to individualise patient management
has, over the years, led to an increased demand for radiological
diagnostic and treatment tools including MRI, CT scan, CT PET,
radiological-guided biopsies and insertion of inferior vena cava
(IVC) filters. It is essential to ensure that the capacity in radiology
matches this clinical demand and a constant review of manpower
is required.
Current staff comprises one post-doctoral scientist, two research
technicians and two PhD students. Research aims to identify
clinically useful biomarkers for screening and early diagnosis
of women’s cancers and advance the understanding of
carcinogenesis through the application of proteomic methods.
Nursing and Patient Care Research
Breast
Lead – Dr Anne Lanceley
The creation of a breast cancer network with the different units
working seamlessly together. One head of service would work
across the trusts to co-ordinate this structure. This head of service
would also lead the Academic Health Science Partnership for
Breast Services, thus embedding translational research and
clinical trials across the centre.
Dr Lanceley is in the process of expanding her group with a focus
on enabling women to proactively manage their health and to
identify ways in which carers, including health care professionals,
can work to support this objective (Appendix 7.2).
Computational and Systems Medicine (CSM)
Breast
Lead – Professor Alexey Zaikin
As part of a linked network, UCLH can reduce both mortality
and morbidity from breast cancer and its treatment. The major
impact of the service will be as part of a combined centre with
700 cancers across the network. This will create a substantial
resource to link to translational research and the biomedical
research centre.
Currently with three PhD students, the group investigates new
biological phenomena and functions related to cancer, and
analises high-throughput mass spectrometry, epigenetics and
genomics data. The long-term strategy is to develop a systems
approach to cancer and establish links between experimental
groups of the IfWH and theoretical departments at UCL
(Appendix 7.3).
78
Paul O’Gorman Building, where many of Women’s Cancer Research
laboratories are now located
79
WOMEN’S CANCER – RESEARCH
WOMEN’S CANCER – clinical
UCL EGA IfWH 1st Quinquennial Review
Lead – Dr Jayant Vaidya
The recent appointment of Jayant Vaidya as a Senior Lecturer at
the IfWH and Division of Surgery and Interventional Science aims
to forge research collaborations between surgery and IfWH on
optimal treatments for breast cancer (Appendix 7.4).
Clinical Cancer Genetics
Lead – Dr Lucy Side
Strategic development of clinical genetics services for breast
and gynaecological cancers is a priority for the Women’s Health
theme of UCL Partners. The appointment of Dr Side as Senior
Lecturer in the IfWH is crucial to taking this forward.
STRATEGY, AIMS AND OBJECTIVES
Mission
To reduce deaths and suffering from women’s cancers through a
combination of research, training and clinical implementation in
the key areas outlined above
Strategy
There have been fundamental conceptual shifts in identifying risk
factors for disease and in implementing screening and public
health measures during the last 10-15 years. These advances
have led to a reduction in deaths from a number of conditions
such as breast cancer and cardiovascular disease. Our aim
is to make similar inroads into deaths from gynaecological
malignancies by focusing on risk prediction screening and early
diagnosis. The ethos is one in which the multidisciplinary team
works at the highest levels of mutual support and collaboration
to realise the potential of a series of translational research
programmes.
Aims and objectives
Risk prediction and prevention
Our ability to lead and contribute to international efforts to
establish risk prediction strategies to prevent women’s cancers
is built around our long-standing expertise in population-based
screening trials and cohort collections, and in the areas of
genetic and epigenetic susceptibility to cancer.
Current objectives are set out below:
• To identify epidemiological and genetic risk factors in the
population and develop strategies to predict women at
highest risk for targeted intervention, for example screening
• To identify novel methods of risk prediction by analysis of
vaginal secretions and liquid based cytology
• To construct in silico models and classifiers, which are able to
explain experimental results, classify or predict them
Screening and early detection
• To discover and validate new biomarkers for early detection
• To enable earlier diagnosis of ovarian cancer through better
understanding of symptoms
• To apply genomic and proteomic screens of models of
carcinogenesis to identify novel, differentially expressed
biomarkers for screening
• To establish homotypic and heterotypic three dimensional
in vitro models of the normal ovary, to study the early stage
progenesis of ovarian cancer
Egyptian figurine (500-580BC) used
in the bedside touch and heritage
object-handling project with women
with gynaecological cancer
• To characterise the basis of stem cell chemoresistence to
ovarian cancer
• To establish homotypic and heterotypic three dimensional
in vitro models of ovarian cancer for identifying and testing
novel molecular therapies for the disease
• To establish an animal model to test and support the
hypothesis that endometrial cells serve as the cell of origin for
ovarian cancer
• To utilize in vitro and in vivo models of disease described
above to follow-up the functional effects of genetic and
epigenetic susceptibility markers of disease
Management of disease
• To test whether intraoperative radiotherapy is sufficient for
local control in breast conserving therapy.
• To improve risk prediction by exploring the role of systematic
screening for known gene mutations in high risk populations
• To establish molecular approaches to the clinical diagnosis
and management of gynaecological cancers based on
genetic and DNA microarray technologies
• To develop new diagnostic and treatment methods based on
computational and experimental research of new biological
phenomena and functions related to cancer
There has been an active policy to recruit and retain high calibre clinical and basic
scientists. There are currently 55 members of staff. Funding has recently been identified to
recruit dedicated staff to manage collaborations involving trial biobanks.
Equipment
Financial
Molecular carcinogenesis
We have developed a basic research theme in molecular
carcinogenesis for ovarian cancer to complement and support
our translational research focus. By establishing models of
disease development we aim to both identify and test functionally
relevant biomarkers associated with susceptibility, screening and
therapeutic intervention. The specific strategies are:
Staff
The genomics and epigenomics laboratories benefitted from equipment purchased as
part of the carefully planned move to UCL in 2004. These laboratories have top-of-therange, high-throughput technologies, including Tecan liquid handling robotics, an Alphelys
Mincore semi-automated tissue microarrayer, a CGH microarray facility, Class II Cell
Culture Suite, and a Zeiss fluorescence microscope. The proteomics laboratory is well
equipped, with four mass spectrometers (including LTQ Orbitrap XL), chromatography and
2D gel running systems for protein separations, clean rooms, MS data analysis software.
In addition to this high quality laboratory kit we also have innovative trial management
systems, serum processing, storage facilities and equipment for biobanking and
facilities for 21st century computer modelling. Funding will be needed in the future for
new equipment, for example, multiplex genotyping platform and digital video and audio
recording systems for qualitative research, as well as essential equipment upgrades and
maintenance.
• To optimise screening strategies for familial ovarian cancer
(UK Familial Ovarian Cancer UKFOCSS)
• To test whether aromatase inhibitors are superior to tamoxifen
in adjuvant treatment of early breast cancer
80
• To investigate the therapeutic potential
of heritage and arts engagement by
women with cancer
To establish the need for an ovarian cancer screening
programme by assessing the impact of screening on ovarian
cancer mortality while comprehensively assessing cost,
psychological issues and morbidity though large multi-centre
randomised controlled trials in the general (UK Collaborative
Trial of Ovarian Cancer Screening UKCTOCS) and high–risk (UK
Familial Ovarian Cancer UKFOCSS) population.
• To further identify and characterise high penetrance
susceptibility genes for ovarian cancer
• To identify and validate risk predictors in serum and in
free circulating serum DNA for (a) developing disease and
(b) dying from breast, ovarian, endometrial or cervical
cancer using the UKCTOCS cohort
• To evaluate the risks and benefits of
nurse-led models of
follow-up care
RESOURCES
Total grant awards to academic gynaecology during the review period was £15.72 million,
of which £11.8 million was funding for 2003-08. This included funding from Research
Councils (MRC, AICR), UK based Charities (CRUK, Eve Appeal) EU Govt Bodies (FP7),
EU Other (EORTC), UK Central (Dept of Health, CBRC), Industry, and Other Overseas
(such as NIH) (see figure). Unlike Section 4 below, these figures do not include awards to
collaborating centres. In addition, during 2003-8, UCLH funding for salary costs towards
time spent by clinical academics on their clinical duties was £2.11 million. Support for core
posts through the University by the Higher Education funding stream (HEFCE) amounted to
£1.34 million (8.9%). Support for core posts especially at Senior Lecturer and above from
the UCL HEFCE budget is limited in gynaecological oncology with only 2 FTE of senior
academics being HEFCE funded. The ratio of external grant funding to HEFCE funding is
much higher in gynaecological oncology than in other academic sections of the IfWH and
this needs correcting in the next phase of development of the IfWH. As can be seen from
the figure below the gynaecological oncology group has had great success in generating
additional external funding with only limited increase in HEFCE funding.
Resources within the Unit are summarised
below with additional information detailed
in Appendix 7.5-7.7 (grants and other
funding; staff and equipment).
Facilities and infrastructure
The seven research groups operate across
three distinct spaces. There is office space
in Maple House (324m2), which is home to
the gynaecological cancer research unit,
nursing, and clinical cancer genetics teams.
High quality facilities for molecular and cell
biology research in the Paul O’Gorman
Building accommodate the Gynaecological
Cancer Research and Epigenomics Groups
(340m2) and the Tumour Marker (clinical
trials) Laboratory (total 36.77m2). Finally,
the Cancer Proteomics group is based
in a purpose-built facility (166m2) in the
Cruciform Building with space for 20 staff.
NHS
HEFCE
Other Overseas
EU Other
EU Govt. Bodies
UK Industry
UK Central
UK based Charities
Research Councils
5
4
£m pa Funding
Breast Cancer Clinical Research Unit
UCL EGA IfWH 1st Quinquennial Review
3
2
1
0
2003–4 2004–5 2005–6 2006–7 2007–8
UCL IfWH Gynaecology Oncology Funding 2003 – 08
81
WOMEN’S CANCER – RESEARCH
WOMEN’S CANCER – RESEARCH
UCL EGA IfWH 1st Quinquennial Review
PERFORMANCE AND MEASUREMENT
OF QUALITY OF ALL ACTIVITY
The groups demonstrate quality and high performance across a
range of measures summarised below and detailed in Appendices
7.7 (Students), 7.8 (Collaborations), list of 10 key publications at
the end of Women’s Cancer – Research section and in separate
Publication Booklet. Please note there will be overlap between
groups across some of these measures.
Gynaecological Cancer Research Unit
Publications
56 publications in peer-reviewed journals and 10 chapters since
2004.
Funding
Total grant funding of ongoing projects is over £33m of which
~95% (£31,716,005) is from major UK funding agencies.
PhD and MD Students
Five since 2004, three in their final year.
Collaborations
Numerous national and international collaborations.
Other
Annual inspection of the trials by their specific independent body
as below.
Data Monitoring Committees – latest on 28th January 2009,
UKFOCSS in May 2009 and GCaPPS in November 2008. In each
instance the trials have been commended.
Review by scientific boards of the funding bodies – the most
recent review by the MRC scientific board was undertaken in July
2008 when UKCTOCS scored 5 and trialists were commended on
the quality of what they had achieved in the trial.
Clinical Pathology
Accreditation Services report following inspection of the Tumour
Marker Laboratory (most recent August 2008). The report
commended the well managed and well trained team and their
overall commitment. Detailed report available on request.
Genomics
UCL EGA IfWH 1st Quinquennial Review
Other
Simon Gayther is a member of the UCL Genetics Institute
Executive and Advisory Boards, the EGA Institute for Women’s
Health Postgraduate Teaching Committee, the Platform
Technologies Development Group (Genomics) and the EGA
Institute for Women’s Health Academic Board.
Epigenomics
Publications
34 papers.
Funding
Austrian Science Fund: “DNA Methylation Markers Analyzed in
Serum and Nipple Aspirate Fluid for Early Detection of Breast
Cancer”. National Institute of Health (Co-investigator): “DNA
methylation based serum markers for early detection of ovarian
cancer”. European Union (Co-investigator): “Integrated Biosensor
system for label-free in vitro DNA and protein diagnostics in health
care applications”.
Other
Young Cancer Research Award 2004 highly commended
(awarded by the European Association for Cancer Research);
Alois Sonnleitner Award 2007 (awarded by the Austrian Academy
of Science); Schmidt Matthiesen Award for Gynaecological
Oncology (awarded by the German Society for Gynaecology and
Obstetrics). Special Issue Editor of Disease Markers for an issue
on Hypermethylation and Epigenomic Markers.
Patents Epigenetic stem cell markers (application filed).
Association of Breast Cancer DNA Methylation Profiles.
Cancer Proteomics
Publications
29 peer-reviewed research articles and 9 reviews, editorials and
book chapters, including invited guest editor for Current Opinion in
Biotechnology.
Funding
£4 million in research and equipment funding since 2004 as
Principle or Co-investigator from CRUK, MRC, AICR, Eve Appeal
and CBRC.
PhD Students
63 original articles and 7 review articles and editorials since 2004.
Supervision of seven PhD students, four of whom have completed;
eight publications with students as lead and co-authors; several
travel awards poster prizes.
Grants
Other
£17 million principle and co-investigator funding including MRC,
CR-UK, FP7, UCL-CDRC, Geneservice, Eve Appeal and Oak
Foundation.
John Timms is a member of the IfWH Academic Board and UCL
Proteomics Platform Technologies Development Group; an invited
journal and grant reviewer for numerous journals and funding
bodies; successfully established several novel proteomic platforms
for sample analysis and biomarker discovery; and led one of
the first groups world-wide to apply and report the 2D-DIGE
expression profiling technology.
Publications
PhD and MD Students
Eight current PhD students and one submitted.
Collaborations
OCAC, COGS, CIMBA, MARIBS, Cambridge, Denmark.
82
AREAS OF EXCELLENCE
Gynaecological Cancer Research Unit
The group is known internationally for its pioneering work on
ovarian cancer screening which commenced with a pilot study of
the initial 1010 women screened reported in the Lancet in 1988
on the first 1000 women screened and has progressed through
establishment of the ability of screening to detect asymptomatic
ovarian cancer (1985-90), proof of a significant survival effect
(1985-99), to refinements of the screening strategy (1995,
2000), field testing in a pilot trial (1995-2000) of the new strategy
and finally the current trial, UKCTOCS with a report in 2009 in
Lancet Oncology. UKCTOCS is the largest RCT ever undertaken
worldwide and will establish whether screening will save lives while
comprehensively addressing cost, psychological and physical
morbidity, compliance and the performance characteristics of two
screening strategies. In parallel the UKFOCSS trial of women at
high risk of ovarian cancer is a key international trial and is the
only one of its kind in Europe. In the UK high risk women who
wish to undergo screening can only do so through this trial. Both
UKCTOCS and UKFOCSS are part of the NCRN and UKCRRN
trials portfolio. Our work on ovarian cancer symptoms is nationally
known and the group was part of the advisory committee to the
DoH in 2008-09 to contribute to a national statement on ovarian
cancer and its symptoms and to help formulate the awareness
strategy (http://www.dh.gov.uk/en/Healthcare/Cancer/index.htm).
Our Familial Cancer Clinic leads nationally and is one of the few
tertiary referral services of its kind in the UK. Most women at
increased risk of familial gynaecological cancer in London and the
Southeast requiring advice on risk management are referred.
Genomics
The group is recognised as one of the international leaders in
studying susceptibility genetics in ovarian cancer, with a track
record stretching back to 1994. The group has led the field
in characterising high-penetrance genetic susceptibility to
ovarian cancer (BRCA1 and BRCA2 genes) in both families and
populations of cases; and more recently, as one of the leads in
an international effort to identify more moderate risk susceptibility
variants for the disease. This has culminated in completion of the
first ever genome wide association study, which has identified
novel susceptibility markers for ovarian cancer. The group has
also established a unique track record for their ground breaking
research in modelling both normal ovarian epithelial cells in vitro
and ovarian cancers in 3D systems. These models show great
potential in identifying and testing novel therapies for ovarian
cancer.
Cancer Proteomics
Our research is placed highly both nationally and internationally as
evidenced by our publication record. There are few groups in the
UK who conduct cancer research using such diverse proteomic
techniques and who have access to such unique sample
collections. We also pride ourselves in our ability to integrate
proteomics with other high-throughput data to better understand
the molecular mechanisms associated with cancer.
Nursing and Patient Care Research
In recognition of the national and international quality of our work
the first UK Senior Lecturer post for a nurse in gynaecological
cancer nursing was established in 2008 and the Nursing and
Patient Care Research Group became a separate identity within
this theme.
Computational and Systems Medicine
The group is known internationally for works on the investigation of
complex biological systems, in particular, in the following research
areas.
• proteasome and immune system research, proved by VW grant,
publications in JMB and setting a web-based resource www.
proteamalg.com
• genetic networks with complex dynamics, proved by seven
publications, including paper in PRL (IF>7)
• systems biology of complex systems with stochasticity, proved
by numerous publications, including several papers in PRL
Clinical Cancer Genetics
This is a new Senior Lecturer post, which is a joint appointment
between the NE Thames Regional Genetics Service (RGS) and
the IfWH. A business plan has been submitted to develop a
register for families with Lynch Syndrome at the RGS. The Familial
Cancer Clinic at IfWH is the only tertiary referral service for these
women who are at increased risk of gynaecological (particularly
endometrial) cancer throughout the London area. With the unique
experience in large scale gynaecological screening studies of the
GCRU, we are ideally placed to investigate endometrial screening
strategies in high risk women.
Epigenomics
We are the leading group in translational epigenetics in women’s
cancer nationally and in Europe, and amongst the leading
groups in translational epigenetics globally. This is reflected in
our publication track record and in the fact that we are invited to
internationally leading conferences covering this theme (e.g. AACR
Cancer Epigenetic Conference in Boston 2008).
Assessing sample quality and cross-checking identifiers on the
database in Tumour Marker Laboratory, which handles samples,
tissues and data from more than 200,000 subjects
83
WOMEN’S CANCER – RESEARCH
WOMEN’S CANCER – RESEARCH
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
CHALLENGES
Multidisciplinary expertise
Coherence and integration
Opportunities have been missed to perform or lead research
that we are well placed to take forward through lack of
necessary expertise within our Unit. In particular, we have
lacked expertise in biostatistics and epidemiology for ovarian
cancer. The appointment of Professor Alexey Zaikin will go
some way to addressing the former although there will be a
lag in productivity as he builds his group. Many aspects of the
strategically planned research have not yet secured sufficient
grants and are still dependent on funding from the Eve Appeal.
The need for funding is being addressed by more collaborative
grant applications (e.g. a collaborative €12 million FP7 project),
a series of external grants which are currently under review and
development of industry links.
The coherence of the research group has benefited from the
move of the laboratory from the Windeyer Building to the Paul
O’Gorman Building. This means that although the group is based
in three locations (Paul O’Gorman Building, Maple House and
Cruciform Building), they are no more than five minutes apart.
Nevertheless, the varied commitments and priorities of the
scientific and clinical research staff mean that ongoing effort is
needed to meet regularly and facilitate collaborative research
efforts. Weekly and monthly research meetings take place; but
daily interaction and informal discussions are required for optimal
exchange of ideas. Ideally the three components of the research
group would be co-located.
Clinical implementation of results
Office space and meeting rooms
From 2004 to 2008 the laboratory was located at the Windeyer
Institute and the geographical separation from the rest of the
group was a challenge, which had a negative impact on research
productivity. The laboratory moved to the Paul O’Gorman building
in June 2008. Substantial time was expended on planning and
co-ordination of the move to the space which is of the highest
quality and ideal for the nature of the research. The move has
not however addressed the lack of office space and meeting
rooms, the latter being a pan-UCL issue. The shortage of rooms
and teaching priorities often results in space having to be
rented outside UCL for research meetings. This compromises
our potential to be at the hub of global forums for research in
women’s cancer.
Equipment
Our research requires the latest cutting-edge technologies for
high-throughout genomics, but there are few funding avenues for
individual groups to purchase the latest technologies and none
for service contracts for current equipment. This has partly been
addressed through an industrial genomics partnership, which
enables onsite-outsourcing of several genetics technologies,
and a UCL initiative to develop important technologies as core
facilities. However, the group is struggling to find either funding
or partnership for multiplex genotyping (a major focus of the
research) due to a lack of multi-user need at UCL.
Long term nature of our clinical trials
The long term, fifteen-year goal of the UKCTOCS project is to
provide definitive RCT evidence to governments concerning
patient benefit of an ovarian cancer screening programme.
There is tension as the core results will not be available until 2015
but there is a need for high impact publications in the shorter
term (five years) for RAE, individual promotion and other similar
exercises. The release of the prevalence screen results has
addressed this to a certain extent, as will use of the Biobank for
secondary studies.
84
UKCTOCS has required an extension until 2015 due to a
healthy volunteer effect in the control group. This extension
will provide the necessary power to detect a significant result.
However, the delay will have a significant knock on effect on
implementation. Some studies with potentially clinically relevant
results require additional validation in prospective clinical trial
to further clarify their role in patient diagnosis and treatment
(for example augmenting traditional histology with molecular
profiling of synchronous tumours to determine if dual primary or
metastasis).
IMPACT AND IMPORTANCE
Actual impact on deaths or suffering
• Risk of Malignancy Index: used nationally and
internationally as a standard approach to triaging patients
with ovarian cancer to specialist units.
• Familial Cancer initiative: prevention of cancer in women
at high risk through surgery.
• Training specialist gynaecological oncologists:
contributing to training of over ten subspecialty trainees.
• UKFOCSS: implementation of a standardised approach
to screening high risk women and early detection of
many cancers, which has led to improvements in service
delivery.
• UKCTOCS programme: evidence of survival benefit in
Lancet paper (1999) and more women detected early
though impact yet to be ascertained (Lancet Oncology
2009).
• Cervical Cancer: introduction of screening programmes
for cervical cancer in Nigeria and Uganda, initially
involving >8,000 women and now being rolled out
nationally. See Global Health theme section
Established research and infrastructure with
potential to reduce death and suffering
Establishment of a multidisciplinary team in genetics, epigenetics,
proteomics and systems medicine working in collaboration with a
large scale Clinical Trials Unit.
Clinical Research Unit with experience of successfully conducting
large scale, complex population based trials including the largest
RCT worldwide with development of automated systems for data
capture and storage. A series of publications in ovarian cancer
(OC) screening going back 15 years which are seminal in this
field and form a basis for current attempts to reduce mortality
worldwide.
Unique sample collections suitable for development of new
diagnostic and screening tests: the UKCTOCS bank of >500,000
samples from 202,000 healthy postmenopausal women; the
UKOPS bank of >700 OC cases and 800 benign cases; UKFOCCS
bank of ~8,000 samples from >3,000 women at high risk of OC
and BC.
Proteomics
Establishment of technology platforms for biomarker discovery
utilising sample collections to identify new markers for diagnosis
and early detection and for the molecular characterisation of cell
models of cancer. New direction in proteosomal splicing research
which has potential in vaccine development.
Epigenomics
Establishment of technology platforms for discovery of epigenetic
markers for risk prediction and early detection and guiding therapy.
A series of 35 publications over last five years which have driven
forward the potential for clinical application of epigenetics in cancer
including an influential Nat Gen paper in 2007.
Genomics
Establishment of a state of the art facility for high throughput
analysis of population based studies of genetic susceptibility and
molecular profiling. Moving from establishing a group in 2002 to
generation of 42 publications since 2007. Key role in establishing
a major international consortium (the OCAC) to study genetic
epidemiology of ovarian cancer.
Systems Medicine
Establishment of systems medicine unit for analysis of high
throughput data and development of recognition and predictive
algorithms (e.g. www.proteamalg.com). Organisation of a
bidirectional information flow between experimental units of WH
and theoretical departments at UCL.
Nurse-led research
Establishment of the first SL post for nurse in women’s cancer
research centre in UK.
Clinical Cancer Genetics
Recruitment of a SL in Cancer Genetics will enable development
in this area and complement and strengthen existing research
projects.
External income
Major peer reviewed external income from MRC, CRUK, DH, EU
totalling awards >£30 million.
Philanthropic income
Long-standing and key link with Eve Appeal charity which has
generated >£6 million income over last seven years. Other
individual donors notably £600,000 for developing world effort.
High quality space
CTU in Maple House, molecular and cell biology (epigenomic and
genomic) laboratory in POG Building, proteomics in Cruciform
Building.
85
WOMEN’S CANCER – RESEARCH
WOMEN’S CANCER – RESEARCH
UCL EGA IfWH 1st Quinquennial Review
Critical mass
Establishment of a team of 55 staff in house and >50 externally
which is thought to be larger than any other grouping in Europe in
this field.
Training
Establishment of a PhD programme involving 5 students, a series
of research fellows, and contribution to undergrad and MSc
training.
FUTURE DEVELOPMENTS
The academic gynaecological and breast cancer theme has
established a strong clinical and scientific foundation since moving
to UCL in 2004 and plans to continue building on its success in
the four main areas of translational research described above. The
Unit has been augmented by recent recruitments in computational
and systems medicine, clinical breast cancer sciences and clinical
cancer genetics, and these will grow with the shared vision of the
Unit. Some of the future developments continuing on from existing
research are as follows.
Clinical Trials Unit
Completion of current trials
Results should be available from UKFOCSS and GCaPPS in
2012. Screening will continue in UKCTOCS till 2011 with follow
up complete in December 2014 and key results available in June
2015. These will have significant and lasting impact on screening
for ovarian cancer globally.
UCL EGA IfWH 1st Quinquennial Review
New trials
Large scale prospective validation of markers of risk and early
detection discovered by the SNP genotyping and epigenetic
studies are underway. We are planning well defined strategies to
maximise the impact of these findings in large cohorts collected
prospectively.
Prospective trials of improving ovarian cancer diagnosis in primary
care by using a well defined algorithm triggered by a symptom score.
Targeted screening in endometrial cancer based on algorithms
developed as a result of UKCTOCS.
Use of the large serum and data banks for the trials for the study of
other diseases in women including other cancers, heart disease so
that use of the resource is maximised for the benefit of all women.
Epigenomics Group
To perform genome wide DNA methylation profiling in white blood
cell DNA (from UKOPS and other collections) and to evaluate risks
for breast and ovarian cancer associated with these data.
To develop DNA methylation analyses in free circulating serum
DNA in the UKCTOCS subjects and establish the efficacy of
this approach as a screening tool for risk assessment and early
detection of breast, ovarian, endometrial or cervical cancer.
Analysis of DNA methylation in pre and post-treatment serum
samples from women undergoing large clinical trials (e.g.
SUCCESS study involving 3600 women with breast cancer) to test
the efficacy of systemic adjuvant therapies.
PEGASUS (Proteomics, Epigenomics, Genomics
Analysis in Samples from UKCTOCS)
Our strength in a range of technologies and methodologies
(systems medicine, statistics, proteomics, genomics, epigenomics)
and unique sample collections provides an outstanding
opportunity to bring together all of these resources in a single
integrated project aimed at providing major advances in cancer
risk prediction and detection.
Capacity building
Strategic planning within the Unit has highlighted areas that are
priorities for capacity building, because they would complement
our multi-disciplinary team and help develop further the level of
excellence in gynaecological and breast cancer research that we
have so far achieved. Specifically, we aim to make appointments in
the following areas.
Genomics Group
Proteomics Group
Molecular epidemiology of ovarian cancer: To integrate the
themes of epidemiology, genetic susceptibility and molecular
characterisation of tumours in ovarian cancer case-control
populations in order to model risk prediction and clinical outcome
for the disease.
Proteomic profiling of ovarian tumour-derived cell lines, tumour
tissues and peripheral white blood cells from UKOPS collections
using newly developed proteomic technologies. This work aims to
identify additional candidate biomarkers which will be tested for in
blood, and will combine genomic and epigenetic data.
Molecular profiling: Develop molecular profiling strategies in
gynaecological tumours that can be taken forward as clinically
relevant diagnostic tools and to evaluate their role in improving
disease management and patient outcome.
Proteomic characterisation of cell models of ovarian cancer
chemo-resistance. This work aims to understand at the molecular
level why some cancers become resistant to chemotherapy.
• Cancer Epidemiology
Senior Lecturer appointment to complement and utilise
population based cohorts in genetic and epigenetic
susceptibility studies and clinical screening trials.
Functional characterisation of putative ovarian cancer oncogenes
and tumour suppressors identified from cell model studies. The
work is aimed at the identification of putative drug targets.
• Breast Cancer
Professorial appointment in Breast Cancer to enhance capacity
and potential of research in this area.
Molecular carcinogenesis: Continue to work on creating
functionally relevant, cell biology models of ovarian cancer to
test the therapeutic potential of genetic risk markers and tumour
markers that we find above.
Nursing and Patient Care Research
Results from the follow-up care study will be available in
2011. These will provide a platform for further testing of nurse
interventions for women on radically different treatment schedules
with molecular targeted treatment advances.
Systems Medicine Group
To develop theoretical and computational methods to construct
in silico a virtual immune system. Strategically this approach
will include studies of degeneracy, ageing, longevity, the role of
stochasticity, miRNAs and alternative splicing.
To develop a synthetic biology approach to cancer, including
theoretical and experimental investigation of synthetic genetic
networks and its utilization in the construction of intelligent drugs,
biomarkers and cancer chronotherapy. Investigation of new precise
control methods of gene expression in synthetic networks.
• Pathology
Senior Lecturer appointment to fill gap in academic pathology resource.
• Cancer Biology
Senior Lecturer or Professorial appointment to enhance capacity
for functional studies.
Links with Cancer Institute
A vital component of our future development is the location of
the Laboratory facilities with respect to the newly formed Cancer
Sciences Institute at UCL. The physical connection between
Cancer Sciences in the Paul O’Gorman Building, with the
Gynaecological Cancer Research Laboratories, Tumour Marker
Laboratory and Cancer Proteomics was a significant factor in
establishing a theme in ovarian cancer (together with Cancer
Therapeutics (Ledermann) and Pathology (Williams)), to be
included as part of the Cancer Institute’s recent application to
become a CRUK Centre. In the future, this is likely to bring benefits
in the breadth and quality of scientific interactions taking place
within the Unit and enhance the links with the UK’s major cancer
charity.
To construct reliable statistical and machine learning classifiers for
cancer detection based on experimental epigenetic and SNP data
and setting the link from statistical analysis towards modelling and
understanding of biological functions.
86
87
WOMEN’S CANCER – RESEARCH
WOMEN’S CANCER – RESEARCH
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
TEN KEY WOMEN’S CANCER PUBLICATIONS AT IfWH 2004-09
GCRU Menon U, Gentry-Maharaj A, Hallett R, Ryan A, Burnell M,
Sharma A, Lewis S, Davies S, Philpott S, Lopes A, Godfrey K, Oram
D, Herod J, Williamson K, Seif MW, Scott I, Mould T, Woolas R,
Murdoch J, Dobbs S, Amso NN, Leeson S, Cruickshank D, McGuire
A, Campbell S, Fallowfield L, Singh N, Dawnay A, Skates SJ, Parmar
M, Jacobs I. Sensitivity and specificity of multimodal and ultrasound
screening for ovarian cancer, and stage distribution of detected
cancers: results of the prevalence screen of the UK Collaborative
Trial of Ovarian Cancer Screening (UKCTOCS). Lancet Oncol. 2009
Apr; 10(4):327-40
The paper reports the first findings from the largest ovarian cancer
screening trial UKCTOCS which is run from GCRC. It summarises the
outcome of the prevalence (initial) screen in women randomised to
annual CA125 screening (interpreted using a risk of ovarian cancer
algorithm) with transvaginal ultrasound scan as a second-line test
(multimodal screening [MMS]; n=50 640); or annual screening with
transvaginal ultrasound (USS; n=50 639) alone. 97 of 50 078 (0.2%)
women from the MMS group and 845 of 48 230 (1.8%) from the USS
group underwent surgery. 42 (MMS) and 45 (USS) primary ovarian
and tubal cancers were detected with 28 (16 MMS, 12 USS) of 58
(48.3%; 95% CI 35.0-61.8) of the invasive cancers stage I/II. The
prevalence screen has established that the screening strategies are
feasible with encouraging performance characteristics.
Menon,U., Gentry-Maharaj,.A, Ryan A, Sharma A, Burnell M, Hallett
R, Lewis S, LopezA, Godfrey K, Oram D, Herod J, Williamson K, Seif
M, Scott I, Mould T, Woolas R,Murdoch J, Dobbs S, Amso N, Leeson
S, Cruickshank D, McGuire A, Campbell S,Fallowfield L, Skates S,
Parmar M, Jacobs I. Recruitment to multicentre trials--lessons from
UKCTOCS: descriptive study. BMJ 2008 Nov 13; 337:a2079
The report describes the factors that contributed to successful
recruitment of more than 200,000 women to UKCTOCS which is
currently the largest randomised controlled trial in the world. The
importance of a committed proactive trial management team,
centralisation and automation of trial processes using web based
trial management systems and use of information videos and group
discussions in recruitment are detailed.
Menon,U., Skates,S.J., Lewis,S., Rosenthal,A.N., Rufford,B.,
Sibley,K., Macdonald,N., Dawnay,A., Jeyarajah,A., Bast,R.C.Jr.,
Oram,D., Jacobs,I.J. (2005). Prospective study using the risk of
ovarian cancer algorithm to screen for ovarian cancer. J Clin Oncol
23(31), 7919-7926.
The paper reports the results of prevalence screening in the first
prospective trial of use of the ‘Risk of ovarian cancer or ROC’
algorithm in ovarian cancer screening in a pilot randomised controlled
trial of 13582 women were recruited. The strategy achieved high
specificity and positive predictive value for detection of invasive
epithelial ovarian cancer in postmenopausal women. The ROC
algorithm is currently being used in UKCTOCS and in the ovarian
cancer screening trials in high risk women in the United States and
UK.
Genomics Quaye L, Dafou D, Ramus SJ, Song, H, Gentry-Maharaj
A, Notaridou M. Hogdall E, Kruger Kjaer S, Christensen L, Hogdall
C, Easton DF, Jacobs IJ, Menon U, Pharoah PDP, Gayther SA.
Functional Complementation Studies Identify Candidate Genes and
Common Genetic Variants Associated with Ovarian Cancer Survival.
Hum Mol Genet. 2009 18:1869–1878 1927002
The paper describes a novel functional approach to identify genes
and common genetic variants associated with survival in ovarian
cancer cases. This led to the identification a gene, RBBP8 for which
both germline genetic variation and somatic alterations in ovarian
tumours were found to be associated with clinical outcome after a
diagnosis of epithelial ovarian cancer.
Ramus SJ, Harrington PA, Pye C, Dicioccio RA, Cox MJ,
Garlinghouse-Jones K, Oakley-Girvan I, Jacobs IJ, Hardy RM,
Whittemore AS, Ponder BA, Piver MS, Pharoah PD, Gayther SA. The
contribution of BRCA1 and BRCA2 mutations to inherited ovarian
cancer. Hum Mutation 2007 28:1207-15.
Gayther SA, Song H, Ramus SJ, Kjaer SK, Whittemore AS, Quaye
L, Tyrer J, Shadforth D, Hogdall E, Hogdall C, Blaeker J, DiCioccio
R, McGuire V, Webb PM, Beesley J, Green AC, Whiteman DC;
Australian Ovarian Cancer Study Group, Goodman MT, Lurie G,
Carney ME, Modugno F, Ness RB, Edwards RP, Moysich KB, Goode
EL, Couch FJ, Cunningham JM, Sellers TA, Wu AH, Pike MC,
Iversen ES, Marks JR, Garcia-Closas M, Brinton L, Lissowska J,
Peplonska B, Easton DF, Jacobs I, Ponder BA, Schildkraut J, Pearce
CL, Chenevix-Trench G, Berchuck A, Pharoah PD; Ovarian Cancer
Association Consortium. Tagging Single Nucleotide Polymorphisms
In Cell Cycle Control Genes And Susceptibility To Invasive Epithelial
Ovarian Cancer. Cancer Res 2007 67:3027-3035
This describes the identification of common genetic susceptibility
variants in a series of cell cycle control genes associated with
variation in the risks of epithelial ovarian cancer. It is notable for
being the first study published by the ovarian cancer association
consortium, a group comprising more than 20 ovarian cancer
studies from around the world that are trying to find genetic and
epidemiological risk factors for ovarian cancer in the population
Brinkmann D, Ryan A., Ayhan A, McCluggage WG, Feakins R,
Santibanez-Koref MF, Mein CA, Gayther SA, Jacobs IJ., A molecular
genetic and statistical approach for the diagnosis of dual-site
cancers. J Natl Cancer Inst. 2004. 96:1441-6. 15467033
This paper describes a novel genetic and statistical approach to the
diagnosis of patients with dual site ovarian and endometrial cancer,
suggesting a future potential for using such an approach in the
clinical arena for the molecular diagnosis of these and other dual site
cancers where a pathology diagnosis can often be equivocal.
EDUCATION AND TRAINING
WOMEN’S CANCER – RESEARCH
UCL EGA IfWH 1st Quinquennial Review
Epigenomics Widschwendter M, Apostolidou S, Jones AA,
Fourkala EO, Arora R, Pearce CL, Frasco M, Ayhan A, Zikan M,
Cibula D, Iyibozkurt CA, Yavuz E, Hauser-Kronberger C, Dubeau L,
Menon U and Jacobs IJ HOXA methylation in normal endometrium
from premenopausal women is associated with the presence of
ovarian cancer – a proof of principle study. Int J Cancer 2009 in print
In this paper we studied HOXA gene methylation in normal
endometrium from premenopausal ovarian cancer patients and agematched healthy controls without ovarian cancer and found that the
overall risk of ovarian cancer was increased 12.3-fold by high HOXA9
methylation in the normal endometrium for all stages, and 14.8-fold
for early stage ovarian cancers, independent of age, phase of the
menstrual cycle and histology of the cancer. The results of this proof
of principle study demonstrate the potential to detect ovarian cancer
via analysis of normal endometrial cells and provide insight into the
possible contribution of this novel approach in ovarian cancer risk
prediction and prevention.
Widschwendter M, Fiegl H, Egle D, Mueller-Holzner E, Spizzo G,
Marth C, Weisenberger DJ, Campan M, Young J, Jacobs I, Laird
PW. Epigenetic stem cell signature in cancer. Nat Genet. 2007
Feb;39(2):157-8.
Embryonic stem cells rely on Polycomb group proteins to reversibly
repress genes required for differentiation. We report that stem cell
Polycomb group targets are up to 12-fold more likely to have cancerspecific promoter DNA hypermethylation than non-targets, supporting
a stem cell origin of cancer in which reversible gene repression is
replaced by permanent silencing, locking the cell into a perpetual
state of self-renewal and thereby predisposing to subsequent
malignant transformation
Proteomics Timms JF, Arslan-Low E, Gentry-Maharaj A, Luo Z,
T’Jampens D, Podust VN, Ford J, Fung ET, Gammerman A, Jacobs IJ
and Menon U. Preanalytic influence of sample handling on SELDITOF serum protein profiles. Clinical Chem 2007. 53: 645-656.
This paper describes the effects of sample handling on serum protein
profiles using high-throughput MS profiling and identifies unstable
proteins which have been previously reported as cancer biomarkers.
The study highlights the importance of optimised and identical
sample handling for biomarker discovery studies using clinical serum
samples.
This paper describes the characterization of the BRCA1 and BRCA2
genes in the largest series of ovarian cancer families in the published
literature, joining together two familial registers from the UK and USA.
The paper also correlates BRCA1 and BRCA2 status with clinical
characteristics of ovarian cancer highlighting the potential value of this
research in the future in the genetic testing arena.
88
89
UCL EGA IfWH 1st Quinquennial Review
EDUCATION AND TRAINING
Rekha Bajoria
Ratna Chatterjee
UNDERGRADUATE EDUCATION
Joyce Harper
Joseph Iskaros
OVERVIEW
RESOURCES
The breadth of undergraduate education provided consists of
contributions to all phases of the University College London
medical curriculum, BSc degrees and a learning environment to
allow an understanding of a future career in Women’s Health. The
overall aim is to provide a broad education beyond the remit of the
phase 2 module in Women’s Health.
Funding for academic staff is via HEFCEt. A large component of
the teachers are NHS staff, their funding being through Service
Increment Funding for Teaching (SIFT) to the base campuses
at the Royal Free, UCLH and the Whittington Hospitals (HEFCE
Undergraduate Teaching Income table – Appendix 8.2).
On average 400 students per year are taught during Year 4, with
a further teaching input for 400 students within the Reproduction,
Development and Genetics module in Year 2 of the course. For
the clinical attachment during Women’s Health 17 students are
allocated to UCLH, 17 to the Whittington Hospital and 12 to the
Royal Free Hospital Trust at any one time. Three times per year in
excess of 130 students have a final MBBS assessment comprising
an Observed Structural Clinical Examination (OSCE) and a written
Extended Matching Question (EMQ) plus Single Best Answer (SBA)
examination paper. The undergraduate organisational structure can
be seen in Appendix 8.1.
Innovations (see below) introduced into the undergraduate
curriculum in Women’s Health have been recognized by UCL
Medical School and adopted within other modules. Examples are:
Allan MacLean
Heulwen Morgan
Ray Noble
Creation and introduction of a logbook for all students and review
of student achievements at the OSCE. This has allowed continuing
improvements to be made. These are outlined for students within
the following year’s Study Guide.
Donald Peebles
Consent for intimate examinations, now being adopted by surgical
specialties.
Involvement of Allied Professionals in the education of medical
students both as tutors and within interprofessional seminars to
create an understanding of differing roles and responsibilities
Quality assurance visits assessing Women’s Health and Child
Health undergraduate education within the base campuses
occurred during the 2007-08 academic year (teaching space –
Appendix 8.3, SIFT reports – Appendices 8.6-8.9).
The facilities for teaching are partly summarized in the SIFT
reports. In addition there are now seminar rooms on each floor
of the UCLH tower block and a state of the art Education Centre
has recently opened on the Euston Road. Three Clinical Skills
Laboratories are available for regular use with manikins and models
for teaching and assessment. The WHCD module OSCE takes
place at the Whittington Clinical Skills laboratory. The Cruciform Dry
Labs are used for poster demonstrations and judging the student
presentations.
The majority of teaching staff during the clinical weeks are NHS
consultants. The number of PAs for medical education within job
plans do not always equate with the time taken to prepare, perform,
assess and receive feedback for the teaching. It is suggested by
UCL Medical School that 1PA per full time equivalent (FTE) student
should be the norm. Please see Appendix 8.5, which illustrates 3.5
PA provision for both postgraduate and undergraduate education
for a group of consultants who collectively teach and train 9.84 FTE
medical students (2007-08) and their postgraduate trainees. More
transparency for both SIFT and HEFCEt is warranted.
STRATEGY, AIMS AND OBJECTIVES
The strategy is to induce an investigative approach to learning with
strong enforcement of the value of working in teams, in particular
with allied professionals.
Anthony Silverstone
Melissa Whitten
Within the medical school curriculum Women’s Health is partnered
with Communicable Diseases (WHCD) in the second clinical
year (Study Guide available on request, containing details of
components and module). The aims of this course are:
to achieve a basic level of understanding of women’s health issues
and obstetric and gynaecological conditions, both in hospital and
community settings
to be able to apply the knowledge and skills acquired when
dealing with women’s health issues.
The provision of role models is highlighted during Student Selected
Components (SSC) of the course when a a one-to-one tutorstudent relationship exists. Teaching involvement during Phase 1
(year 1 and 2 and BSc) gives students an insight into Obstetrics
and Gynaecology that is built upon during later years.
90
Cruciform Building with UCH Tower in the background – both
important sites for undergraduate teaching at UCL and IfWH
91
UNDERGRADUATE Education
Education AND training
UCL EGA IfWH 1st Quinquennial Review
PERFORMANCE AND MEASUREMENT
OF QUALITY IN ALL AREAS
Undergraduate Teaching Committee
Heulwen Morgan is the obstetric and gynaecological lead and
chairs the Institute Undergraduate Teaching Committee that
meets each term. Membership is multidisciplinary and includes
Professor Peebles, the site leads, NHS consultants and Phase 1
NHS tutors. District General Hospital consultant representatives
and medical students attend. The discussion informs and enables
an equivalence of learning experience to be achieved for students.
Feedback is analysed with a plan of action agreed. This action
plan is outlined within the next academic year’s Study Guide as
an example of feedback having been acted upon. The minutes
are sent to the Institute Academic Board and the medical school
curriculum committee. The Institute undergraduate administrator
and the Women’s Health course co-coordinator are in attendance.
Further evidence of quality performance is contained within the
SIFT Quality Assurance reports (Appendices 8.6-8.9).
National Undergraduate Curriculum in
Obstetrics and Gynaecology
Having reviewed the report of the RCOG Working Party into
a national curriculum it is apparent that all components of the
proposed curriculum are fulfilled within the UCL module. It is
evident that the UCL course stretches the student beyond the
confines of basic obstetrics and gynaecology.
The merit of our emphasis on clinical involvement for students
is based on our belief that this is almost the first time during the
students’ training that they are exposed to direct clinical care. The
opportunity for the student to care for a woman during labour is
invaluable, in particular reflecting the importance of continuity of
care in medicine. Indeed, we use the student-labouring patient
relationship as a paradigm for clinical care in general. At the
Institute we understand how the concept of continuity of care in
medicine is under threat and use the labour ward experience to
highlight its importance.
UCL EGA IfWH 1st Quinquennial Review
AREAS OF EXCELLENCE
Midwifery firm
A successful bid for SIFT monies to appoint midwifery Principal
Lecturers enabled more midwifery involvement in medical student
education. Improvement in feedback from students was documented
for this aspect of the clinical course after this innovation. Poster (in
Undergraduate Centre) presented, AMEE, 2006.
Medical students have a four-week Obstetrics placement at their
home base hospital. During this time they will spend between one
and two weeks in a midwifery attachment. They work one-to-one
with midwives on the labour wards and birthing centres caring for
women and their partners during labour, birth and postpartum.
Additionally some will work on the wards and all will experience
a day in the community with a locally based midwife giving them
valuable insight into normal pregnancy, maternity care and the role
of the midwife. The students additionally have the opportunity to
attend midwifery focused tutorials and clinical skills sessions from
senior and specialist midwives.
Interprofessional education
Scenario sessions involve general practitioners, social workers,
midwifery lecturers, medical student tutors, paediatricians and
nursing staff for students of medicine, nursing, midwifery and
social work courses. The first scenario session was a simulated
case conference for a pregnant woman addicted to drugs that
could harm her unborn child, a situation that would have involved
all members of the multidisciplinary team as above. Some medical
students did attend. Feedback indicated the need for further
sessions which although labour intensive are being organized.
Gynaecology Teaching Assistants (GTA)
A pilot project at the Whittington Hospital has been started for
trained lay women to teach female intimate examination. Feedback
has been excellent and students from all campuses now have this
teaching session at the start of their base campus attachment. The
funding is from SIFT.
Seminar on Women’s Health and
Complimentary Medicine
Phase 2 (year 3) students have an opportunity for two weeks of
self selected learning – within Maternal Medicine and Midwifery at
the Whittington Hospital.
Students are invited to attend, and this is timetabled within their
clinical four weeks at the Whittington Hospital.
Phase 3 (year 5) medical students can undertake a four-week SSC
within Women’s Health. They have a choice of Complimentary and
Alternative Medicine at the Whittington campus, Maternal Medicine
and Reproductive Medicine (including polycystic ovaries) at UCLH
and the Whittington, Fetal Medicine, Gynaecological Oncology
and Fibroids at UCLH. Student involvement with specialists in the
above subject areas, plus conducting detailed projects during their
attachments provides added motivation for the subject of Women’s
Health. This contributes to the objective of recruiting and retaining
health professionals in the disciplines covered by the Institute.
The SSC with the highest grade is awarded a Royal College of
Obstetricians and Gynaecologists (RCOG) prize. The first has been
presented at the RCOG in January, 2009.
Poster project
All students participate in group investigation of an area of their
choice within Women’s Health or Communicable diseases. 6-7
students form a group and present the findings of their literature
search, research, investigation or survey in the form of a poster at
the end of the module. A monetary prize is available for the winning
team. The best poster of the year is awarded a prize from the Royal
College of Obstetrics and Gynaecology (RCOG), and the first was
presented at the RCOG in January, 2009.
Moodle: web-based information system
Course materials, revision information and questions can be
accessed by students both at the base campuses and District
General Hospitals via the UCL website.
Phase 1
(Years 1 and 2 of 5-year MBBS Medicine course (which takes 6
years with Intercalated BSc)
Institute staff contributes substantially to courses in Phase 1 of
the medical curriculum providing lectures and workshops on the
cardiovascular and respiratory systems in Year 1 and reproductive
system and developments in reproductive health care and women’s
health in Year 2. This teaching provides continuity with phase 2
with sessions on acid-base balance, microcirculation, pregnancy,
treatment of infertility, IVF and preimplantation genetic diagnosis as
well as tutorials on clinical scenarios in reproduction.
Intercalated BSc
Teaching Awards
Dr Ray Noble received the Inaugural Provost’s award in 2008 for
his innovative teaching and contribution across the breadth of
education at UCL.
The Dean’s award for teaching was presented to Miss Heulwen
Morgan, Miss Carol Saunders and Therese Bourne (the latter two
being midwifery lecturers) at the degree ceremony, 2007.
CHALLENGES
• With changes in SIFT calculations due to the MPET Funding
Review the monies available for undergraduate education may
become a set amount per FTE resulting in a loss of money for
Trusts. Liaison with NHS management will be doubly important
to retain as much teaching facility and time as possible in
order to maintain the quality of teaching. As mentioned above,
transparency in all funding pathways for education will be
imperative.
Clinical involvement in gynaecology has changed dramatically over
the last few years and it has become more difficult to teach at the
bedside. We recognise this and as a consequence use both our
antenatal clinic setting and all gynaecology clinics as active teaching
environments. We aim, for instance, to allow some doctors to see fewer
patients to allow more teaching during clinic time, although, as you
can imagine, with targets to be met, this is a difficult circle to square.
Nevertheless, we recognise that there is simply no substitute for
patient contact during student training in obstetrics and gynaecology
and it is constantly maintained as a high priority. We believe as a
consequence that students find their exposure to women’s health,
particularly their involvement on the labour ward, an enormously
rewarding experience and one that will inform their expectations for
clinical practice (whatever their specialty) in the future.
The BSc course module in Fetal and Neonatal Physiology is
amongst the most popular and successful of the courses offered
for biomedical science and intercalating medical students with
over 70 students each year. The course is organized in the Institute
with most of the teaching by Institute staff. The aim of the course
is to develop a critical understanding of recent developments in
reproductive, fetal and neonatal science and clinical practice. The
course has been praised by external examiners and in QAA visits
for its innovative teaching and continues to receive strong feedback
from students. The aim of the Institute is to develop this to an
Intercalated BSc in Women’s Health in the future whilst current
priority is the new MSc in Reproductive and Women’s Health due
to start in September. Laboratory based and library based projects
are offered in the BSc year. One objective is to introduce students
to the range of exciting developments in research within the
Institute.
• Patterns of care with increasing day surgery warrant innovative
ways of providing student time with patients. In addition NHS
targets could increase clinic activity and throughput thus
reducing time to teach.
Child and Family Health
Student Selected Components (SSC)
In addition to approximately 400 undergraduate students per
academic year in WHCD the Institute contributes significantly to
education within the Child Health module.
We run an SSC in Reproductive Ethics (Reproductive Medicine,
Science and Society) in Year 2 developed in collaboration with the
Ethics Unit at the medical school in KwaZulu Natal (South Africa).
• Obtaining a portfolio for all educators. Currently a mandatory
portfolio is being developed for postgraduate educational
supervisors, and ideally this could be combined with the
undergraduate portfolio.
92
Undergraduate clinical skills teaching
• Junior staff hours becoming 48 hours per week may impact on
continuity of care and motivation to teach. Interesting ways of
working must be achieved to entice students into the specialty.
• “Moodle” – web-based education is bringing innovative
initiatives to enhance learning, a challenge that will involve
educating some educators!
• The perennial challenge of limited time available for education.
For example, clinical managers need to agree to reduce clinical
activity for assessments to run smoothly.
93
UNDERGRADUATE Education
UNDERGRADUATE Education
UCL EGA IfWH 1st Quinquennial Review
WHCD module
From the 2008-09 academic year onwards the module has been
reduced from 15 to 14 weeks. This allows a week for career
counselling and another for information giving about Foundation
Year post applications and preparation for practice.
The current module lead is Professor Alan MacLean. The
rationale for the changes in response to the shortened course
from September, 2009 is to give the students a one-week break
between modules to allow reflection and provide guidance for
underperforming students. The 14 week programme now consists
of a one week Introduction, and a final week for assessment, and
3 x 4 week clinical attachments at one of the base campuses, at a
DGH (for 8 weeks Women’s Health), and 4 weeks Communicable
Diseases. Additional teaching has been added to the 4th Friday
of each 4 week block to allow teaching including ethics, and a
revision session (Week 13).
IMPACT AND IMPORTANCE
There is a wealth of enthusiastic educators amongst the staff of
the Institute, which encourages student interest to be developed
into a keen motivation to be involved with the medical care of
women. The provision of future expertise and careers within
Women’s Health will ensure appropriate holistic health care for
women in both hospital and the community.
UCL EGA IfWH 1st Quinquennial Review
Involvement of Gynaecology Teaching Assistants to teach each
student a sensitive approach to intimate examination allows insight
into improved communication with the patient population, an
essential element of medical practice.
The Institute has a proven track record within clinical academic
training (see postgraduate academic training). This had a knock-on
effect to the undergraduate training with provision of academic Y2
posts involving research in all areas of obstetrics and gynaecology
as well as in medical education.
FUTURE DEVELOPMENTS
In consideration of some of the challenges above, a pattern of
apprenticeship and student shadowing of career doctors during
Year 4 could be considered.
With funding from the British Council UKIERE, a short course
in Medical Ethics in Women’s Health for medical students was
completed successfully in December 2007. Under the auspices
of the Institute of Women’s Health the aim is to extend access
and opportunities through distance learning both overseas and
in the UK.
POSTGRADUATE EDUCATION and training
OVERVIEW
Postgraduate education is provided in the Institute through
• clinical training
• research for PhD and MD
• an established MSc and post graduate diploma (PG diploma)
in Prenatal Genetics and Fetal Medicine and a new MSc/PG
diploma in Reproductive Science and Women’s Health
The Institute provides a supportive, stimulating and accessible
learning environment for postgraduate clinical trainees at all levels
fulfilling the requirements of the Royal College of Obstetricians
and Gynaecologists, the London Deanery School of Obstetrics
and Gynaecology, the North Thames Foundation School and
the Postgraduate Medical Education and Training Board, and
to proactively support the personal and career development of
potential future senior appointments within the Institute. Education
and training opportunities are provided from Foundation Year 1
through to subspecialty training. We are frequently cited as the
most popular trust for obstetrics and gynaecology trainees in our
sector based on requests for training rotations within the North East
Thames training programme.
The Graduate Research Programme, formally established on 1st
October 2007, provides a multi-disciplinary and cross cutting
environment for students across the breadth of the Institute with
tailored academic training and clear milestones (See diagram
Appendix A) including generic academic competencies provided
by seminars, tutorials and workshops organised by the Institute
and UCL. Students have regular scheduled meetings with their
supervisors whose responsibility is to facilitate progress. Currently
there are 31 PhDs in the programme - 22 full-time and 9 part-time
and additionally 12 MD students.
The MSc and PG Diploma in Prenatal Genetics and Fetal Medicine
were set up in 1997 catering for approximately 12 students each
year and are run by Dr Joyce Harper, Dr Sioban SenGupta, Dr
Anna David and Professor Eric Jauniaux. Both are one-year
full-time or two-year part-time degree programmes designed
for biological scientists and obstetricians who wish to specialise
in prenatal genetics and fetal medicine. The MSc programme
structure consists of a eight month lecture and practical
programme and a four month research project. The PG Diploma
consists of an eight month lecture and practical programme only.
Clinical skills teaching: mechinisms of delivery
94
A new MSc/PG diploma programme in Reproductive Science
and Women’s Health starts in September 2009 with the same
format. Both courses consist of eight modules, four of which are
common between the two programmes. Each module is run over
a three week period and examined by workbooks, essays and
exams. Each module can be offered as a short, external course.
Throughout the course all students have observation days in the
IVF and Fetal Medicine unit.
The new MSc/Diploma in Haemoglobinopathies, an innovative
distance learning course in partnership with Thalasaemia
International Federation, is due to start in February-March 2009.
Graduate Education is led by Ray Noble (research programme)
and Joyce Harper (taught programmes) with oversight by the
Graduate Teaching Committee (see diagram Appendix 9.2) with
administration provided by a Graduate Administrator (Eleonora
Massella). Postgraduate clinical training is led by Joseph
Iskaros, RCOG College Tutor. Melissa Whitten is a new consultant
appointment for Education and Training at both undergraduate
and postgraduate level. Janet Halsey is a midwife educational
practitioner. Karla Isaacs provides administrative support.
We employ more than 30 junior doctors at all levels of training in line
with RCOG Specialty Training Curriculum and organised within the
context of clinical service activity including day and night-time work.
We run 3 separate rotas:
A SHO Rota
3 ST1 and 3 ST2 trainees, 5 GP trainees, 1 FY2 trainee.
Trainees rotate through a variety of clinical areas to gain a
balanced and broad experience. We participate in the Trust
Foundation Programme by providing training for FY2 trainees
who are with us for 4 months as part of their second year of
training. We also have 2 FY1 doctors who receive daytime
training in gynaecology, obstetrics and breast.
B Registrars’ Rota
A 10 person rota soon to be increased to 11. We have 8
doctors in Deanery recognised funded posts; the majority are
a combination of ST3-ST7 posts; all ST6-7 level trainees are
registered for specials skills training modules and advanced
training skills modules in line with the RCOG advanced training
curriculum. Four of these trainees are academic clinical fellows,
a result of successful bid for Walport funding. These posts
are part of the UK Council for Research Clinicians initiative to
encourage academic training with 25% of their time involved
in research and academic work. UCLH and UCL’s strength
in clinical and academic work has meant that we were able
to have 4 of these prestigious posts, the largest number for
NHS Trusts in London. We also have 3 trust funded academic
fellows, currently in maternal medicine, paediatric gynaecology
and urogynaecology.
C Specialist Registrars’ Rota
We have 8 trainees in RCOG recognised sub-specialty
programmes (one of the largest number in the UK for one
training environment) and 1 trust funded clinical fellow
(currently for advanced laparoscopic surgery, an innovative
post which is currently the model for development of this area
across the country). We currently have 2 sub-speciality posts in
reproductive medicine, 1 in gynaecological oncology, 1 in urogynaecology and 3 in maternal-fetal medicine, one of which is
divided between two academic clinical lecturers.
95
postGRADUATE Education and training
UNDERGRADUATE Education
UCL EGA IfWH 1st Quinquennial Review
We have been successful in obtaining
additional Walport funding and University
funding for Academic Lecturer posts which
are senior training posts at subspecialty
level. These comprise 50% academic
and 50% clinical work over a four year
programme of training.
The department is further enhanced by
a number of senior visiting fellows from
outside units, usually from outside the UK,
who bring with them ideas and academic
contributions.
The registrars are allowed appropriate
study leave within their allocated slots.
There is funding allocated for each
registrar for each doctor on the rota
including the non-training grades.
UCL EGA IfWH 1st Quinquennial Review
Strategy, Aims and Objectives
Our aim is to deliver a high standard of teaching education and training to carefully
selected and enthusiastic trainees. We aim to provide a healthy environment for delivering
the College curriculum. The department is fully engaged with the over-riding principles of
providing a supportive and encompassing atmosphere for learning. We see education and
training as a key component for providing excellent and safe patients’ care.
We aim to provide the following:
• Being actively involved in regional teaching afternoons for
ST1-ST3 trainees as well as regional teaching programme for
ST4-ST7 trainees. Effective educational supervision with the help
of all the Consultants in the department. Rolling out mentoring
programme for junior doctors with Consultants and other senior
trainees continues work and relationships with general practice
to deliver obstetrics and gynaecology training for the different
vocational schemes.
• Comprehensive local induction programme to all new trainees in the department. These
include policies, guidelines and patients’ safety issues. It also provides practical skills
and drills for obstetrics and gynaecology emergencies.
• Work closely with the School of obstetrics and gynaecology at
the London Deanery to deliver the curriculum as established by
the Royal College of Obstetricians and Gynaecologists.
• An active teaching programme through regular weekly meetings including perinatal
morbidity and mortality, gynaecological pathology meeting, gynaecological ultrasound
teaching, cardiotocogram (CTG training), clinical case presentations, as well as
dedicated Friday afternoon teaching sessions. This is together with a monthly
departmental audit meeting.
• Implementation of multiprofessional learning by means of
workshops, simulations and practical skills teaching for both
doctors and midwives within the department.
Several courses held on site are run by
consultants within the Institute. These
• Peer-to peer teaching of clinical skills
include exam-based courses (DRCOG),
gynaecological ultrasound theoretical
and practical, Dilemmas in Obstetric
Ultrasound, and perineal repair. Many of
these hold an international reputation.
We have in the past year appointed a new post to support
organisation and provision of education and training (Melissa
Whitten) at both undergraduate and postgraduate level. We have
an active postgraduate education committee to plan organisation
of training. The New UCLH Education Centre will provide additional
educational opportunities not previously provided for including
simulation workshops and After Action Review training.
The department runs its own education
programme as well as actively contributing
to regional teaching programmes for
ST1-ST5 as well as ST6-7. Our weekly
educational programme includes
perinatal morbidity and mortality
meetings, clinical case presentations,
CTG teaching, reproductive medicine,
journal club, gynaecological pathology
meeting, ultrasound teaching and case
presentations, and weekly Friday afternoon
teaching programme covering key areas
of the curriculum. Multidisciplinary skills
and drills teaching is an inherent part of
the teaching programme. We also have
half a day of departmental audit day which
includes presentation of different audits as
well as lectures covering different areas of
the audit topic. The Institute for Women’s
Health runs an annual meeting with
outstanding speakers covering not only
clinical obstetrics and gynaecology but
also other areas of research and midwifery
and nursing output. The registrars are
encouraged to present posters of their
work during that annual meeting.
The key strategy or our PhD and Masters programmes is to
develop 1) a coherent programme that encourages and attracts
high calibre students and fosters scholarship and research in
Women’s Health; 2) a robust programme of supervision to ensure
success; 3) an enhanced taught Masters programme. The Institute
aims to provide an environment in which students can develop
and pursue research at the highest level of accomplishment
with opportunities for research in groups at the leading edge
internationally in a recognised centre of academic excellence.
It seeks to develop research and academic skills of scholarship
and to enable students to contribute to and learn from the broader
objectives in women’s health in basic and clinical science. In
conjunction with the UCL Graduate School the Institute graduate
research programme, through its supervisory structure and
seminar programmes, develops and fosters not only the specific
skills required in any particular areas of research but also
generic and transferrable skills enabling students to compete
in the broadest range of career opportunities. A limiting factor
is obtaining funding for graduate positions. We aim to enhance
funding opportunities through robust supervision to further improve
completion rates and to enrich student experience.
PhD duration and completion
Teaching in the workplace – obstetric ultrasound
96
• E-learning: all trainees are registered for the K2 CTG e-learning
programme, in addition to supporting access to the RCOG
StratTOG modules. We have developed an intranet support site
for learning.
Currently time to completion for PhDs in the Institute is a little above
the average for UCL. A key objective is to improve completion
rates. The standard period for a full-time PhD programme at UCL
is 3 years with completion (PhD examined and awarded) within 4
years. UCL policy is that submission of a thesis should happen
within the year following the final registration (18 months for parttime students). Funding and Higher Education agencies (HEFC,
CVCP, CPHC, EPSRC, etc.) will only take into account completions
within 4 years in their assessments of submission rates which
have become a key indicator for funding. For students registered
for research degrees part time there is no set limit for completion;
however the Institute policy is that part time PhD students should
complete within 4 - 5 years. The Institute graduate studies
programme is designed to enable completion to be met within
these time periods with clear goals and timelines and to prepare
students for their subsequent career moves. It is important to
ensure that full-time students are able to, and do, complete within
their research programme within 3 years. Thus, graduate research
projects should be of sufficient substance to constitute work for
PhD but also be possible to accomplish within 3 years. The Institute
must also ensure that there will be sufficient supervision and
resources to enable a 3 year completion. More rigorous milestones
and assessment of progress is a key element of the programme
adopted in 2007.
Development of taught MSc and Diploma
Programmes
A key objective is to develop opportunities for study at Masters
and Diploma level. A new MSc/Diploma in Reproductive science
and Women’s Health has now been approved by college and will
start in September 2009 with the aim of attracting both biomedical
sciences and clinical students.
Resources
The primary resource is provided by the excellence of the research
base providing a breadth of opportunities for graduate research
and supervision. Funding for PhD’s is a limiting factor for expanding
student numbers and opportunities (See Challenges and Strategy).
The taught courses are self funding with student numbers limited to
12 each year because of the research projects (which are always
noted as being of high quality and often lead to publication), with
income supporting a course tutor and facilities necessary to run
them. The seminar room in Chenies Mews provides an ‘in house’
teaching space. We have a dedicated room to provide IT resources
for students but this is very small and limited.
We are hopeful that any future move from Chenies Mews to
consolidate the Institute will include extra facilities for graduate
students. A dedicated Graduate Administrator supports all aspects
of the graduate teaching working closely with the two graduate
tutors (for graduate research and taught course), this could be
strengthened by the establishment of a teaching office as we
expand the taught graduate courses.
Space
The move to the new EGA wing has provided us with a dedicated
teaching seminar room plus computer facilities. Further resources
including upgrading of current AV facilities and provision of a quiet
work room are still required.
UCLH has recently opened a new Education Centre which
provides training support, rooms, AV equipment and simulation
rooms to support teaching.
97
postGRADUATE Education and training
postGRADUATE Education and training
UCL EGA IfWH 1st Quinquennial Review
Finance
Funding for educational activities comes from several sources
including the Medical Postgraduate Education Budget, Deanery
funding, and the Postgraduate Education Committee for O&G.
We have successfully bid for additional funding from the Deanery
for items such as simulators.
Staff
detailed in Appendix 9.1
Equipment
• A dedicated teaching seminar room with AV facilities
and a commitment from the Trustees to enhance this
with videoconferencing, thus enabling links with other
units both within the UK and overseas
• Computer access
• Ultrasound training models
• Minimal access models
• Clinical Skills Lab
• Obstetric emergency simulation models and
mannequins for multidisciplinary learning
• Further including provision of a quiet work room with
computer access are still required.
UCL EGA IfWH 1st Quinquennial Review
Performance and
Measurement of Quality
The graduate programme has expanded significantly since the
creation of the Institute and we now have completion rates above
the average of UCL. The taught MSc/Diploma in prenatal genetics
and fetal medicine receives outstanding approval in reports from
external examiners and student feedback in respect of organisation,
teaching and the standard set and achieved in examination. The
standard of teaching is peer reviewed to maintain and improve
quality and performance. A measure of the success of this course
is that it is not necessary to advertise specifically to recruit students.
The reputation of the course is sufficient to maintain a constant
demand for places. The Staff Student Consultation Committee
reviews issues as they arise and working through the course
organisers and the Graduate Teaching Committee these are
dealt with speedily and improvements made in the delivery of the
courses. The graduate programmes are reviewed through the UCL
quality assurance procedures with annual reports and conform to
their guidance and best practice.
We have recently established regular meetings of graduate
supervisors to discuss issues and develop a robust approach
to supervision and student review. The dedicated student
seminar programme provides opportunities for assessment
and development of student progress and contributes to
improving skills and improvement in completion rates and career
opportunities for our graduates. Research students have an annual
appraisal with a report and a meeting with the graduate tutor to
ensure progress is being made.
Key performance indicators for postgraduate
clinical training
• PMETB survey – this has consistently shown our unit to provide
a good level of training in comparison to other units (for O&G)
and to other specialties (for UCLH) in particular for access to
resources, educational supervision and processes such as
effective handover.
• Annual Assessment of Competency Progress Reports – these
Deanery-led reviews have given positive feedback to our trainers
in terms of provision of training. All trainees are supported in
completing portfolios, undertaking formative and summative
assessment and multi-source feedback.
• Examinations – we have a high number of trainees who have
passed their RCOG Membership examination
• 100% compliance with induction processes
• ULCH holds an enviable position as one of the most popular
Trusts for trainees to rotate to from within the North East Thames
Training Programme
Areas of Excellence
Impact and Importance
The MSc/Diploma in prenatal genetics and fetal medicine has been
an outstanding success. Many of the graduates go on to do PhDs
in the Institute or elsewhere and the course makes a significant
contribution to developing capacity in prenatal genetic diagnosis
and fetal medicine with many students from a clinical background.
It continues to receive excellent approval from external examiners
and from the students themselves. The expertise in teaching this
course is a factor in being able to expand our taught graduate
programme.
Our aim as an institute is to attract and retain high caliber
biomedical and clinical scientists into a career in women’s health.
Creating a vibrant and robust graduate programme provides an
environment to achieve this by providing a clear training path, not
least for the clinical fellowship and lectureship programme. Many
of the graduates of the MSc course either enter or return to a
clinical environment in women’s health with greater expertise; many
go on to do PhDs and contribute to scholarship and translational
research in this field. Graduate research also forges a link between
basic biomedical and clinical science which is important for
developing skills in translational research.
Challenges
The main challenge during last three years has been to develop
a coherent graduate programme with a clear identity in the
Institute, to strengthen the organization and quality assurance
of the graduate research programme to improve completion
rates and to develop new teaching initiatives. This has been a
key priority of the Institute where teaching has been identified
as an important contribution to the future of women’s health. The
PhD and MD programme, establishing clear milestones and a
robust review of progress, has improved the quality assurance
process with a concentration of developing transferable skills.
This will strengthen our funding capability. This was achieved by
bringing supervisors and all graduate students together in regular
bi-monthly seminars where the students present their work as
part of the review and PhD upgrade process. In addition to the
graduate teaching committee we hold meetings of supervisors to
discuss developments and ideas for the future. Another key factor
in developing this programme was the creation of a small team
(graduate tutors, two supervisors and the graduate administrator)
to develop and push it forward. Dividing the work of the graduate
tutor between research and taught programmes (a mirror of
the organization at faculty level) has also been beneficial in
concentrating expertise in these areas and developing initiatives.
We have developed a number of key areas for education which
have made an impact upon supporting training and thereby
furthering the effective provision of safe care for women:
•Mentoring programme for trainees
•Regional training programme
•Embedding of curriculum based training and teaching
•Practical ultrasound training for junior trainees (ST1-2) to be able
to practice effectively in the labour ward environment.
•Clinical audit days
•Incorporation of junior trainees to teach medical students
and midwives in order to achieve part of the teaching skills
requirements of the curriculum
Clinical training
•Institute for Women’s Health Academic Fora and Annual Study
Days which provide an opportunity for all those working across
Women’s Health to communicate and participate with each other.
We have worked hard to implement the new Specialty Training
Curriculum since its inception in August 2007. We acted as a
pilot site for use of the new assessment tools and this has proved
valuable to us in learning how to incorporate these into a busy
working environment.
Future Developments
Ongoing conflict between service and provision with the
implementation of the European Working Time Directive. We have
addressed this by increasing our numbers of non-training posts
and by working with Human Resources to redesign rotas in order
to ensure that trainees retain a structured and progressive focus to
the weekly work, whilst minimising disruption to training.
In recognition of these first two challenges and the potential impact
they might have upon patient safety and upon training needs, we
developed an education and learning stream as part of a major
Maternity Quality Project during 2008. This is ongoing and has
proved valuable in identifying needs and addressing them both
across obstetrics, gynaecology and midwifery.
Space issues within the new maternity wing.
98
Developing taught MSc and PG diploma courses provides training
for career progression in women’s health for nurses, midwives,
clinicians and biomedical sciences and helps attract and retain
staff on a career path in women’s health. The MSc/ PG diploma
in prenatal genetics and fetal medicine is a clear example of the
success of this approach.
The new MSc in Reproductive science and women’s health is due
to start in September 2009 and recruitment of students is already
under way. Our aim is to develop a portfolio of modules for further
development of taught postgraduate degrees. These modules will
form part not only of degrees offered in the Institute but will also
contribute to courses elsewhere in the college. This will have two
effects:
1) to further extend opportunities for study in the institute
and
2) to increase the income base to build funding for the
education programmes.
There are particular opportunities in nursing and midwifery and a
strengthened education office bringing together all the components
of the education programme in the Institute will provide the
resource necessary to support this. We must however be realistic
99
postGRADUATE Education and training
postGRADUATE Education and training
UCL EGA IfWH 1st Quinquennial Review
in terms of the demands on academic staff time and careful use
of existing modules should keep this load within reasonable limits.
Development of courses in conjunction with other divisions will
be a major part of the strategy. Current developments includes
funding for a MRes/MSc in Translational Clinical Science under the
NIHR Clinical Academic Training Pathway for Nurses, Midwives
and Allied Health Professionals (Lead for the Institute: Dr Anne
Lanceley) in association with the UCL Patient Care Research and
Innovation Centre and UCL Partnerships.
The educational strategy within the unit recognises that continued
development will be key to maintaining strength in both education
and training. Key areas for development have been identified as
follows:
•
Development of e-learning tools
•
Simulation workshops (to alleviate lack of practical
training from reduction in working hours)
•
Further incorporation of ultrasound training within
the curriculum
•
Expansion of courses for trainees to be able to achieve
all objectives of the postgraduate curriculum whilst within
our area.
100
UCL EGA IfWH 1st Quinquennial Review
GLOBAL HEALTH
postGRADUATE Education and training
UCL EGA IfWH 1st Quinquennial Review
101
UCL EGA IfWH 1st Quinquennial Review
GLOBAL HEALTH
Scaleable – we focus on projects which, if proved successful, have
the potential to be rolled out nationally and perhaps internationally
in similar settings. For example, the cervical screening and
treatment project in Kampala. The model used has proved
successful and cost-effective; negotiations with the Ugandan
Department of Health are currently under way with a view to
establishing similar programmes throughout the country.
OVERVIEW
Currently, the Global Health Division is
running projects in several countries, with
the majority being based in Uganda. At an
early stage these projects were discussed
in detail and agreed with counterparts
in Uganda, following which the Ugandan
Women’s Health Initiative (UWHI) was
set up. The UWHI is a collaboration of
UCL EGA Institute for Women’s Health,
Makerere University, Kampala, and
Hospice Africa, Uganda (Appendix 10.2).
Charged with supervising all the projects
run in Uganda, the UWHI Board is
comprised of members from both the
IfWH and Uganda, and meets twice a year.
Each individual project is assigned joint
leads from London and Uganda and they
periodically provide progress reports to the
Board. Where appropriate, projects have
received ethics approval from Makerere
University Ethics Committee.
Projects
• Cervical screening and treatment
(Kampala, Uganda)
• Postpartum haemorrhage
(Jinja, Uganda)
• Neonatal resuscitation
(Mulago Hospital, Kampala, Uganda)
• Radiotherapy machine (Mulago Hospital)
• Radiotherapy hostel (Mulago Hospital)
• Palliative Care consultant
(Mulago Hospital and Makerere
University, Kampala, Uganda)
102
The Global Health Division contributes to raising the international
profile of the Institute by:
The UCLH Trust has taken an accommodating approach,
allowing staff some extra time off to contribute to Institute work.
For example, clinical activities have been cancelled to maximise
attendance at the Institute annual scientific meetings, and some
extra days’ leave have been granted to staff spending time
working on Institute projects abroad. The UCLH Trust also donated
approximately £300,000 of equipment from the Middlesex Hospital
when it closed which is now located at Mulago Hospital, Kampala.
• Organising an International Women’s Health Conference in
Kampala in November 2006). This successful conference was
attended by over 350 Ugandan and international delegates.
No specific Institute space or equipment is available to support the
work of the Global Health Division but the UCLH Trust has been
happy to allow its office space, computers, etc to be used.
We wish to work when possible within the existing local
infrastructure, and establish roles for local trainers to promote the
spread of information, innovation and best practice.
The Global Health Division of the Institute
for Women’s Health is a multidisciplinary
team open to all staff (all grades and
all disciplines) in UCL and UCLH; the
details of the core team are provided in
Appendix 10.1. Membership of this group
is supplemented by temporary participants
such as junior doctors on rotation at UCLH.
The division has initiated and oversees a
series of international projects, described
in further detail below, each of which is led
by named members of the team.
• Lecturing at national and international conferences about the
Institute’s work and international projects.
• Collaborating internationally to develop partnerships with the
common goal of development in women and children’s health
(see below).
Resources
Family sorting beans
• Neonatal cooling to prevent asphyxia (Mulago Hospital)
• International Women’s Health Conference, November 2006 (Kampala)
• Improving the understanding of ethics in women’s health
(UCL, Andhra Pradesh, India and Durban, South Africa)
• Cervical screening and treatment (Lagos, Nigeria)
• Securing hospital equipment from the Middlesex Hospital on its closure
and transportation of this to Mulago Hospital
• Six-month secondment of a Specialist Registrar in Obstetrics from UCLH to work
in Mulago Hospital and participate in several of the UWHI projects
Strategy, Aims and Objectives
In line with the Institute’s mission statement, our overall aim is to make a major contribution
to women’s health internationally. Specifically, we aim to contribute to a reduction in
maternal and child mortality, and to affect positively the health of women, their families and
communities. We also want to raise the international profile of the Institute with the ultimate
goal of being acknowledged as an influential voice in this arena. With these aims in mind,
we have favoured international projects which are:
Affordable and feasible – particularly relevant to projects in resource-poor settings such as
Uganda. For example, we are investigating the management of postpartum haemorrhage
with misoprostol, a drug which is inexpensive and heat-stable, so affordable and
appropriate in rural Uganda.
Sustainable – when a project finishes, the health intervention must be sustainable within
the context of the resources of that country or district. For example, misoprostol can be
dispensed through existing antenatal clinics in Uganda, mirroring the existing system for
dispensing antiretroviral therapy to HIV positive pregnant women (women in Uganda have
little antenatal care, but over 90% have at least one visit).
recruit women to the study, then follow them up and collect data
after they have given birth. People are a vital resource so we have
established several national and international collaborations in
order to maximise the impact of our joint projects.
Funding for the work of the Global Health Division until now
has come primarily from a two philanthropic donors who have
contributed £600,000 and £150,000 to support our international
projects. These donations have now been entirely allocated, and
will be spent by the end of 2009. Further personal donations
from these donors are possible. Our major donor has also
underwritten another major Institute project, the installation of a
new radiotherapy machine in Mulago Hospital, Kampala.
This donor and his family have now set up the Arem Foundation,
a charity whose aim is to raise money to support the work of the
Institute. In September 2008, members of the Institute’s Global
Health Division participated in a charity dinner organised and
hosted by the Arem Foundation. This successful dinner was
attended by over 150 supporters and raised £88,000 for the
Institute’s international projects. The Nigerian screening group
raised £30,000 at an art auction held at the RSM in 2007. The
Leventis Foundation, a Nigeria-based organisation donated a
further £50,000 to this program.
All UCLH and UCL staff participating in the work of the Global
Health Division give of their time freely. The obstetric Specialist
Registrar who worked in Uganda for 6 months was paid a salary at
Ugandan rates by the Institute. A project manager, previously in a
similar role within UCLH, has moved to Uganda and is employed
part-time by the Institute to manage all our projects there; his input
has proved invaluable. Several projects employ local staff whose
salaries are paid by the Institute for the duration of the project.
For example, the cervical screening projects employ Ugandan
and Nigerian nurses who have been trained to examine and treat
cervical lesions, as well as provide health education for local
women. The misoprostol postpartum haemorrhage study has
employed local midwives and healthcare assistants to educate and
Performance and
Measurement of Quality of
Activity
The performance of each project will be measured against the
Global Health Division’s aims, specifically whether it provides
a health benefit for women and/or their children, is feasible,
sustainable and scaleable and whether it raises (or has the
potential to raise) the international profile of the Institute.
Cervical screening and treatment
These projects have been very successful. Over 5,000 women have
been educated and undergone cervical screening. In Kampala
approximately 20% of women screened have premalignant
disease and the screening strategy has been shown to have
encouraging sensitivity and specificity – paper in preparation.
Approximately 10% of the women screened in Lagos were found
to have premalignant cervical lesions, which have been treated.
The Nigerian Group held an open day in May 2008, attended by
heads of government and the Lagos State Government announced
its commitment to one-stop screening. This was widely covered
by the local media. Since then a program of training for health
care professionals in Lagos and Abuja has been instituted. The
Ugandan Department of Health are also excited by the results and
are actively exploring the possibility of rolling out this programme
across the country. Local evidence of the value given to the IfWH
effort is the agreement in 2008 of Janet Musuveni, Ugandan MP and
wife of the President of Uganda to become a Patron of the UWHI.
Postpartum haemorrhage
Recruitment to this project has finished recently and data collection
is approaching completion. Data analysis has not yet started but
our impression is that this method of distributing misoprostol using
the existing limited infrastructure has been safe and effective. If
this is the case, we will have proved that the efficacy of the model
could be replicated in the poorest areas in Uganda and potentially
other resource-poor countries.
103
GLOBAL HEALTH
GLOBAL HEALTH
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
Neonatal cooling to prevent
asphyxia
We investigated early cooling of the
newborn to ameliorate the effects of
intrapartum asphyxia in a resource-poor
setting, using inexpensive equipment.
This intervention was shown to reduce
significantly the risk of adverse neonatal
outcomes. These findings have been
published in the Lancet. This technology is
affordable to hospitals in most developing
countries.
International Women’s
Health Conference
Image from IfWH Ugandan Women’s Health Initiative photoarchives
Neonatal resuscitation
This success of this project has demonstrated that it is feasible and scaleable. Two Institute
staff (a neonatal consultant and neonatal nurse consultant) spent a week training a small
group of local staff in basic neonatal resuscitation. Following their departure, that small group
cascaded this training so that now most medical and midwifery staff at Mulago Hospital,
Kampala are trained. This training is ongoing and the neonatal consultant there has confirmed
a significant fall in the number of asphyxiated babies being admitted to the neonatal unit.
Radiotherapy machine
Project not yet in progress. Measures of success will be successful installation of the
machine; doubling of the total Ugandan capacity to treat patients with radiotherapy
(currently, there is a single machine for the whole country); ability of local personnel to run
and, when necessary, repair this machine.
Radiotherapy hostel
Currently the rate-limiting factor in treating patients with radiotherapy at Mulago Hospital is
the lack of in-patient beds. We have funded the planning and building of a patient hostel
which is now complete and can accommodate these patients. Success will be measured
by the increase in the number of patients treated by the radiotherapy machine – the only
one at present.
Palliative Care consultant
This consultant is in post and has increased both the capacity for providing palliative care
in Kampala and for academic research in this area. Future performance will be judged by
audit of both quality and quantity of care, and by relevant publications. We also hope to
see the Ugandan Department of Health will be convinced of the added value such that
they agree to continue funding the post in the longer term.
104
This conference was a success,
attracting more than 350 delegates from
many disciplines involved in women’s
healthcare. Delegate feedback was very
positive. The conference engaged the
Ugandan Government, helped us to
establish relationships with and increase
our influence with Ugandan Government
officials. It also significantly raised
the Institute’s profile in Uganda and
neighbouring countries.
Improving the understanding
of ethics in women’s health
In 2005 the Collaborative Centre for
Reproductive Ethics and Rights was
established in the Institute for Women’s
Health as a collaboration with Professor
Ames Dhai, Head of Bioethics at the
University of Witwatersrand, South Africa.
The centre has published papers on ethics
of HIV and Pregnancy, PGD for late onset
disorders, ethics of developmental origins
of disease, fetal therapy and access to
healthcare in India. With support from the
British Council UKIERI we are working
with colleagues in India to develop short
courses in medical ethics for the medical
curriculum in India. The course has now
been run three times in India. The poster
presentation of this work was awarded a
prize at the UCL Teaching and Learning
Conference in 2008. To facilitate this work,
Dr Ray Noble of the Institute has been
appointed Honorary Visiting Professor of
Medical Ethics at the medical school in
India and is Honorary Associate Professor
of Ethics at the University of KwaZuluNatal, Durban.
We have also carried out research with
small cohorts of women in rural India
investigating views on informed consent
and confidentiality and their impact on
health care access. A report of this work
has been presented to the British Council
and at the Institute International Meeting
in 2008.
These include:
Future success of this work will be
assessed by monitoring its incorporation
into the medical curriculum in India, by
publication of further research, and by
progress made in other international
collaborations.
•Lagos University Teaching Hospital, Nigeria
Second hand equipment
Securing second hand hospital equipment,
furniture, fittings, etc. from the Middlesex
Hospital when it closed; transporting
all this equipment to Mulago Hospital
in Kampala. The outcome has proved
the success of this project: selection
(by Ugandan colleagues) of suitable
equipment, transportation to Uganda, and
successful installation and use in Mulago
Hospital. While this project was the result
of a unique opportunity so is not scaleable,
it has been a real success as evidenced
by feedback from staff and managers at
Mulago Hospital.
Obstetric Specialist Registrar
Secondment of an Obstetric Specialist
Registrar (SpR) from UCLH for 6 months
in Uganda, to work in Mulago Hospital
and participate in several of the UWHI’s
projects there. This project was an
experiment which was largely successful.
The SpR was satisfied with being paid
at Ugandan rates for 6 months but could
probably not have sustained it financially
any longer. His contribution to the Institute’s
projects in Uganda was significant; the
rate of progress in the studies with which
he was involved was considerably faster
during his secondment. Communication
with colleagues in Uganda (a major
barrier) was considerably enhanced
when he was there. On the other hand,
the clinical experience he hoped to gain
in Uganda, while adequate, was less than
expected.
A number of national and international
collaborations have been established in a
relatively short space of time, raising the
Institute’s international profile and building
a firm foundation for future international
studies in women’s health.
•Venture Strategies for Health and Development, University of California, Berkeley
•British Council (UKIERI)
•Makerere University and Mulago Hospital, Uganda
•University of KwaZulu-Natal, Durban
•University of Witwatersrand, South Africa
• Alluri Sitarama Raju Academy of Medical Sciences (ASRAMS), Eluru, Andhra Pradesh, India
•Hospice Africa, Uganda
•Centre for International Health and Development, Institute of Child Health, London
Areas of Excellence
Cervical cancer
The Institute for Women’s Health at UCLH is an internationally renowned leader in the field
of gynaecological cancer, with a wealth of clinical and academic expertise and many
publications in this area. Building on this foundation, the Global Health Division has tackled
cervical cancer in resource poor settings. Cancers of the cervix and breast are the most
common causes of death from cancer amongst women in many developing countries.
Both of these cancers are characterised by presentation at an advanced stage by which
time treatment is generally limited to palliative measures. Cervical cancer is a preventable
disease and screening programmes in western countries have dramatically reduced its
incidence and mortality. Developing countries have neither the resources nor the healthcare
infrastructure to support such a screening programme. The Global Health Division
has utilised an inexpensive, one-stop, ‘see and treat’ method of screening for cervical
disease using a validated method of visual inspection with acetic acid and treatment
of premalignant lesions with cryotherapy. This model is proving very successful in both
Uganda and Nigeria. Recognising the extremely limited radiotherapy facilities in Uganda
(a single radiotherapy machine for the entire country), we have built a new patient hostel to
improve throughput and are in the process of procuring a second radiotherapy machine.
We have also collaborated with Hospice Africa, pump priming a new consultant post in
palliative care, thus significantly augmenting the terminal care of women diagnosed late
with cervical cancer.
Traditional dance at the Prevention of Cervical Cancer Open Day in Nigeria
105
GLOBAL HEALTH
GLOBAL HEALTH
UCL EGA IfWH 1st Quinquennial Review
The Institute is home to a leading perinatal brain injury
research programme combining the expertise of obstetricians,
neonatologists and clinical scientists, who have published widely
in this field. The Global Health Division was keen to try to build
on this expertise. The neonatal resuscitation project described
earlier has already significantly reduced neonatal unit admissions
due to asphyxia in Kampala. The neonatal cooling work pioneered
in developed countries by, among others, Institute clinicians has
been successfully adapted for our project in Mulago Hospital in
Kampala. Publication of these findings in the Lancet has brought
them to a wide audience, fuelling the hope that this technique may
be introduced in similar settings across the world, and adding to the
reputation of the Institute and its international work.
Postpartum haemorrhage
Postpartum haemorrhage (PPH) is the major cause of maternal
mortality in developing countries. Many of these deaths are
preventable through administration of a single dose of a drug
to stimulate uterine contraction in the third stage of labour. The
standard drug used in developed countries for this purpose is
syntometrine but it is expensive, unstable unless continuously
refrigerated and must be administered parenterally. Ten years ago
in UCLH, we pioneered the use of misoprostol as an alternative to
syntometrine. This drug is cheap, stable and can be administered
orally or rectally. At the Institute, we have led the field by showing
that misoprostol is highly effective in preventing and treating
established PPH. The challenge now is to find a safe and effective
method of getting this drug into the hands of those women who
need it most – those delivering in villages remote from medical care.
We have addressed this in our PPH project in Uganda. The data
will soon be analysed but our initial impressions suggest that it has
achieved our aim.
Combined expertise
The Global Health Division benefits from the combined intellectual
capital of experts in varied fields, including obstetricians,
gynaecologists, midwives, nurses, scientists, epidemiologists, social
scientists, anthroplogists, lawyers, counsellors, etc. The collaboration
of UCLH and UCL within the Institute allows us access to expertise
in many other fields; colleagues can be co-opted when required.
Challenges
Communication has proved to be one of the major challenges for
the Global Health Division over the past three years. Communication
with India has been relatively straightforward but with colleagues in
Uganda has been problematic. Even in the capital Kampala, few have
good internet access and none have broadband. Phone connections
are of poor quality, unreliable and expensive. On occasion, it has
been very difficult to continue to motivate, instruct and monitor
researchers in Uganda. Having an Institute project manager based in
Uganda has helped, and seconding our obstetric SpR there certainly
accelerated the pace of several projects for the six months he was
there. This lesson has been learned for future projects.
106
A perpetual challenge is the fact that few people working on the
Institute’s projects do so full time. The project leads in both the
UK and Uganda supervise their project(s) in addition to doing
their own full-time jobs. Even the Ugandan midwives and doctors
employed by the Institute are mostly part-time, supplementing
their income with Institute work. This, combined with the difficulty
in communication, made it a constant challenge to keep these
projects towards the top of everyone’s agenda. The presence
of a project manager and, for six months, an obstetric SpR from
UCLH mitigated this to some extent, but the importance of at least
some full-time staff for any future projects is clear. The possibility
of funding some senior clinician protected time within the Institute
could also be explored.
The local and national healthcare infrastructure in a country like
Uganda is poor and, in some areas, non-existent. This obviously
presents major challenges to initiating and maintaining projects
there, particularly as we are keen to work within existing structures
so that projects are sustainable. Measuring hard outcomes
following our interventions has proved difficult in resource-poor
settings. Audit is not a priority in developing countries and any
healthcare staff (including those we have employed) are invariably
too busy delivering care to have time to measure outcomes.
There was briefly some tension between the demands of the NHS
clinical service at the UCLH Trust and the demands of the Institute
on clinicians’ time, but a mutually acceptable compromise was
negotiated. Nevertheless, it is conceivable that this tension could
again become an issue, particularly if the Trust suffers further
financial constraints over the next few years.
Impact and Importance
The World Health Organisation has made the point that we already
have medical interventions capable of preventing or treating
many of the major causes of maternal and neonatal mortality
in developing countries (for example, rehydration solutions for
children with diarrhoea, syntometrine for postpartum haemorrhage,
immunisation against common infectious diseases).The real
challenge now lies in identifying practical and affordable methods
of delivering these interventions to the people with the greatest
need, in resource-poor settings. This ethos lies at the heart of
several of our programmes.
Cervical screening and treatment
Cervical cancer is the major cause of death for women between
the ages of 20 and 40 in many developing countries. It is often
diagnosed late and most women die a miserable death, often in
pain, with infections and fistulae, and ostracised by their family
and community. This is all the more tragic because cervical cancer
is an almost entirely preventable disease in countries with the
resources and infrastructure to provide a national screening and
treatment programme. There is an urgent need to address this
disease in developing countries.
The Institute’s programme has tackled this issue in a
comprehensive way. In Uganda, women’s awareness of cervical
cancer and screening is very limited. We addressed this by training
Image from IfWH Ugandan Women’s Health Initiative photoarchives
Perinatal brain injury
UCL EGA IfWH 1st Quinquennial Review
local nurses to educate women in some of the poorest areas. The one-stop screen-andtreat technique we employed is inexpensive, portable, and does not require an electricity
supply. We have demonstrated that it is feasible and effective.
In Nigeria, efforts have been concentrated on raising awareness. A public information
film, explaining the importance of screening was made with the support of Armand Eye
Films, London. This has been distributed widely in Nigeria and there is a plan to show it in
the High Commision offices in London where statistics have shown that black and ethnic
minority individuals are less likely to accept screening.
Treatment facilities in Uganda for women diagnosed with advanced cervical cancer have
been extremely limited: a single radiotherapy machine supported by insufficient hospital
beds. We have addressed both of these barriers by working to provide a second machine
and build a patient hostel nearby.
Palliative care for terminally ill women is in its infancy in most developing countries. We have
extended the clinical and academic capabilities of palliative care in Uganda by appointing
a consultant in this specialty.
We have thus contributed to all points in the care pathway of these women which will have
a major impact on prevention and treatment of this disease. Of greatest importance is
that we have demonstrated a pathway of care that is affordable and sustainable in many
developing countries. Our model of education, screening and immediate treatment could
have a significant impact in many countries. Although we obviously cannot afford to provide
radiotherapy machines in other countries, it is important to note that we have identified
that the expertise and resources to support its use already exist in Uganda. By studying
patient flows and identifying that a lack of beds was limiting patient throughput, we found a
relatively inexpensive solution. This systematic analysis could be applied in other settings.
Postpartum haemorrhage
The WHO estimates that 100,000 women die in childbirth every year, 99% of whom die in
developing countries. The major cause of maternal death in those countries is postpartum
haemorrhage. Syntometrine, the drug commonly used in affluent countries, is very effective
at preventing PPH but is not affordable in developing countries. We initially showed that
misoprostol is almost as effective as syntometrine at preventing major PPH.
Our current study describes a simple,
effective and affordable method
for delivering this drug to women in
the poorest, most remote villages in
Uganda. We believe that this method, if
implemented across Uganda and other
similar countries, has the potential to
reduce the incidence of maternal death
and morbidity from PPH by around 50%.
In the past two years, Tanzania,
Bangladesh, Ghana, Kenya, Nepal, Sudan,
Uganda, and Zambia have succeeded in
registering misoprostol for this critical use,
influenced in part by our earlier work. The
next step is to persuade Governments
in these and other developing countries
to implement our system of distribution
and make our goal of reducing maternal
mortality and morbidity a reality. We plan
to collaborate with Venture Strategies for
Health and Development and the University
of California, Berkeley, to lobby the
Ugandan Government, and have already
made preliminary approaches to the
Indian Ministry of Health and Federation of
Obstetricians and Gynaecologists of India.
In January 2009, Zambia successfully
launched a programme promoting the use
of misoprostol for PPH in five districts.
Neonatal resuscitation
This project was motivated by the
observations of a consultant neonatologist
colleague in Kampala. We were surprised
to learn that many babies were admitted
to her neonatal unit with asphyxia
which could have been prevented, had
the midwife attending the birth been
armed with basic neonatal resuscitation
techniques. Our training programme,
which has been successfully cascaded
throughout the department there, has had
a significant impact on reducing such birth
asphyxia. Enquiries abroad have found
that a similar problem exists in hospitals
in other developing countries. This simple,
inexpensive and sustainable intervention
has the potential to have a similar impact
on birth asphyxia in other countries.
Neonatal cooling to prevent
asphyxia
Neonatal cooling to reduce the impact of
intrapartum asphyxia is a very promising
technique. Until now, however, it had
seemed that its application would be
107
GLOBAL HEALTH
GLOBAL HEALTH
UCL EGA IfWH 1st Quinquennial Review
limited to developed countries because of the expense of
the equipment used. However, the Institute has shown that in
resource-poor countries (where the incidence of birth asphyxia is
relatively high), an inexpensive adaptation of this technique can
produce similar benefit. The potential of this technique in other
similar settings is exciting.
Improving the understanding of ethics in
women’s health
In collaboration with the WHO, the Medical Council of India aims
to incorporate the study of ethics into the curriculum of medical
schools in India. Most schools have not yet begun to do this.
Major problems include a shortage of staff trained in medical
ethics and the need for training and development. Introducing
ethics into doctors’ training can have a major impact on women’s
health. Reproductive health can be a cause of domestic violence
against women in India; poor ethical practice, such as the
insistence of spousal consent and lack of confidentiality, can
be a major factor in preventing access to healthcare. Lack of
informed consent in medical practice remains a problem. The
Institute’s Collaborative Centre for Reproductive Ethics and Rights
aims to improve understanding of ethics in women’s health by:
(a) running courses in ethics in the medical curriculum at UCL
and incorporating ethics into existing programmes by running
workshops for students at UCL; (b) research and scholarship
in ethics in women’s health; (c) international collaboration in
teaching and scholarship. If successful, this ground-breaking
collaboration could be replicated in other developing countries
with emerging medical ethics curricula.
Future Developments
We wish to continue to have an impact on women and children’s
health in developing countries. The projects underway will be
completed and the data analysed. Publication will follow, relating to
both the research findings and the practicalities of running studies
and implementing health interventions in resource-poor settings.
UCL EGA IfWH 1st Quinquennial Review
We plan to continue to raise the national and international profile of
the Institute by publishing and presenting our findings widely and
by collaborating with other organisations and individuals who share
our goals.
Funding will be critical to achieving these aims and to conducting
further studies. The Institute’s International division will work with
the Arem Foundation to continue to raise funds; it is hoped that the
fund-raising dinner will become an annual event. The Institute as
a whole will work with UCL to raise money through corporate and
personal sponsorship. It is likely that the international projects will
prove attractive to potential donors.
clinical and academic administration
GLOBAL HEALTH
UCL EGA IfWH 1st Quinquennial Review
Our aim is to use our evidence demonstrating the effectiveness
of interventions to influence decision makers with a view to rolling
out these interventions across Uganda and other developing
countries. We hope that by demonstrating that our interventions
make a real difference to women and children’s health, and are
affordable and scaleable, local policy makers will be convinced
to consider implementing them on a wider basis. Professor Ian
Jacobs has been invited to take part in the Ugandan Health
Ministry’s working party to consider national implementation of
the cervical screening programme. Adeola Olaitan is working with
the Lagos State Government to ensure that screening is phased
in in a manageable fashion and that quality assurance is in place.
The Institute will collaborate with Venture Strategies for Health
and Development and the University of California, Berkeley; initial
discussions have already taken place with the Ugandan Ministry of
Health with regard to developing a national misoprostol distribution
programme. The Government of India has also shown some
interest in further discussions. Plans are already underway to carry
out an RCT in neonatal cooling in Uganda and Malawi.
108
109
UCL EGA IfWH 1st Quinquennial Review
clinical and academic administration
CLINICAL AND ACADEMIC ADMINISTRATION
OVERVIEW
The IfWH is an overarching structure for strategic planning
in Women’s Health, which acts through consensus without
governance authority, as explained on pp. 8–9. The Institute is led
by Director Professor Ian Jacobs and three Deputy Directors,
Professors Judith Stephenson, Donald Peebles and Neil Marlow.
Strategic Planning Board brings together clinical and academic
staff to agree and plan joint developments.
Tamara Davies
Marcia Jacks
Shahina Mohamed
Susan Sinclair
The Institute is a joint UCL/UCLH structure, but the main
administration for the IfWH runs through the academic UCL
side of the partnership.
UCLH
The Women’s Health Division is one of six divisions in the Specialist
Board within the Trust, and both the Clinical Director and Divisional
Manager report to the Medical Director for Specialist Hospitals
(Appendix 11.1).
The Division consists of four specialist clinical units: Gynaecology,
Breast, Maternity and Neonatal Medicine. Each is supported by
a Medical Clinical Lead and a Senior Manager. There is a single
divisional nurse or midwife, who reports to the Divisional Manager
and is supported in her role by the Head of Midwifery and Head
of Nursing for Specialist Hospitals, who are professional leads for
midwifery and nursing services respectively.
The Clinical Director, Tim Mould, and Divisional Manager, Susan
Sinclair, have overall accountability for the operational performance
of the division.This includes quality of care, governance of the
division, financial and staff performance.
In order to support the division, a business partner model exists
with human resources, finance and information, which means that
we have dedicated support to the division.
UCL
The Administration team for the Institute belongs to the UCL
academic component of women’s health and supports academic
staff, both clinical and non-clinical. The lead individual is the
Institute Manager, Gemma Escorial, who at the time of writing is
on maternity leave and is being replaced by Marcia Jacks for the
duration of one year, from February 2009 to February 2010.
Staff
There are curently 13 members in the team, including the manager.
The team is divided into four areas of administration: staffing,
teaching, research and finance, and laboratory management.
The teams are made up as folllows:
Staffing – two full time staff
Finance and research administration – one full time senior
administrator and two part time finance officers
Teaching – two full time staff, specialising in postgraduate and
undergraduate teaching
Laboratory management - a full time manager and part time
purchasing officer
Outside of the teams above is also the Institute Research
Coordinator, Dr Tamara Davies, who facilitates research on both
the UCL and UCLH sides. The whole team is supported by two
office assistants.
In addition to the core administration team, Shahina Mohamed
is the Institute Coordinator and Executive Assistant to Professor
Jacobs, and is supported by an assistant. There are also several
personal assistants who provide support to professors and
research leads.
STRATEGY, AIMS AND OBJECTIVES
UCLH
A key priority of the Women’s Health Team is to link both
strategically and operationally with the Institute for Women’s Health
in order to ensure that academic and clinical excellence are
achieved in the clinical setting.
The objectives of the team within Women’s Health include:
Care objectives
Providing consistently high quality care
Treating people with compassion
Using treatments and interventions which are evidence based
and up to date.
Access to services
Ensuring our services are easy to access, whether by
telephone, fax or walk in
Ensuring our services meet the needs of vulnerable groups
Treating women, babies and their families as individuals, and
recognising their needs.
Seeking to continuously improve the service by:
Listening to the feedback received
Engaging with internal and external stakeholders
Measuring clinical outcomes and the quality of it’s service
Investigating situations which have not gone well and ensuring
the individuals and the organisation learns from its mistakes.
110
111
CLINICAL AND ACADEMIC ADMINISTRATION
CLINICAL AND ACADEMIC ADMINISTRATION
UCL EGA IfWH 1st Quinquennial Review
Managing the Division in order to ensure that the above
objectives are met
Ensuring that there is a career structure and opportunity for all
members of staff
Performance managing all staff to ensure that they reach their
full potential
Ensuring financial rigour and accountability underpin decisions
made within the division.
UCL
The team will support the overall aim of the Institute which is to
bring together the expertise of clinicians and research from a
diverse range of disciplines so that they can deliver excellence
and innovation in research and clinical practice, in order to make a
real and sustainable difference to women’s health locally, nationally
and worldwide.
The staffing team is responsible for providing a comprehensive
and effective service by facilitating the smooth employment
administration for all categories of staff (see Appendix 11.2 for
categories of academic staff at IfWH). They will advise staff on
human resources policies and procedures and with the Institute
Manager ensure the implementation of relevant policies and
procedures throughout the Institute. The team will liaise with UCLH
personnel for the administration of joint and honorary contracts.
The teaching team is responsible for providing a comprehensive
and effective service by facilitating the smooth teaching
administration of postgraduate, undergraduate teaching and short
courses, within the Institute. This includes the management of
student numbers and reporting of student statistics for internal
and external purposes (see Appendix 11.2 also for categories
of graduate students). An important aspect of the work of
the Undergraduate Teaching Administrator is coordination of
medical students’ clinical attachments in Women’s Health and
Communicable Diseases.
The finance and research team is responsible for providing
financial support to the Institute. The senior administrator is
responsible for providing a comprehensive and effective service
UCL EGA IfWH 1st Quinquennial Review
at Institute level, facilitating the coordination, management and
administration for research grant applications, awards as well as
financial aspects of the Institute. The post holder provides initial
advice and guidance on all aspects of UCL Finance procedures,
as well as Pre-award and Post-award guidance for research grants.
The Research Coordinator coordinates, facilitates and assists both
academic and clinical research activity within the Institute, and
leads the administration of key research-related strategic initiatives.
The Coordinator will liaise with both UCL and UCLH in the areas of
research administration and governance as required.
The laboratory management team is a new team within
administration and is an additional resource for the laboratories
in the Institute. The Laboratory Manager is responsible for the
coordination of laboratory work across the Institute, instigating and
developing systems that will be beneficial to all the laboratories.
In particular the role holder will oversee the whole purchasing
process for the laboratories, ensure facilities are always at the
required standard and oversee accreditation processes.
The objectives will be achieved by:
Maintaining the morale of the excellent administration team that
is currently in place. Supporting the team and ensuring training
is given and that training becomes an important part of their
development.
Liaising with leads in the various groups to ascertain
objectives in respective areas of activity and ensuring this is
communicated to administration team who will be involved in
specific areas. Communicating effectively with group leads
and other staff with respect to procedures and policies that will
impact on their work.
Each role holder will ensure they are up to date with the relevant
policies and procedures for their area of work in order to
communicate effectively to staff on request or through routine
work.
Each role holder will adhere to good work ethics, for example,
consideration of the team members, a willingness to contribute
to tasks outside of their immediate work area when required.
Each role holder will be aware of the organisations’ equal
opportunities policies and will respect and treat work
colleagues fairly.
The staffing administrators will ensure the smooth running of
recruitment, and management of appraisals and promotions.
The Institute Manager and senior members of the team will
ensure attendance at relevant meetings in order to gain a wider
knowledge of the work of the various groups within the Institute.
The manager with the help of the relevant administration team
will, where necessary, instigate policies and procedures. They will
ensure up to date knowledge in the areas of human resources,
finance, research and communications, amongst others, in order
to effectively share this information with relevant staff. They will
ensure that, as much as is possible, that all groups work in a
similar fashion, yet at the same time recognising the peculiarities
of each group. The manager will keep track of all the work that
Launch of Haemoglobinopathies MSc
112
goes on in the Institute, in order to ensure coordination across the
Institute. The team will bring together the expertise of clinicians
and researchers by ensuring effective communication channels
are in place. The research coordinator will ensure that policies
on research governance is disseminated and acted upon. The
manager will advise on all issues that affect the work of the
Institute and will be the channel for procuring information on areas
of unfamiliarity to the various groups.
RESOURCES
UCLH
The division is funded primarily through payment by results, and in
line with Commissioning guidance will be increasingly managed on
the quality of care it offers.
The divisions overall direct costs budget is circa £30 million, with a
total income of £50 million. Changes in the funding arrangements
will mean that over the next 2 years, the Trust as a whole will be
required to save approximately 15% of overall expenditure.
There are over 550 staff employed through the Women’s Health
Division, notably medical, midwifery and nursing staff, allied health
professionals, secretarial and management staff.
The overall performance of the division is reported to the
Medical Director each month, and areas of review include:
Financial position
Activity profile
Workforce performance
Quality, complaints and risk issues
Attainment of National Targets such as Cancer Waiting Times,
18 weeks
UCL
Within the admin team this can be defined as:
Completion of given tasks
Meeting of deadlines, e.g. processing of research grant
proposal to meet sponsor’s deadline.
Successful organisation of conferences, e.g. the international
women’s health conference, the annual meeting
Efficient provision of service in relevant area, e.g. satisfied staff,
lack of complaints, good feedback
Meeting the evolving needs of the Institute
Nursing and Midwifery postgraduate training is provided through City
University, with the contract managed centrally through the Trust.
AREAS OF EXCELLENCE
The Trust also has an education centre and teaching and training
programmes that support a wide range of in house training.
UCLH
UCL
The staffing budget for the admin team for 2008-09 academic
year is £478,467 of which £324,982 comes from HEFCE funding,
£108,851 from UCLH and £44,634 from other sources, such as
research grants and discretionary funds. There is currently one
unfilled vacancy in the teaching team, that of a short courses
officer. The staffing team is currently split over two buildings
and for optimum working, this will need to be addressed in due
course. The teaching team is also split over two campuses but
this is relevant as the undergraduate teaching takes place at the
Hampstead Campus. The Teaching Administrator spends two days
in Bloomsbury and this goes someway to addressing coordination
between the two administrators. Overall the core team is spread
over four buildings. The administration team currently have
equipment to the worth of £7,500.
Recruitment
The management team have an excellent track record in building
clinical services. Davor Jurkovic and his team have been recruited
in the last year to set up the new gynaecology outpatient diagnostic
and treatment service which has reduced emergency gynaecology
admissions by around a quarter, reduced consultant to consultant
referrals and reduced follow up. The gynaecological oncology
cancer centre clinical team have been recruited over the last seven
years, and the business case for the recruitment of Professor
Jacobs had significant input for the trust as well as UCL.
Quality of care
The Women’s Health Division has undertaken multidisciplinary work
in partnership with McKinsey’s regarding quality of care. This work
continues to be built upon, and this year in-patient gynaecology
services are participating in a quality project that focuses upon the
patient experience.
PERFORMANCE AND MEASUREMENT
OF QUALITY OF ALL ACTIVITY
UCLH
The Divisions success is increasingly being measured through the
use of scorecards, which evaluate outcomes and quality of care.
These are reported through the Umbrella Governance Group each
month.
Clinical administration staff work closely with clinicians
113
CLINICAL AND ACADEMIC ADMINISTRATION
CLINICAL AND ACADEMIC ADMINISTRATION
UCL EGA IfWH 1st Quinquennial Review
UCL EGA IfWH 1st Quinquennial Review
As the Institute continues to develop, so does the team. Over
the past five years it has undergone extensive expansion and
restructuring. Several key posts have been introduced, including
those of Finance Administrator, Teaching Administrator and
Research Coordinator.
As well as quickly reacting to the changing needs of the Institute
itself, the team has been just as efficient at introducing the
necessary improvements following the Faculty of Biomedical
Sciences Administration Review in 2007. At IfWH this was promptly
followed by the introduction of Senior Administrator roles across
the following areas: Finance and Research, Human Resources,
and Postgraduate and Undergraduate Teaching. This has resulted
in a much greater degree of specialisation and clearer lines of
accountability, overall leading to more efficient operation across all
the areas.
Finance and Research
Academic administration at Maple House
There is a strong emphasis on getting the basics right, for example
the telephone being answered, and audits are carried out in order to
ensure this is the case and remedy the situation if it is not the case.
Leadership and team work
The focus of the management team over the next year is to build
and work in effective partnerships. An example of where we have
successfully done this is in fetal fibronectin where the management
team at UCH worked with procurement to negotiate a sector wide
price for this technology.
UCL
UCL IfWH Innovations and Progress in Healthcare for Women
Annual International Meeting.
In April 2008 the IfWH convened its first International Meeting,
which was an exciting and challenging undertaking. It was a great
success and has resulted in a number of positive outcomes for the
Institute, raising its profile and enabling numerous new research
and business connections to be established. The Meeting took
place at the Queen Elizabeth II Conference Centre in Westminster
and brought together up to 400 international clinical and research
experts in women’s health. Several world-leading keynote
and invited speakers gave talks over the course of two days,
complemented by 24 oral and 108 poster presentations. One of
the highly valuable outcomes of the International Meeting was the
Ovarian Cancer UK Consensus Statement, produced as a result of
the Ovarian Cancer Symptom Awareness Consensus Conference
hosted by the Meeting, which was later used to inform a set of key
messages from the DoH.
The preparations for the next International Meeting are currently
underway, with the Research Coordinator as the administration
lead. This will take place in November 2009 and this time focus
on Prevention, Screening and Risk Prediction in Women’s Health.
The Institute’s aspiration is for the International Meeting to grow in
reputation and prominence every year.
114
One of the significant contributions that the Finance and Research
team has made to the development of the IfWH was assisting with
the process of negotiations and arranging a partnership between
the Medical Solutions (Nottingham) Limited and IfWH Medical
Solutions. The latter is based in the one of the Institute’s laboratory
areas. The partnership is a key part of developments at the Faculty
level in our Platform Technology Initiative.
Teaching
The teaching team has participated in the process of setting up the
new MSc in Reproductive Science, which is designed for biological
scientists and obstetricians and will run from September 2009.
The MSc in Prenatal Genetics and Fetal Medicine was also
restructured to introduce modularisation. It is envisaged that
modularisation will lend towards modules being shared more easily
across departments in the Faculty and the NHS.
In October 2008, the Virtual Learning Environment (VLE) Moodle
was introduced with the view that it could be used for Self
Directed Learning particularly for gynaecological pathology
where interactive teaching may be useful. Since October 2008 the
Women’s Health Communicable Disease (WHCD) Moodle site is
being utilised and developed to help communicate teaching and
settle timetabling issues. It has received positive feedback from
students as an extremely useful resource in enabling access to
lecture materials during the introductory week, as well as practice
questions.
CHALLENGES
UCLH
The economic situation in the UK, coupled with changes in the
Market Forces Factor (a regional uplift to funding) and Research
and Development Funding mean that the next years will be difficult
ones within the Health Service. The response to this challenge is to
ensure that the care within the division is second to none, and that
the patients and referrers are treated well.
UCL
One of the problems that the team has had to face over the recent
years was the high turn-over of staff, in particular those employed
on a temporary basis through recruitment agencies. It took
considerable time and effort on behalf of the existing staff to train
the new-comers, yet due to the nature of this recruitment route it
was necessary to repeat this on several occasions. The problem
was addressed through reviewing the situation and priorities of
the team, following which the necessary funds were allocated and
steps taken to recruit staff on a more permanent basis.
IMPACT AND IMPORTANCE
UCLH
The administrative team are in a position to provide leadership
and guidance to the clinical work in the division. To this end, clear
strategy and objectives are made, and fed through the division.
The main objective for the next 1-2 years is a comprehensive safety
strategy across the division.
The administrative team provide the financial basis to allow the
developments for the division to proceed. The administration
system set up in the UCLH NHS Foundation trust is one of
individual autonomy for divisions. Thus the Women’s Health Division
is responsible for its £50 million budget. If the division is within
budget, it is able develop services through its own regulatory
systems. Furthermore, the division is able to generate business
plans that can be approved by the trust and that enable the
division to effectively ‘borrow’ funds from the trust in order to pump
prime the initiative.
UCL
Due to the very nature of our work its impact somewhat differs
from that of most of the other themes. Less direct and measurable,
but nonetheless vital, this is delivered by means of providing an
efficient support network, addressing a variety of professional
needs of the Institute’s academic staff.
The finance team enables financial accounting, monitoring
and reporting of the £8 million budget, the team also ensures
processing of the Institutes research proposals and management
of research grants.
The team, along with the Institute Coordinator is responsible for
maintaining the website and this is in the context of the website
being the gateway to the external world.
The team is responsible for project managing office moves and
coordinating changes within the 1,700 square metres of space
occupied by the Institute.
FUTURE DEVELOPMENTS
UCL/UCLH EGA Institute for Women’s Health administration teams
will be vital to drive through the expected changes that occur
as part of the Academic Health Sciences Partnership (AHSP).
Collaboration between UCL and the trusts in the partnership is
the cornerstone of the venture. The Institute is ideally placed to
achieve the aims of the AHSP.
UCLH
Key clinical developments over the next year include: Providing
an IVF service as part of the fertility unit, developing midwifery
care further for low risk women, developing and enhancing the
diagnostic and surgical care for women with breast cancer.
UCL
The team will play an important part in the development of staff
by assisting in the management of training, for example ensuring
staff with management responsibilities are trained in UCL/UCLH
management competencies. In teaching the team will assist
graduate tutors with the marketing of new MSc degrees and the
administration of short courses for income generation.
The administration is key to the work of the Institute in that the work
of the Institute needs to be organised and linked together. The
support of the administration team is vital to enable this to happen.
Each team within administration is organised to ensure systems
are in place to deal with every aspect of their area of expertise.
The teams set up systems to enable the work of the Institute to
run smoothly and efficiently. They keep abreast of the relevant
regulations, policies and procedures to ensure governance in
all areas of work. The work of the administration team frees up
academic and clinical staff time to focus on research and teaching
activities.
The staffing team is responsible for ensuring the recruitment and
induction of new staff to the Institute is processed efficiently and
that procedures that affect the 111 members of staff are carried
out satisfactorily, ensuring compliance with the various employment
laws.
115
CLINICAL AND ACADEMIC ADMINISTRATION
CLINICAL AND ACADEMIC ADMINISTRATION
UCL EGA IfWH 1st Quinquennial Review
First Quinquennial Review
www.instituteforwomenshealth.ucl.ac.uk