Podcast Episode 18: Saving Limbs, Saving Lives.

Hi, my name is Nasir Ahmad and I'm a vascular surgeon based in Manchester. I've also got a couple of other titles. I'm the clinical director for the Greater Manchester Aneurysm Screening Programme. I'm the deputy chief clinical information officer for our hospital. But for this podcast, I'm mainly speaking as the lead for the MARS project, the Manchester Amputation Reduction Strategy. The reason I'm having a chat and I just want to really extend my gratitude to Ellie and the Lindsay Leg Club Foundation for giving me the opportunity to speak about Mars. And what we're trying to do with Mars is reduce not only the number of amputations that we have across Greater Manchester, but also the inequality that we see across Greater Manchester. To give a background, across England, we have huge inequalities in amputations. There's 30% more amputation in the north of England compared with the south. There's three times more amputations in men compared to women. And there's about 70% more in the black population compared with the white population, although interestingly far lower in the South Asian population compared with the white population. Now I should say that when people think about amputations they generally just think about diabetes and that is right but the reality is only about half of all major amputations are in people with diabetes. The other half are mainly in people with peripheral arterial disease and of those you know even those with diabetes about 70, 80 sometimes 90% of people who have diabetic foot ulcers and diabetic amputations have a vascular component to those ulcers. Now, about 5% of amputations are due to, you know, either trauma or cancer. But those that that sort of 5% is not really the focus of Mars itself. Generally, it's related to chronic disease. And the reality is, you know, to reduce amputation and the inequality of amputation, you need to address all amputations, not just diabetes. And the reason why these chronic diseases lead to amputation is because they cause ulcers. So to reduce amputations, you've got to treat ulcers better. And how do we treat ulcers? Well, we have a, you know, a patient limb wound approach to those ulcers. So you've got to address the wound properly by the correct dressings and the bandaging and the offloading as appropriate. You need to address the leg issues. So, you know, the general skin condition and the vascular supply and and the edema and all that. Then you've got to address patient issues as well, such as managing the chronic disease better, make sure their medicines are optimised, as well as their, you know, the mental health issues and their social issues as well. So the whole patient-limb-wound approach really provides a framework for treating ulcers better and ultimately reducing amputation. This is where I think we are doing, trying to do something quite unique in Manchester. We want to have a whole systems approach to reducing wounds, treating wounds better and ultimately amputations. And the principle we've adopted is just is we want we want to bring public health, community services and hospital services together for all wounds to address not only the public health and the chronic disease issues, but also to ensure the patient journey is as as optimum as it can be through harmonized protocols and, you know, reduce duplication of services. And the principle we've developed or that we've incorporated into MARS to try and, you know, have an umbrella term to bring all these together, it's basically called the 3-4-50 idea. And this is the principle that three lifestyle behaviours contribute to four medical conditions that lead to over 50% of deaths. And that is, it's all common sense, you know. So the three lifestyle behaviours are smoking, lack of exercise and poor diet contribute to four conditions, which is cardiovascular disease, respiratory disease, type 2 diabetes and cancer. And between them, those four lead to over 50% of deaths. And the link with ulcers is that these chronic diseases are seen in patients with ulcers. So if you want to treat ulcers better, you've got to get obviously the dressings right, but you've got to address the chronic diseases and also the risk factors as well. So if you want to put 3450 into action, you need to bring in public health services, community services and hospital services through a unified protocol and to unify the services as well. And as you can tell, that's a huge project. And the trick is to do it in bits, do it slowly and try to do all of it somewhere with a view to bringing it all together and therefore you can then do everything everywhere. And how do you choose which areas to do. It's simple. You do what's easy in particular areas. But the key thing is collaboration. You've got to bring a team of people together with a unified vision and work with those people that have a similar way of thinking. And the second thing to do is to have the arguments for doing what you want to do that speak to all the different groups of people that you will need to speak to. So you know you'll have to speak with commissioners, you'll have to speak to public health, you'll have to speak to finance guys, you'll have to speak to nurses, doctors, podiatrists, physios, all these kind of people. And they all will need, you know, tweaking of your argument of why to do things. The general argument that people have is, you know, it's the right thing to do, which is correct. But when you're speaking to a diverse group of people who don't know the clinical background, or many of them won't have a clinical background, what you'll need to do is develop arguments around the clinical need for it, the evidence for doing it, the financial reasons for doing the, you know, the inequality argument, as well as having, you know, the patient experience argument as well. So my my key lesson is if you want to have change, you know, speak to all these people beforehand that you need to speak to, identify who stakeholders are and understand what their asks are. What will they need to hear for change? And then you can start building your argument around what they want to hear. And this is because, you know, language matters. You know, although you know your problem and you know it well, other people don't. So I would say, you know, spend time in understanding the arguments of why change is needed from other people's perspective. And then understand what the system wants to achieve in itself around, you know, saving money, reducing inequality, harmonizing services, and then work out how your project will fit into their agenda. Because it's only if what you want to do fits in with what they want to do, then you can start collaborating. So it's a win-win for everyone. And having that principle of a win-win for everyone is what really does lead to success. And I think that's my golden rule really if I think if you take away from this the principle of 3-4-50 Understanding that you need a whole systems approach to make system change But then you know to understand what the system wants and needs And to understand other people's arguments and the ability to tailor what you want to do with what they need to hear And I think that Would be my my golden lessons, and I hope If you take that away from my little chat today, I'll be extremely happy. I again want to thank Ellie for inviting me to this podcast and look forward to hearing from you guys in the future. Thanks very much.