Latest / 'Bone Up' / Improving equity of care for osteoporosis

Transcript

Improving equity of care for osteoporosis · 'Bone Up'

0:00
Hello and welcome to Bone Up, the podcast all
0:04
about bones, how we make them, why we break them
0:07
and if we fully understand them. I'm David Armstrong.
0:11
Hi and I'm Richie Abel and over this series we're
0:15
going to be exploring osteoporosis, bones, what
0:18
we know and what we're yet to discover and we
0:21
hope you will join us on the journey. So for
0:24
anyone keen to learn more about our infrastructure
0:27
of calcified collagen, this is Bone up. So hello
0:55
again and welcome back to this episode of Bone
0:59
Up, our first episode for 2023. Richie, probably
1:03
a little late to say Happy New Year, but great
1:06
to be back in what is now our third year of talking
1:10
about bones on the airwaves. Wow, three years
1:14
already. Time flies, doesn't it? It's been a
1:18
lot of fun. I hope we keep this up for a long
1:20
time yet. Yeah, it's been good. And we're still
1:23
getting lots of positive feedback from patients.
1:26
I have a few patients who listen to the podcast
1:28
and ask about it. And it seems to be popular
1:32
as well with medical students. I get some feedback
1:35
from local students and even from students in
1:37
other parts of the UK who listen. So certainly
1:40
if you're a listener, do contact us, drop us
1:43
a line, let us know what you would like to hear.
1:46
that's wonderful it's great to think that medical
1:48
students are listening to the podcast that's
1:50
you know that's an important audience isn't it
1:52
yeah next generation of doctors and in terms
1:56
of data you you've got some numbers for us is
1:59
that right about the about the number of listeners
2:01
yeah listeners we have some really good news
2:04
thanks to you we have passed 10 000 downloads
2:08
which is absolutely wonderful and the bone up
2:14
live The episode we recorded at the Bone Research
2:17
Society conference is our most popular episode
2:19
so far. We've had about 1 ,200 downloads. So
2:25
it looks as though we're getting some traction
2:28
in the bone research community as well as the
2:30
clinical community. Yeah, well, that's really
2:34
one of the aims we had, wasn't it? The fact that
2:35
you're from a research background and I'm from
2:37
a clinical background and we were trying to,
2:39
I suppose, educate and inform and also... bring
2:44
everyone who works with bones closer together
2:47
and hopefully bring the sort of laboratory bench
2:50
closer to the patient as well so everyone understands.
2:52
So the patient understands what's going on in
2:54
the laboratory and so those working in the laboratory
2:57
understand what patients want and what patients
3:00
need to prevent fractures. Yeah, I think that's
3:04
a really wonderful approach. I think it's great
3:07
that you're a clinician and I'm a scientist and
3:09
we're working together and hopefully we can...
3:11
promote that a bit more across across our whole
3:14
community and uh the guests that we're going
3:17
to interview later on today i think is going
3:18
to be a really good example of how that can happen
3:21
i'm really pleased that we got such good a good
3:26
response from the bone live at the conference
3:31
and also with the listening figures afterwards
3:34
i think that's really wonderful It was a really
3:37
wonderful couple of days meeting people from
3:39
our community and chatting to them. It was amazing
3:41
how happy people were to talk to us and how fun
3:44
the conversations were. And I hope that we can
3:47
go and do that at other conferences as well.
3:50
For me, going to conferences is really critical.
3:53
As a scientist, it's the best way to keep up
3:56
on what's going on in the field. And the really
3:59
nice thing for us was that not only did we get
4:02
to go and see people give their talks, but afterwards
4:04
we got to speak to them, you know, two to one
4:07
or two to two and ask them more detailed questions
4:10
about their work and delve a little bit more
4:12
deeply into what they were doing. That was exciting.
4:15
Yeah, it was really good. We thought we brought
4:16
some a little of the flavor of what it's like
4:18
to be a scientific at a scientific conference
4:20
to the people listening. So and as you say, we're
4:23
planning, hopefully planning to get to another
4:25
one in the next few months. We'll hopefully have
4:27
another episode of Bone Up Live. So listeners,
4:31
we'll keep you posted about that. So David, it's
4:37
only a short while since you left university.
4:41
It's not actually true, but go ahead. Since leaving,
4:48
how do you keep up on best practice for medical
4:53
care? And how do you keep up on how to, best
4:57
manage and treat your patients? That's a good
5:02
question. Just last year there, I realized that
5:05
I had been a doctor for a greater part of my
5:08
life than I hadn't been a doctor, if I can put
5:10
it like that. And it's sometimes hard to remember
5:14
when you think back what you knew about medicine
5:16
and what you knew about the body before you started
5:19
to study. And the changes that have occurred
5:22
even in the last 25 years within medical practice
5:26
have been amazing. And even to the point, I was
5:29
speaking to a colleague yesterday about some
5:31
specific instances where we used to advise, and
5:35
I mean 20 years ago, we used to advise patients,
5:38
you know, one way. And now, in fact, we advise
5:41
patients the complete opposite. And that is because...
5:44
You know, we've done research or maybe people
5:46
like you, Richie, have done research. We have
5:48
the data and we put that data into practice.
5:52
As an example, when I was a medical student,
5:54
we were told not to give beta blockers to patients
5:57
with heart failure. It will make them worse.
5:59
There were some large, well -designed trials
6:01
set out, which showed that, in fact, giving beta
6:04
blockers improved heart failure in most cases.
6:07
Now we give the opposite advice to people. So
6:09
it's really important to keep up to date with
6:11
what's going on. Traditionally, people talked
6:14
about journals and reading journals. Probably
6:18
very few people read physical journals nowadays,
6:21
although we do follow them online. But one of
6:24
the issues is there is so much research going
6:26
on and so much data there that you really don't
6:30
have time, even as an expert, to assimilate and
6:34
to think about and to sort of put it all into
6:36
an order and indeed to look at the quality of
6:38
the research as well. And that's why we depend
6:41
very much now on conferences for a start and
6:45
on reviews, but particularly on guidelines. um
6:48
and in the field of bone and in my specialty
6:52
there are a number of guidelines of different
6:55
types they're obviously in the uk nice set out
7:00
guidelines about treatment those are based substantially
7:04
on on value for money and essentially what nice
7:08
will suggest what treatment should be funded
7:12
In clinical terms, however, in osteoporosis in
7:15
the UK, and I think in other parts of the world,
7:17
we depend very much on the NOG guidelines, the
7:21
National Osteoporosis Guideline Group. And every
7:25
few years, the NOG produce a new set of guidelines,
7:29
and there were a new set produced in 2021. And
7:33
what the experts on NOG do is go through all
7:36
the important published data in the area of bone
7:40
health and osteoporosis and grade it in terms
7:43
of the quality of the data. So they don't just
7:46
take anything that's published. They look to
7:48
see how well the research was published and look
7:51
in really quite surprising depth, I think, to
7:53
many people at just how good the quality of research
7:56
is. And then they synthesize that into guidance
8:00
that can be... given to people sort of across
8:04
the country and say that this data suggests this
8:08
is the best treatment at the moment. Research
8:10
suggests this is the best treatment for you at
8:13
the moment. And as I say, we have a new guidance
8:16
from NOG just published in 2021, and we've already
8:20
started to put that into our clinical practice.
8:24
And how are you made aware of changes in guidelines?
8:28
Do you have to make the effort to go and find
8:30
out when the guidelines have changed or do you
8:32
get notified? Well, there's a lot of publicity,
8:36
obviously. I mean, to declare an interest here,
8:40
I'm on the group of experts who has provided
8:44
or contributed to the last NOAA guidance. Obviously,
8:48
I was aware it came out because I had contributed
8:50
just a very small part to it and a very small
8:54
section. But there's a lot of publicity and certainly
8:57
if you're working as a clinician in the field
9:01
of bone health. and you're receiving emails,
9:05
you're following things online, you will be made
9:07
aware that NOG are producing guidance. And in
9:10
fact, you'll be looking forward to it. I think
9:12
there was a lot of things people were wanting
9:13
to hear what the latest data was and to see what
9:16
the synthesis of all the latest research was.
9:18
And so it's something people will actively seek
9:20
out because they find it helpful day to day.
9:24
And because I think they want to reassure their
9:26
patients as well that they're getting the best.
9:30
treatment because ultimately we try to do anything
9:32
everything for the benefit of our patients and
9:35
while you want to be the best doctor you can
9:38
be and be using the best treatment and the most
9:40
up -to -date treatment you can as a professional
9:43
you also want to be able to reassure your patients
9:46
that you're getting the best treatment And I
9:49
think from the patient's point of view as well,
9:51
it's important to have these guidelines. And
9:54
in fact, the latest Nod guidelines, they're published,
9:56
they're on the internet. There's the full guidance.
9:59
There's a summary of the guidance. There's information
10:02
there for patients. You know, we encourage patients
10:04
to read this. and to use it to use it to make
10:08
sure that you are getting the best treatment
10:10
and it's therefore actually quite a useful tool
10:12
in ensuring that you know there's equity of access
10:16
and fairness right across the uk in terms of
10:20
people getting the best treatment because as
10:22
i say this is open to patients now and they can
10:25
they can look at you know the management they're
10:28
getting and compare it to what is the published
10:30
gold standard uh treatment that's available And
10:35
when it came out at first, the first few times,
10:40
maybe 10, 15 years ago when NOG started, it was
10:44
aimed very much at doctors. I think we're very
10:46
keen now that everyone reads it, everyone looks
10:48
at it, and that it's used as a tool for equity
10:53
and fairness and something that is useful for
10:56
patients as well as for doctors. There does seem
10:59
to be a move across all of medicine. to empower
11:03
and involve patients more in the decision -making
11:06
processes about their care, about their treatment.
11:11
And it's wonderful that the guidelines are being
11:14
written in a way which everybody's going to be
11:16
able to read and understand because then you
11:18
can facilitate those discussions. You mentioned
11:22
something there while you were explaining the
11:26
guidelines. You said equity. What do you mean
11:29
by equity? Equity, I think, just means that everyone
11:35
gets the best treatment for them and that the
11:42
treatment is not restricted because of where
11:46
they live or because they're part of a particular
11:49
social group. It's not restricted by their ability
11:53
to access the care related to their income, to
11:57
their education, to whether English is a first
11:59
language or not. and again it's something to
12:03
just bring it back to my clinic you know I was
12:05
doing an osteoporosis clinic literally this morning
12:07
and you know doing my best for the patients who
12:11
were in the clinic one of the ladies had actually
12:13
cancelled a number of clinics before she came
12:16
to see me cancelled a number of appointments
12:18
had missed an appointment she just this was her
12:21
you know last chance if you would say to turn
12:24
up and on speaking to her she clearly needed
12:27
treatment she terrible osteoporosis multiple
12:29
fractures I was able to use the guidelines to
12:33
get her onto one of these anabolic treatments
12:36
which I think would make a big difference to
12:38
her life but because of many other things in
12:40
her life and her social circumstances her distance
12:43
from the hospital and many other things she almost
12:46
missed out on that one more failure to attend
12:49
and that would have been You know, that would
12:50
have been the end of that section of her offering
12:54
to get treatment. And it made me reflect, I might
12:58
do my best for the people in the clinic, but
13:00
there's a whole world of people out there who
13:03
haven't been to the clinic yet. People who are
13:05
fracturing without ever having had a DEXA scan
13:08
done. The majority of people who fracture their
13:11
hips and come into the hospital here. have never
13:13
had an assessment done, have never had a DEXA
13:16
scan. And we really need to think outside the
13:19
clinic to think, can we make sure that our services
13:22
are available equally to everyone? People with
13:26
learning difficulties, people with addiction
13:28
issues, people who maybe don't look after their
13:32
health well in other ways. We use a lot of virtual
13:35
clinics now, which is good and enables us to
13:38
contact people who can't come to the hospital.
13:40
There are groups of people who find it very difficult
13:43
to communicate on the phone or communicate over
13:46
the computer. So there's many, when we think
13:47
of equity, we sometimes think of very well -defined
13:50
groups, maybe male or female, racial groups and
13:53
so on. But actually, when we're talking about
13:55
equity in the real world, there's all sorts of
13:58
groups, all sorts of hidden inequalities in society.
14:01
And it just behoves us to do our best to try
14:04
to make sure that everyone in our society has
14:07
access to the best treatment for them, according
14:11
to the guidelines, according to the funding that
14:13
we can get. So listeners, we'll put a link to
14:18
the guidelines in the synopsis for this episode,
14:20
including a link to the guidance for patients
14:25
to read. And maybe if you're going to have a
14:27
consultation or you're worried about osteoporosis,
14:30
go and read those guidelines and see what they
14:32
say. I suppose now that brings us on to the next
14:36
part of the show. And maybe it's time to introduce
14:39
our guest. You know, Richie, the one thing I
14:42
forgot to mention as well in terms of keeping
14:44
up to date with everything you need to know about
14:46
bone health, it's listening to your favorite
14:49
infotainment podcast, Bone Up. Welcome back,
14:54
listeners. Today we have a really exciting guest.
14:57
Today we're going to be talking to Professor
14:58
Celia Gregson, who's a professor of clinical
15:01
epidemiology at the Bristol Medical School, a
15:04
consultant orthogeriatrician, and if that's not
15:07
enough, also chair of NOG, the National Osteoporosis
15:10
Guideline Group. Welcome, Celia. Thanks, Celia,
15:14
for making the time to speak to us today. It's
15:17
really good of you. Oh, it's a pleasure to be
15:19
here. Thanks for the invitation. So to kick us
15:22
off then, I suppose the best place to start is
15:25
talk about the enormous range of research that
15:28
you've been doing. You've been leading a lot
15:30
of research into inequalities in the incidence
15:34
and care of hip fractures all around the UK.
15:37
I wonder if you could tell us about the variation
15:39
that you've discovered. Yeah, so this work started
15:43
some years ago, and actually credit to Arti Bindjiani,
15:47
who did a PhD with us, funded by the ROS. which
15:51
was some of the first work that we did in this
15:53
area and we were looking at big data sets hospital
15:58
episode statistics and looking at incidents of
16:01
hip fracture over more than a decade in England
16:05
and we saw that over the course of time individuals
16:10
who live in deprived areas had higher hip fracture
16:15
rates than those individuals who lived in less
16:17
deprived areas and actually The difference in
16:21
terms in the rates of hip fracture over time
16:24
became more profound in those individuals who
16:29
are living in the deprived areas. So I growing
16:31
health inequalities in terms of instance of hip
16:34
fracture. We looked at areas across the UK. We
16:38
saw that deprivation is probably having the greatest
16:42
role to play as a risk factor for hip fracture
16:46
in men in the north of England. um which i think
16:49
really speaks to the higher levels of deprivation
16:51
um that is experienced by a lot of the population
16:55
particularly in the northeast of england um and
16:58
uh those uh that that sort of initial project
17:02
led on to further work that we've done um in
17:06
the reduced study um but that was also very much
17:08
informed by data that i mean anybody can have
17:11
a look at on the on the national hip fracture
17:13
database website So where you can look up any
17:16
hospital, your local hospital, you can look up
17:19
and see how that's performing compared with the
17:23
national average and in fact other hospitals
17:25
around the country. One of the great things about
17:27
the NHFD is its transparency of data access.
17:31
And you can see within the caterpillar plots,
17:35
as they're called on the NHFD website. marked
17:38
variation in the delivery of hip fracture care
17:41
in many domains of hip fracture care time to
17:45
surgery time to get out of bed post -surgery
17:47
time to see an ortho geriatrician in a hospital
17:50
and so on i was looking at some of the outcome
17:58
figures from reduce and they're they're fascinating
18:00
and i mean they're worrying the the difference
18:03
there is between different areas of the country
18:07
but Maybe just ask you about them. Some of them,
18:09
for example, if you had surgery within 36 hours
18:13
of your fracture, then there was a reduced risk
18:17
of death. That seems logical. That seems a fairly
18:20
hard -edged thing that we could work towards
18:23
doing. But there were other outcomes like if
18:27
you, for example, if patient feedback was discussed
18:30
at the clinical governance meeting, that reduced
18:33
the risk of death. Now, that seems a much more...
18:36
nebulous type of outcome from your point of view
18:41
how would you explain those how would you explain
18:45
those sort of softer outcomes i think there's
18:47
another one if if hospitals published how long
18:49
you had to wait before starting community therapy
18:53
it reduced your risk of readmission is that yeah
18:58
so so there i mean the first thing to say is
19:00
their associations so um you know, an exposure
19:04
is associated with outcome and saying that there's
19:06
a direct causal pathway one can't really do from
19:10
the data set. But what we can say is that those
19:13
hospitals that routinely review patient feedback
19:16
in terms of friends and family, classically,
19:21
are at a clinical governance meeting. those are
19:25
also the hospitals that have lower mortality.
19:27
And that's probably because that exposure, that
19:32
review of friends and family data. is an indicator
19:37
of a service that it's got itself a monthly governance
19:41
meeting, clinical governance meeting, that is
19:45
reviewing the hip fracture service and pathway
19:48
on a regular basis and has got an eye on patient
19:51
experience and is willing to review that information
19:54
and reflect on their practice from a patient
19:58
perspective. And those elements are probably
20:02
a marker of a service that is providing better
20:05
care and therefore one sees lower mortality.
20:08
The second example that you gave around services
20:13
that have insight into the time difference between
20:17
discharge and the initiation of intermediate
20:21
rehabilitation services, those hospitals were
20:25
also the hospitals that saw fewer 30 -day readmissions.
20:29
And that kind of makes sense. If you are a therapist
20:32
planning a discharge, and a handover of therapy,
20:36
rehabilitation care to a community team, and
20:38
you have an understanding of when that community
20:40
team may or may not pick that patient up, i .e.
20:43
how much delay there might be, because the delays
20:45
are extremely common within the stretched intermediate
20:48
care services as they stand, then you can risk
20:51
mitigate in your discharge planning so that a
20:55
patient doesn't get home, get stuck and then
20:58
come back and be readmitted. So I think they
21:00
both actually make sense. And it's surprising,
21:03
actually, how many hospitals don't have clear
21:07
understanding of when a patient is going to be
21:09
picked up by community intermediate care. I thought
21:13
that was interesting because it didn't say if
21:16
you have a short time or a long time. It just
21:18
said if the hospital was reporting. The length
21:23
of time. So, yeah, I suppose really what I was
21:26
asking with the question was, is this cause or
21:28
effect? Is if you have a well -run unit, well
21:31
-staffed, people are doing well, you're publishing
21:35
your outcomes, you're listening to patients,
21:37
or perhaps if you're not doing as well as a unit,
21:40
perhaps you're less likely to do that? Yeah,
21:44
I think a lot of the things that have come out
21:46
of the REDUCE study are markers. of a higher
21:49
quality more efficient well -functioning hip
21:52
fracture service but there are also things that
21:55
you know you can do something about you can set
21:57
up a system where your hospital does have a regular
22:01
communication with intermediate care services
22:03
and does have an understanding on a weekly basis
22:05
of what the delays are for the start of intermediate
22:08
care and that's relatively modifiable at not
22:13
a lot of cost and would provide inpatient hip
22:20
fracture services with a bit more information
22:22
for their discharge planning. And how do you
22:25
feed this back then? Because, you know, that's
22:26
one thing with research now, we're encouraged
22:28
not just to publish research, but to sort of
22:31
pick it up and try to feed it back and try to
22:33
use it, because we were talking about equity
22:35
earlier, you know, how do we make the service
22:37
more equitable in the UK? So how have you taken
22:40
this research? Who have you spoken to? What are
22:43
you doing with it to try to make things better,
22:45
let's say, in socially deprived areas? Yeah,
22:49
so three things, really. One, we're feeding all
22:52
of our results back to GERFT, who have been very
22:55
receptive to hearing about our research and our
22:59
findings. Just explain what GERFT is, because
23:01
we have listeners from right. way around the
23:03
world believe it or not getting it right first
23:07
time is a national initiative and there is a
23:11
girft for trauma orthopedics and that is about
23:15
service and quality improvement in order to ensure
23:21
that patient pathways get it right first time.
23:25
You do the right operation at the right time
23:27
initially so you don't have to go back and revise
23:29
things. You provide care promptly at the right
23:33
time that is the right care so you don't have
23:35
to then go back and unpick an inappropriate decision
23:40
at the outset. So there is an expanding girth
23:48
coming through I think this year, next year and
23:51
I think Reduce will feed into that. The second
23:54
thing we're doing is feeding it into the National
23:56
Hip Fracture Database. So Anthony Hanson, clearly
24:00
a key member of the NHFD team. He's also one
24:04
of the Reduce co -investigators. So that's really
24:09
helpful in terms of collaborative working between
24:11
the Reduce team and the NHFD team. And then the
24:14
thirdly, and perhaps the most important and the
24:16
key output from Reduce. that is really quite
24:19
exciting is that we're building a toolkit. And
24:22
the listeners might be familiar with the Royal
24:25
Osteoporosis Society Fracture Liaison Service
24:27
Toolkit. So a whole array of tools freely available
24:30
on the ROS website. So we're producing one the
24:34
same, well, taking the same principles, but for
24:37
hip fracture care. And we've already designed
24:40
quite a lot of those tools. They're at the stage
24:44
of proofreading and that kind of thing at the
24:45
moment. And we're aiming to launch that toolkit
24:49
in February 2023. And that toolkit includes things
24:54
like checklists for different components of delivery
24:58
of hip fracture care, how -to guides for multidisciplinary
25:02
care, for how to do clinical governance well,
25:05
a template handbook for a hip fracture service
25:08
that you can take and populate with your own
25:10
hospital's information, an organogram for kind
25:16
of the structure of a hip fracture service but
25:19
really importantly and where the health economics
25:22
has fed into um invaluably is a cost benefit
25:26
calculator so this is a tool which you just have
25:31
to you'll just have to put your kind of name
25:33
and your email address in and then you can download
25:35
it for free and it's a tool that allows you to
25:39
look up your hospital so we've We've done it
25:41
for every hospital in England and Wales. So you
25:43
look up your hospital and there are a load of
25:45
metrics which we have either generated through
25:48
Reduce or are freely available on the NHFD website,
25:51
which allow you to then look at the potential
25:55
impact of modifying up to 14 different components
26:00
of how you deliver your hip fracture service
26:03
and work out what the cost saving would be. if
26:07
you were to implement a change that enabled you
26:10
to achieve that particular parameter and you
26:14
can follow the working through so that you end
26:16
up with your calculations and some kind of standardized
26:19
text which then goes into a model business case
26:23
which you can then top and tail with your local
26:25
bits of information and you then have a business
26:29
case for example one of the strongest cost savers
26:33
is the delivery of weekend physiotherapy post
26:35
hip fracture And I can tell you that for each,
26:41
on average, for each patient who has access to
26:45
weekend physiotherapy, you're going to save about
26:49
£667 per patient per year. Now, you can multiply
26:55
that kind of thing up based on the number of
26:58
patients who you manage. And you can offset against
27:00
that how much it would cost to employ a physiotherapy
27:02
at the weekend. And then you can work out the
27:05
kind of benefit. expenditure and you can do the
27:09
calculations to go into a business case. So that's
27:11
really exciting because I think one of the things
27:14
that clinicians and service managers struggle
27:16
with is finding the time to sit down and think
27:19
through how to write a business case for this
27:21
sort of stuff and it will all be automated. I
27:25
mean obviously you can tweak it according to
27:27
your local circumstances but a lot of that will
27:29
be automated and I'm really hoping that that
27:32
makes life a lot easier. for the staff in the
27:36
172 different hospitals around England and Wales.
27:39
Yeah, that's an amazing tool, actually. I look
27:42
forward to seeing that. I mean, it's going to
27:44
be so useful for so many people. I'm conscious
27:50
of monopolising things here. I will let Richie
27:53
in, but I wanted to ask you about one other thing.
27:55
We talked about... about equity and a bit trying
27:58
to make sure that people, for example, in the
28:00
northeast of England get the same care as people
28:02
in the southeast of England. But you're involved
28:05
in looking at sort of equity of care right across
28:09
the world, aren't you? You've been involved with
28:11
work in Africa and in, I think I'm right, the
28:15
Samson Research Network. Could you tell us just
28:19
a little about that and why you got involved
28:22
in that study? What exactly it involves? Yeah,
28:26
sure. So SAMPSON is the Sub -Saharan African
28:29
Musculoskeletal Network. We have a website, the
28:31
SAMPSON .org. And that's something that actually
28:35
Kate Ward, who you've interviewed before, who's
28:38
down in Southampton and has a program in the
28:40
Gambia. And I and colleagues, particularly in
28:45
South Africa, we got some a small kind of startup
28:49
amount of money some years ago, I think 2015,
28:53
16. And that allowed us to to do some work together.
28:59
And that led to a desire to set up a network
29:05
to link people up across sub -Saharan Africa
29:08
who were all interested in musculoskeletal research.
29:14
It's a network of like -minded scientists, some
29:18
clinicians, some non -clinicians, who are all
29:21
interested in MSK research. And the idea was
29:25
to build a platform and a network to enable collaboration
29:28
and conversation between people who are otherwise
29:31
not connected, to share learning between groups
29:35
in different countries, to build... capability
29:39
within musculoskeletal research. So we pre -pandemic,
29:43
we were running workshops teaching the methods
29:47
of MSK research, for example, and also to try
29:51
and standardize the measurement of musculoskeletal
29:55
disease. So making sure everybody has grip strength
29:57
the same way or DEXA the same way or PQCT the
30:00
same way so that you can then do inter -country
30:02
comparisons and pull data. So, yeah, that's the
30:05
principle of. In the last series, when we spoke
30:13
to Prof Kate Ward, we learned about the research
30:18
going on in the Gambia. You've also been leading
30:21
research in Zimbabwe. And we wondered if you
30:24
could tell us about your findings of the IMVAS
30:26
study, which you published in Lancet Child and
30:29
Adolescent Health. Yeah, so that research was
30:32
led by Ruramira Cooney as part of her PhD fellowship
30:36
funded by Wellcome. and working closely with
30:40
my other colleague in Zimbabwe, Rashida Farrand.
30:43
So that was a cohort study of 600 children, half
30:49
of whom are living with HIV, half of whom not,
30:52
aged 8 to 16, and we recruited them and followed
30:59
them up for a year. And the project was all very
31:02
much around understanding the associations between
31:06
HIV and musculoskeletal deficits. So that first
31:11
paper that was published in Lancet Child and
31:14
Adolescent Health showed quite substantial deficits
31:19
in both cortical and trabecular bone compartments
31:23
as assessed by DEXA, which became even more apparent
31:28
in those children in the latter stages of puberty.
31:32
And we also saw that of those children who were
31:36
established, well, all the children were established
31:38
on antiretroviral therapy. I should say, actually,
31:41
that so the average age in the population was
31:44
12. The average length of time on treatment for
31:48
HIV was eight years. So that means that most
31:51
children were getting started on antiretroviral
31:54
therapy for four years at the age of four. So
31:57
these children are born with HIV. It's not recognised.
32:01
And they get picked up as young children and
32:05
then they get started on antiretroviral therapy.
32:07
So they've had four years of active HIV without
32:11
treatment. And that tends to set children on
32:14
a trajectory that increases their risk of stunting
32:17
quite dramatically. So significant linear growth
32:21
impairment. So it was that background that led
32:26
us to want to understand. more about the detail
32:30
about the bone deficits so the paper as I was
32:34
saying was is around DEXA and so in those children
32:37
who were established on ART so those children
32:42
with HIV about a third of them were taking tenofovir
32:45
so TDF which is recognized in adults and other
32:50
populations to be associated with low bone mineral
32:53
density and indeed in this population we saw
32:56
something very similar so it looks as if tdf
33:01
is not necessarily helpful in terms of bone density
33:10
health in children it's obviously helpful in
33:13
terms of controlling hiv disease The sorts of
33:17
levels of deficit that we saw in the children
33:20
equate in other populations to a 50 % increased
33:23
risk of fracture. So they're quite significant
33:25
bone deficits. And actually, just this month,
33:29
you might have seen a new paper come out in JBMR
33:34
published by Cynthia McQuaisey. Kahari, who is
33:39
another PhD student with me. She's funded by
33:42
the NIH Fogarty team in Zimbabwe. So she is a
33:45
radiographer. She's used PQCT in the Invasc population.
33:49
So she extends the work of Ruramai to show that
33:54
there are significant deficits in terms of predicted
33:59
bone strength. So SSI, as measured by PQCT, which
34:05
become, again, more manifest at the end of puberty.
34:08
So I think the concern from all of this is that
34:11
there is there are many millions of children
34:14
living in sub -Saharan Africa who had delayed
34:16
initiation of ART for HIV. If our results are
34:21
generalizable to those other children and there's
34:23
not a lot of reason why they ought not to be,
34:25
then it looks as if as. children are growing
34:31
through puberty with HIV that they are accruing
34:36
substantial bone deficits compared with their
34:39
peers and we wonder whether that is going to
34:43
have an impact on their peak bone mass. I mean
34:45
they may have an extended pubertal period and
34:48
ultimately achieve the same bone mass as somebody
34:52
who doesn't have HIV but just later in life but
34:56
I suspect I suspect that might not be the case.
34:58
And I suspect we might see a birth cohort across
35:02
sub -Saharan Africa who actually will achieve
35:05
a relatively impaired peak bone mass. And that
35:08
means some years down the line from now, the
35:12
population as a whole will be at substantially
35:13
increased risk of fragility fracture because
35:16
that peak bone mass has got to see them through
35:18
the rest of their life course. And of course,
35:21
it's at a lower level. So I think that that is
35:25
the concern and the implication of what we're
35:28
seeing so far. Is there anything that can be
35:31
done, do you think, to try and mitigate that
35:34
risk? Some kind of intervention that might be
35:38
able to help people develop better bone mass?
35:42
Yeah, so potentially, and actually we are in
35:45
follow up of a randomized double blind procedure
35:49
control trial in Zimbabwe and Zambia. only in
35:53
children who are living with HIV 11 to 19 called
35:57
the vitality trial and I know that people say
36:01
that haven't we had enough vitamin D trials but
36:03
there's never been one in the context of HIV
36:07
in southern Africa so we're doing an RCT of a
36:10
relatively high dose of vitamin D and a relatively
36:12
low dose of calcium in children with HIV to see
36:16
if that can improve bone accrual during adolescence.
36:24
I think otherwise, I mean, population, well,
36:31
the other thing to say is, you know, in the UK
36:33
or in a high income setting where a mother has
36:37
HIV, and increasingly in Sub -Saharan Africa,
36:43
because of the rollout of mother to child prevention
36:47
programs, that hiv is not necessarily being transferred
36:53
onto an infant so um there is much less uh there
36:57
sorry there are many fewer babies being born
36:59
with hiv to mothers who have hiv now because
37:03
of those programs um and so i think that this
37:10
entity that we're seeing here in this particular
37:13
birth cohort is hopefully not going to be as
37:18
common in the future in Sub -Saharan Africa as
37:21
it has been in years gone by. Of course, there
37:24
will still be some children who don't get picked
37:27
up and are born or do acquire HIV soon after
37:35
birth. But yeah, that has been a significant
37:40
improvement in terms of HIV programs in Southern
37:43
Africa. So if we could, let's say, eradicate
37:47
HIV in Zimbabwe, how much difference would that
37:50
make to the bone health of those children? Is
37:54
this the only thing? For example, I see people
37:57
living with HIV in my clinic here in the UK,
38:00
and we discuss is it the disease, is it the antiretrovirals,
38:03
what's contributing to it? But the understanding
38:05
is if we could make that go away, then, you know,
38:07
their bones would be a lot healthier. Is living
38:10
with HIV a marker of other musculoskeletal issues
38:14
in Zimbabwe? Is it a marker of people who are
38:17
from lower socioeconomic groups? You know, how
38:20
much is it the big problem or how much is it
38:23
a marker of other things? Yeah. So in the population
38:27
who don't in the children who don't have HIV,
38:30
their bone density is about half a standard deviation
38:33
lower than reference populations in Europe, in
38:36
the UK, for example. Now, that might be because
38:39
the reference populations aren't right for them,
38:41
or it might be that they truly do have lower
38:44
bone density. Certainly the environment that
38:48
children. are growing up with is very different
38:51
from a high income setting. There are many more
38:55
nutritional and environmental challenges that
38:57
make it more difficult for a child to achieve
39:03
its sort of genetic potential in terms of musculoskeletal
39:08
growth. Question about whether there's an association
39:16
between socioeconomic deprivation and HIV. Yes,
39:18
yes, there is. But I don't know that HIV is necessarily
39:22
a marker of deprivation in that HIV is really
39:27
quite common and it affects people in all stratas
39:32
of society. So but there is an association, but
39:38
it isn't. Yeah, you couldn't describe it as a
39:41
marker, I don't think. Aside from leading these
39:46
global research projects, which are going to
39:49
have a huge impact on people's lives, you are
39:54
also chair of the NOGG, the National Osteoporosis
39:58
Guideline Group. And we've talked a little bit
40:00
about NOG in the last series of Bone Up, but
40:04
we wondered if you could tell us exactly what
40:06
the group is and what it does. Yeah, so it's...
40:12
It's a group of professionals who work in the
40:16
field of osteoporosis in the four nations in
40:20
the UK. And it spans different disciplines. I
40:26
mean, the large majority of people are rheumatologists,
40:29
but it includes geriatricians, primary care,
40:31
endocrinology, for example. And it is entirely
40:36
voluntary and it's quite a time contribution,
40:38
actually, to to donate on a voluntary basis.
40:43
But nevertheless, we do. And we come together
40:48
to I mean, I guess our main role is is the guideline.
40:54
So NOG has had a guideline for many years and
40:58
every few years. the guideline is updated to
41:03
reflect the emerging evidence. So NOG's role
41:07
is to appraise the quality and robustness of
41:13
the evidence and to use that to make recommendations
41:16
that guide primary and secondary care delivery
41:20
of osteoporosis services and to make those recommendations
41:26
in as practical, digestible way as possible so
41:31
that they can be operationalised by clinicians
41:35
and allied health professionals working in primary
41:38
and secondary care. The other thing actually
41:41
I should add is that it has been very important
41:45
both for this guideline and the last that we
41:48
were able to secure NICE accreditation for that
41:50
guideline. What that means is that NICE judge
41:54
that the process that we have followed to generate
41:58
that guideline abides by the really quite strict
42:02
rules that NICE sets out in terms of impartiality
42:06
and the system by which recommendations are made
42:12
by a group of individuals. So we're very happy
42:16
that the NOD guideline has that NICE accreditation.
42:21
For that NICE accreditation, That then is a UK
42:26
organisation that sets guidelines in the UK for
42:30
doctors to follow when treating patients. Do
42:32
any other countries around the world use NICE
42:36
guidelines as a guide for their own guidelines?
42:40
Yeah, I think NICE, I think both Nog and NICE
42:42
are looked at by many countries around the world.
42:47
In fact, we were just looking the other day at
42:51
a map. around the world of all of the countries
42:55
that have downloaded the new NOG guidance from
42:59
the new NOG website since it was launched in
43:01
April of this year. I was staggered by, I mean,
43:04
obviously the lion's share of downloads are in
43:06
the United Kingdom, but there are people accessing
43:09
NOG across Europe, North America, Southeast Asia,
43:13
Australasia and Africa. So, I mean, in much smaller
43:17
numbers, but nevertheless, it does have a global
43:19
reach. We are always amazed when we hear and
43:22
find people who have been downloading our podcast
43:25
right across the world. As well, Celia, in South
43:28
America and Africa and around the world. You
43:31
know, I had a medical student a few years ago
43:34
and she asked me, what's the point of guidelines?
43:37
And I thought it was a rather odd question. And
43:40
I said, well, they helped me at the clinic. Obviously,
43:43
they stopped me having to think too hard at the
43:45
clinic. And they give the patient reassurance
43:48
that they're getting good evidence based. treatment.
43:51
And I suppose there's a role also in healthcare
43:53
providers in terms of, you know, if there's guidance
43:57
that say you need a treatment or you don't need
43:59
a treatment, then that can help with funding.
44:02
But, you know, the more I was involved, as you
44:05
know, with this NOG guidance and thinking about
44:07
it, I do think equity comes through guidance
44:10
as well, because we're setting out saying this
44:13
is what best care looks like. And whether you
44:17
live in the Scottish you know, the Scottish Hebrides
44:21
or whether you live in London or whether you
44:23
live in West County Tyrone or whether you live
44:26
in Sunderland or wherever you live, you should
44:28
be getting these, this standard of care. This
44:31
is what, this is what our reading of all the
44:34
research suggests is the best. And we often talk
44:38
about empowering patients in this podcast. And
44:42
it strikes me, and I don't know what you think
44:44
of this, that actually it's a way of empowering
44:46
patients as well. They can take the note guidance
44:49
and say, this is what's best and why am I not
44:52
getting it? Yeah, I agree entirely with you.
44:55
I think there are kind of two components to the
44:57
answer. For equity, clearly there may be some
45:01
practices, primary or secondary care, that are
45:06
already delivering everything that's in the guideline.
45:09
That's great. But then at the other end of the
45:11
spectrum, there will be some practices that are
45:13
actually delivering very, very little of that.
45:15
And they need to change their practice really
45:17
quite profoundly in order to provide equity in
45:22
their care. And I think the other thing to mention
45:26
is that we have a number of patient representatives
45:30
on NOG who are very active participants within
45:34
the whole process of writing guidelines. I mean,
45:36
their help is invaluable. And they specifically
45:40
have written a patient information leaflet that
45:43
accompanies a guideline that puts the content
45:47
of the guideline in patient language and makes
45:50
that accessible. And so if patients are listening
45:53
to this, you know, you can go on the website
45:55
and download that as a PDF. And if there are
45:58
elements in that that you think you're not getting,
46:00
then that is the evidence to suggest that. you
46:05
should be getting those elements that are described
46:08
in that leaflet. And that does empower patients
46:12
to ask healthcare professionals for the appropriate
46:17
evidence -based treatments. And some of the evidence
46:20
is quite new and therefore practice is changing
46:24
currently quite rapidly. And so I strongly suspect
46:29
that there are elements in the guideline that
46:31
not all patients are getting because, you know,
46:33
we've got new drugs that have just recently come
46:35
online. So, yeah, it's an evolving place. But
46:39
I think that the patient information leaflet
46:40
is really helpful for patients. And I know you
46:43
have been very, I mean, you've been at the forefront
46:45
of pushing this for patients as well. Probably
46:48
when the first no guidance came out, would it
46:51
be fair to say it was written? by professors
46:53
of metabolic bone disease for professors of metabolic
46:56
bone disease but almost with each iteration you
47:00
know we're not pushing it very much to gps that
47:02
they should be using this guidance and as you
47:04
see now it's for patients as well it's for it's
47:06
for everyone um because everyone needs to know
47:09
about about what's what's best practice i suppose
47:13
um i mean you talked about some of the some of
47:17
the new drugs, some of the newest findings. If
47:19
I had to ask you to maybe highlight one or two
47:21
things from the latest NOG guidance that people
47:25
might need to hear about, what would you say
47:27
were the newest and freshest and most important
47:29
points from the latest guidance? Yeah, I think
47:36
that we've introduced, as other guidelines around
47:39
the world have, This concept of very high fracture
47:42
risk and acknowledge that some of those people
47:44
at very high fracture risk ought to be considered
47:47
parenteral therapy as a starting point. And along
47:53
with that, we've made IVs aledronate first line.
47:56
We've all been using it for years. It's a drug
47:58
that's very familiar to us. And I think we should
48:01
be using a lot more of that, frankly. I think
48:05
the other thing around treatments is around.
48:08
cautions of denosumab cessation and ensuring
48:11
that that's planned because of the rebound bone
48:13
turnover and paradoxical increase in vertebral
48:16
fractures. And then that brings me on to the
48:18
vertebral fractures. That is a very strong theme
48:21
that runs through the NOG guidance, the identification
48:25
of vertebral fractures, the management of vertebral
48:28
fractures, which, and there's a section that,
48:33
you know, hasn't appeared before around vertebral
48:36
fractures as we have realized as a community
48:38
the importance of identification of fractures
48:41
and getting people onto treatment promptly. And
48:45
then I guess the other bit is a little bit of
48:49
a nuance change around length of treatment with
48:54
oral bisphosphonates. I think one of the things
48:56
that we were a little worried about is the evidence
48:59
that this sort of five -year drug holiday, you
49:04
know, drug holiday, an inverted comma is a phrase
49:06
I really don't like, following five years of
49:10
treatment tends to actually manifest in you get
49:13
five years and then people forget about the fact
49:15
that you ever had osteoporosis in the first place.
49:17
And then you see this increased risk of fractures
49:19
in a population who actually are really at quite
49:22
high risk and they would actually probably benefit
49:26
for more than five years. So although the...
49:31
absolute um message from nog you know the the
49:35
actual rule hasn't changed as it were there's
49:37
a nuance around how we phrased it to err on the
49:40
side of default to 10 years and only give five
49:44
years in those at lower risk so it's a slight
49:46
change in wording really they're probably my
49:50
highlights yeah is it fair to say just viewing
49:52
the way things have moved in the last five years
49:55
that while the hip fracture is still the big
49:58
outcome fracture but the vertebral fracture has
50:02
now moved center stage as being the red flag
50:05
for osteoporosis and that we should be sort of
50:08
pushing both of these fractures as the because
50:10
i mean you know as well as i do 20 years ago
50:12
vertebral fractures no one cared about them yeah
50:15
no i agree i think um i think there's a We've
50:19
all woken up to vertebral fractures and the importance
50:23
of identifying them. And it gives you a window
50:27
of opportunity to intervene to prevent the hip
50:29
fracture. I mean, unfortunately, after hip fracture,
50:33
we still have a one year mortality of around
50:35
28 percent. And actually mortality after vertebral
50:39
fracture is also high. Yeah. And, you know, the
50:43
other thing is about the evidence base. You know,
50:45
all of the drugs that we have available work
50:48
particularly well at preventing vertebral fractures.
50:51
So we need to find them, give the drugs and stop
50:54
more vertebral fractures. Listeners, if you want
51:00
to read more about the guidelines, we've attached
51:03
a link to NOG in the bio for this episode. So
51:08
we're nearly at the end of the podcast now. Celia,
51:10
thank you so much for your time today. It's very
51:13
clear that you are one of the busiest people
51:15
in the bone research community. I was wondering,
51:19
a theme that really runs through your leadership
51:22
in research is equity of care. And we were wondering,
51:26
how was it that equity became so central to all
51:30
of the work that you do? Yeah, I think that that
51:35
is quite a deep rooted thing. I just think that
51:43
society should be fair and just. And I think
51:47
that goes back to actually my childhood and feelings
51:50
of fairness and justice. And I can't really explain
51:55
that, but it's a trait or something that I have
52:00
thought all of my life, really. Things should
52:04
be fair and just. And I think that that underpins
52:07
a lot of what I do, really. It's really clear
52:12
that it does. And it's been fascinating and inspiring
52:15
to speak to you today. Thank you so much for
52:17
your time. Yeah. It's worth paying tribute to
52:21
the amazing work you do sharing NOG, my limited
52:25
experience of working on NOG, where I think we're
52:28
all in awe of the... amount of work that goes
52:30
into that. And the quality of the guidance that
52:32
comes out of it is really second to none, I think,
52:35
internationally. So thank you for taking time
52:38
to come and speak to us today. We could talk
52:41
for twice as long. I can't believe that the time
52:43
has gone in already. So a huge thank you. And
52:47
we hopefully maybe speak to you again in the
52:49
future. Yeah, I mean, thank you. They're really
52:52
good questions. And yeah, I hope that it's enlightening
52:56
for your listeners. So thanks very much. Thanks.
53:00
Bye -bye. Wow, David, what a great interview
53:07
that was. I really enjoyed talking to Celia.
53:10
So articulate, so eloquent, real gravitas. What
53:16
a wonderful guest. Yeah, she really is a world
53:19
leader and I don't know how we do so well in
53:21
getting such important people onto the podcast,
53:24
Richie, but really no one has let us down and
53:27
Celia... Celia's contribution is inspiring isn't
53:30
it I think everybody wants a mug yeah I mean
53:34
you're a scientist and a lot of the things she
53:37
was saying about would probably be classified
53:39
as more sort of clinical or practical but I mean
53:43
I could see even you know the way you were listening
53:45
to her what what do you take away from that which
53:48
might might change what you do I think the most
53:54
important thing is that seeing a global leader,
53:59
an innovator like Celia inspires me and makes
54:04
me want to do the same thing. And it makes me
54:08
want to work harder at my basic science and think
54:11
more carefully about ways in which the science
54:13
I'm doing might have an impact on the world.
54:18
And it also makes me want to get involved in
54:21
more clinical science. And on the research front,
54:25
I'm trying to get involved in more clinical science,
54:27
thinking about bone health in people living with
54:31
HIV, thinking about bone health in people who
54:35
have been exposed to high levels of air or water
54:40
pollution, and thinking about ways in which I
54:44
could adapt the ways in which I am measuring
54:47
bone health and bring them into clinical practice
54:49
so it might be possible to make. better diagnostics
54:53
better screening for osteoporosis maybe think
54:55
about ways in which we can measure treatment
54:57
outcomes and give people better advice and better
54:59
support about the positive things that medicines
55:03
are doing for them it just makes me want to do
55:07
better and achieve more and do research that's
55:09
going to change people's lives that's it's just
55:12
so wonderful so wonderful to speak to people
55:16
who have changed the world especially people
55:20
like Celia who've changed the world quite a lot
55:22
and really have that global global approach global
55:27
ideas global solutions like it's pretty awe -inspiring
55:31
really what were your takeaways from today I
55:38
mean I think you probably even heard me heard
55:41
me as I was listening to her and the questions
55:43
we were asking her I think a lot of doctors think
55:46
of guidelines as primarily for their benefit.
55:50
In other words, I don't have to read the 100
55:54
new papers published in osteoporosis this week
55:57
and last week and the week before because a group
56:00
of experts have done that for me and have put
56:03
the best evidence together and have said this
56:07
is what is best for your patient. So if I see
56:10
a patient who's... just had a new vertebral fracture
56:14
and has low bone density I can look at the guidelines
56:17
and say that patient is best managed if it's
56:21
suitable for them with an anabolic injection
56:23
as opposed to maybe an oral bisphosphonate that
56:26
I might have used 10 or 15 years ago so that's
56:29
very helpful for me and that takes a weight off
56:31
my mind but actually listening to Celia and thinking
56:36
more about this and I think I mentioned it in
56:38
one of the questions I asked her I now see guidelines
56:42
more and more as of benefit to patients because
56:45
the patient can also be reassured that they are
56:48
getting the best and most up -to -date treatment.
56:52
And not only are they getting it, but they can
56:54
also know that if these are guidelines that apply
56:56
across the UK, then patients should be getting
57:00
the same treatment regardless of where they live
57:03
and regardless of which social group they're
57:05
in and regardless of the distance they live from
57:08
the hospital and so on. And that then feeds very
57:13
well into what... the amazing work Celia has
57:16
on equity and the passion she obviously has for
57:20
making things fair and equal and everything that
57:23
she does and it makes me think more and more
57:26
about the hidden inequalities in what we do and
57:31
how I talked earlier about patients. I've seen
57:36
a patient who failed to turn up for several appointments
57:40
because they were a carer for an elderly relative
57:43
with dementia. And that's a group of people who
57:47
maybe don't fit in the standard tick boxes for
57:50
equality. But unless we make our services available
57:53
to people who maybe can't get to the hospital
57:57
at short notice because they're carers, then
57:59
we're not doing well enough. There are people,
58:01
for example, who have alcohol addiction issues.
58:04
If you give them a nine o 'clock appointment
58:06
in the morning, they're much less likely to turn
58:08
up for that. All these hidden qualities that
58:11
exist sort of in society. And I see the passion
58:15
that Celia has for improving things. And yeah,
58:19
that inspires me as well. And, you know, I was
58:23
thinking just about the work you do as well.
58:27
And the guidelines and the equity agenda, that's
58:31
actually really important for making sure that
58:34
the work you do gets to patients as well. Because
58:38
if you make some... amazing discovery about human
58:42
bone tissue then it's important that everyone
58:45
gets the benefit of that not just a highly educated
58:48
patient living in a well -off part of society
58:52
who has sharp elbows and who can get themselves
58:55
to the front of the queue but it's important
58:57
that the work you do is available to everyone
59:00
so everyone gets the benefit of that and in fact
59:05
Guidelines are important for that as well. And
59:09
as I say, the equity agenda is important for
59:12
that. And while as a doctor in the clinic, I
59:16
can look at the patients I saw this morning and
59:18
think, I believe I treated those patients fairly.
59:21
I believe that they all got the best management
59:26
according to the latest guidelines. And in fact,
59:28
I had a student in the clinic with me and we
59:31
compared the fact that. three patients all presented
59:34
with the same type of fracture in the same way.
59:36
And yet they all got quite different treatment
59:38
because we tailored the treatment to what was
59:41
best for them. So that's good. We finished the
59:43
clinic and I went out thinking I did a good job
59:45
this morning. And then I look outside and I realize
59:48
that there are vast numbers of people who aren't
59:51
getting to the clinic at all, who aren't getting
59:52
assessments, who aren't getting DEXA scans done
59:55
and think I should be trying to do better for
59:58
everyone in my. and my trust and my community
1:00:01
we want to make sure things are equal for everyone
1:00:05
across the uk and then celia comes in and says
1:00:08
no everything should be equal for everyone across
1:00:10
the world and i want to see the best management
1:00:13
and the best bone health and the best opportunity
1:00:15
given to everyone whether you live in belfast
1:00:19
whether you live in london whether you live in
1:00:21
zimbabwe or or really any part of the world and
1:00:26
that's sort of mind -blowing to want to take
1:00:29
that that quality of um quality of care and quality
1:00:35
of management and expand it from the patient
1:00:38
sitting in front of me um in the clinic to every
1:00:42
potential patient in the world who has problems
1:00:44
with their bones and that's a You know, that's
1:00:47
an inspiration for all of us. It is, isn't it?
1:00:51
I suppose when it really boils down to it, it's
1:00:54
quite a simple idea that everybody is equal and
1:00:57
everybody should have equal access to the best
1:01:01
care. But to actually try to deliver that, to
1:01:07
actually deliver that is visionary. You know,
1:01:11
it's something that maybe we think about a lot,
1:01:13
but don't actually. do anything about but celia
1:01:16
is celia's doing something about it and you know
1:01:21
the people who fund your research as well richie
1:01:24
they don't want the benefits of your research
1:01:26
just to be available to a small group of people
1:01:28
they want the benefits to be available to everyone
1:01:32
equally across the country and across the world.
1:01:34
So actually that fairness agenda, it's absolutely
1:01:38
central to your research as well, because the
1:01:41
benefits of your research have to be applicable
1:01:43
to everyone and not just to the people with the
1:01:46
sharpest elbows and the deepest pockets. Yeah,
1:01:50
I completely agree. And when I'm writing grant
1:01:54
applications to get money to do research, there
1:01:56
are boxes that you have to fill in. And I think
1:01:58
through a lot of my research life, I haven't
1:02:01
been able to fill out those boxes very well.
1:02:03
And lately I've been trying to improve and change
1:02:05
the direction of my research so that I can fill
1:02:07
out those boxes properly. By looking at things
1:02:10
like global changes in climate and pollution,
1:02:13
etc. It's been a really thought provoking episode,
1:02:18
I think this, for both of us. We put a lot of
1:02:22
effort in before the episode to think about the
1:02:25
questions that we were going to ask Celia and
1:02:26
make sure that we got. really good questions
1:02:29
that try to cover the breadth and depth of the
1:02:32
work that Celia has been doing. And that was
1:02:35
really hard for us to do because there's so much.
1:02:39
And now having done the interview, there's so
1:02:42
much more to think about. Both of us, we have
1:02:46
a lot of takeaways from this episode that's going
1:02:48
to affect and change the way that we work and
1:02:50
hopefully improve it. Yeah, absolutely. You know,
1:02:53
we started this podcast, Richie, thinking we'd
1:02:55
be talking about sort of osteocytes and bone
1:02:58
matrix and, you know, bisphosphonates. And yet
1:03:01
the last few episodes in particular, we've talked
1:03:05
a lot about ethics and morality and fairness
1:03:09
and society in general. And I think that's a
1:03:11
good thing. I think neither medicine nor science
1:03:13
can be divorced from the societies in which we
1:03:17
live. Yeah, it's interesting that. And what strikes
1:03:22
me here is that the leaders in pharma and the
1:03:26
leaders in medicine are both thinking about the
1:03:29
same things there. They're both thinking about
1:03:31
providing the best care and they're both thinking
1:03:34
about equity. That's really wonderful to hear.
1:03:37
It gives me hope. That's hopefully a positive
1:03:41
note to end the podcast on this time. I think
1:03:44
there's another really positive note as well,
1:03:46
which is... I was really pleased when Celia said
1:03:49
at the end that we had really good questions.
1:03:53
That makes me think that we've achieved something.
1:03:57
Yes, I think that's true. We'll take that as
1:03:59
a positive. Okay. Bye, David. Bye, listeners.
1:04:04
See you all again soon. Bye now.