Insight
Expert approaches and ideas
Fuelling the growth of neuromodulation
A recruitment business specialising in the fast-growing field of neuromodulation continues to support the growth of the sector by sourcing expertise globally to take businesses working within it to the next level.
Hanison Green, marking its second anniversary this month, works with a number of key names globally in the high-tech industry, finding talent to fill strategic roles, thus helping them to unlock the next phase of growth.
The growth of neuromodulation continues at a rapid pace, with new ventures being created worldwide to tap into the scientific research-led tech phenomenon which uses electrical nerve stimulation to achieve life-changing results for patients living with conditions including spinal cord injury, OAB, and chronic pain.
Working primarily with startups in the United States and Europe, London-based Hanison Green - established to ‘do recruitment differently’ and place top-level neuromodulation leadership in early-stage companies at a crucial stage of their development - continues to add new businesses to its client portfolio, in addition to major clients already being works with in the sector such as ONWARD.
"We’ve seen great progress over the past two years, both for neuromodulation as a sector and for Hanison Green,” says Lindsay Hartland, founder and CEO of the business, who was previously a partner at global recruiter SThree."
“I’m really happy with what we’ve done, but mainly the way that we’ve done it. We’re incredibly customer led. We invest a lot of time into working with our candidates, as well as the client, and I’m really pleased we’re able to often exceed the expectations of our customers.”
Despite having only been in business for two years, Lindsay has noted significant growth within the neuromodulation field globally during that time, but particularly in the US.
“We’re currently tracking the progress of around 350 neuromodulation startups, but we haven’t found them all yet, in fact around three or four new ones are coming onto my radar each week,” he says.
“It’s a very exciting space of MedTech for companies and investors to operate in, and we’re seeing a real surge in activity currently, due to the continued advancement of scientific research, and clinical evidence, with major breakthroughs happening frequently now, but also because it’s becoming more widely accessible, as the FDA continues to clear more devices, and awareness of neuromodulation therapies continues to increase.”
The increase in pace of development, can in some way be attributed to COVID-19, says Lindsay, with the transition to telehealth and home-based therapy.
“It was heading in that direction anyway, but the recent pandemic has sped things up,” he says.
“Historically, neuromodulation generally was implantable devices to treat chronic pain, but now we’re seeing a plethora of pioneering therapies being given the regulatory green light, along with the move towards external, non-invasive or minimally invasive stimulation devices which patients can use, and be in control of, in their own home.
“Through this therapy being moved from clinic to home, it has contributed significantly to the growth and awareness of the whole concept of neuromodulation. We’re now starting to see a glimpse of the real potential of stimulation therapy, and the life-changing impact it can have over so many health issues. Our belief and expectation of what neuromodulation is capable of is evolving quickly.”
Hanison Green’s client base expands across the United States, and Europe, and while the business continues to grow, Lindsay says it will never seek to have huge numbers of clients.
“We don’t operate big numbers and certainly aren’t bombarding the market with loads of CVs. Our approach is very targeted. We attempt to match an excellent candidate exactly to a position or business within which we are confident that will be a great fit,” says Lindsay.
“Many recruiters will get hold of a half-decent candidate and mailshot their details to as many companies on their database as possible, hoping that something sticks. We haven’t done a single mailshot in two years. That’s the opposite of how we work.
“We get to know a candidate, and I mean really know them. We get under the skin of what makes them tick, and if we uncover a need that their current role doesn’t provide them, then we’ll aim to work with them exclusively. We’ll cross reference them to our list of neuromodulation companies and link them to where we see a need and indeed a gap within that company. We’ll then make very pin-pointed, individual and personal approaches to the list, highlighting where we believe the candidate can add real value to this business. It’s strategic rather than scattergun.
“We’ve got a 100 per cent acceptance to offer rate, and for every three resumes we send to a brief we average over two interviews, which shows how well we understand the market, and our customers. We’re not interested in wasting anyone’s time.”
Included in its array of up-and-coming names in the sector is Massachusetts-based NeuroMetrix - traditionally a diagnostics business, now moving into the neuromodulation therapy space, for which Hanison Green found their commercial leader for its US launch - as well as ONWARD.
While in 2020 the venture’s work was lesser know, it has since hit global headlines through its STIMO-BRIDGE trial, which enabled three paralysed patients to regain the ability to walk, run and swim through its spinal cord stimulation technology. It is set to commercialise its first product, the ARC-EX external stimulation device, next year.
“We were only a few months in at Hanison Green and I managed to connect with Dave Marver (ONWARD CEO). The work they were doing was incredible, so I was really keen to speak with them,” says Lindsay.
“ONWARD have seen astronomical growth having doubled their headcount in the past two years, which has been great to see. We were fortunate to place their VP marketing, and subsequently their two senior marketing managers for the US and Europe and I still keep in regular touch with them, they’re doing amazing things and we’re very proud to to be able to call them a client of Hanison Green.”
Looking into year three and beyond - marking its official second anniversary on September 7, 2022 - Lindsay is committed to continuing to do what the business does well and enjoy the work/life balance he sought in becoming an entrepreneur.
“Really, it’s more of the same going forward. We do what we do very well and have made some great relationships, so it’s building further on that,” he says.
“I get to build relationships with some truly wonderful people through my work, and I also get to spend quality time with my kids, which was so important in doing this, and I’m very happy with my life right now. What more could you want?
“Looking forward, our ethos will be unchanged - treat people well, and with respect, and do your best for them, and do what you say you’re going to. It’s that simple, really.
“Our expertise and interest lie in neuromodulation, and I don’t see the need to go outside of that, so that will be the space we continue to build our presence in.
“However, at some point we might look at brain-computer interface (BCI) - it’s sci fi, amazing stuff, and there are some wonderful companies working in that space, on the cusp on achieving something astonishing. Potentially we could move into that sector and support the growth of companies working in BCI at some point, but we’ll see how the sector goes - it’s still very early days.
“But for the foreseeable, we’ll continue to support the ongoing growth and development of pioneering neuromodulation start-ups”
The Walton Centre -
a beacon in neuroscience
Dr Andrew Nicolson, medical director of The Walton Centre - the UK’s only specialist hospital trust dedicated to providing comprehensive neurology, neurosurgery, spinal and pain management services - discusses its pioneering work
Over the hospital’s lifetime of 80 years, The Walton Centre has grown from a single neuroscience unit to a unique specialist NHS Foundation Trust, serving millions of people across the UK.
I have been medical director here for six years and even in this time it has grown and enhanced the service it provides to not only patients in Cheshire and Merseyside, North Wales and the Isle of Man, but also to parts of the rest of the north of England and beyond.
In recent history, the Trust has become the sole provider of spinal services in Cheshire and Merseyside, continues to host the rehabilitation network for the region and launched the first 24-hour thrombectomy service for stroke patients in the North West.
I firmly believe that the Trust will continue to grow, innovate and enhance the many services it provides.
It would be remiss of me not to mention how the COVID-19 pandemic impacted what we do here at The Walton Centre. Like all hospitals across the country, we had to adapt. We provided mutual aid support for the acute hospitals around us in Liverpool, so patients could get the most appropriate, specialist care at the right time in the safest way possible while the region’s general hospitals dealt with hundreds of COVID-19 cases.
Our staff – clinical and non-clinical – did everything they could to support patients and each other during this extraordinary time. This continues, with some our practices changed, and in many cases enhanced, by the experiences of COVID-19.
I’m proud of how staff worked in the very challenging situation and found innovative ways to continue to provide the very best clinical services. Those innovations included quickly bringing in video consultations, something we are continuing where appropriate, and also our development of the Rapid Access Neurology Assessment (RANA) programme.
The aim of RANA is to ensure that a patient presenting with an acute neurological problem is assessed as quickly as possible by a specialist and appropriately investigated.
This is a service open to all of our local Emergency Departments who previously may have admitted such patients for assessment. We would therefore anticipate not only a better patient experience but a reduction in local hospital admissions and investigations, and so is a more efficient use of healthcare resources. So far, 273 patients have been referred through the RANA pathway since it was implemented last year.
The pandemic also made us in the executive team reflect on the future of The Walton Centre, and the importance of providing the care patients need in the right way, and at the right time. Our new three-year strategy outlines key ambitions and drivers, such as education, leadership, research, innovation, collaboration and social responsibility, which will ensure the high level of care we provide will continue to grow and evolve.
Already this new direction has inspired staff to pursue new ways of treating patients with neurological conditions. At the end of 2021 we won a bid to provide MRI guided ultrasound thalamotomy to patients with Essential Tremor in the North of England. Essential tremor causes uncontrollable shaking and is usually treated with medication, or in severe cases Deep Brain Stimulation (DBS).
We treated our first patient in March this year and the results were incredible. It also drastically reduces the amount of time patients need to spend in hospital when compared to other more invasive solutions, such DBS. This new treatment, which targets focused ultrasound onto the areas of the brain causing the tremors, is minimally invasive and completed in a few hours.
We are one of only two centres in the UK to offer this groundbreaking treatment, and I’m excited to see how this will benefit patients with this and other conditions.
In spinal surgery, we have introduced endoscopic techniques that will mean more precision, quicker recovery and therefore shorter stays in hospital.
The technology in this area is very exciting, and shortly we will be one of the first centres in the UK to offer the advanced techniques and improved precision available with robotic spinal surgery.
It’s a testament to staff here at The Walton Centre and their dedication to pursuing these new, innovative ways of delivering outstanding care for our patients.
Finally, when I think of the future of neuroscience and the direction we are taking I can’t help but be enthusiastic about what we’re doing here at The
Walton Centre. Our staff are constantly encouraged to look at the services they provide, and seek to innovate and improve further our already outstanding patient care.
Delivering culturally safe support to South Asian clients
After marking South Asian Heritage Month, Shabnam Berry-Khan, director and clinical psychologist at Psychworks Associates, shares why the traumatic experiences of people coming to the UK in previous generations continue to impact today - and why, for that reason, a wholly bespoke approach to trauma within this community is needed from medico-legal professionals
Recently, we have marked South Asian Heritage Month (SAHM), from July 18 to August 17. It is significant as an opportunity to celebrate the South Asian contributions to the UK - currently there are around two million South Asian people living here - and to recognise stories from these times, both positive and difficult.
This year, additionally, SAHM commemorates two key milestones - the 75th anniversary of the partition of India into India, Pakistan and Bangladesh, and the 50th anniversary of the Ugandan expulsion of South Asians by Idi Amin.
SAHM has been marked by us at Psychworks Associates and is a topic that is dear to my heart - not just because I’m a brown person whose parents were both refugees in the respective India and East Africa crises.
But also because, as a psychologist, these experiences will be alive and active in brown clients that we all see. Regardless of whether it is their direct experience, and regardless of their awareness of it.
South Asian people make up the biggest minority group in the UK - but what is commonly known about their experience? And how does and should that experience impact the work we do with them?
For many of our South Asian population in coming to the UK, there is often trauma associated with that - this can stem from within their family and heritage and can impact for generations to come. You can learn more about the reasons for this in our Q&A below. An interesting paper that came out this year by Prajapati and Leibling (https://link.springer.com/article/10.1007/s40615-021-00993-x) highlighted how South Asians feel
about engaging with professional mental health services.
Notably, these stood out for me:
> How seeking help triggers powerlessness and threat, and how behaviour changes when anxieties are heightened.
> The importance of collaborative care: Service users described experiences of feeling disempowered and dehumanised when accessing services.
> The importance of the input including
family and friends: service users often valued the presence of family members for reassurance and support and felt services did not always value family input, seeing it as a hinderance.
> Language is important to feeling like a service hears them in a way they want to be heard, because sentiments can be lost in translation.
> The importance of trust in the professional relationship which can be enhanced when professionals look like them or can demonstrate at all times a sensitivity to the impact of cultural experiences on daily living.
If you look beyond the mental health context, many of the themes will apply to our work as personal injury professionals. As a trauma-informed psychological service, trauma and its impact is central to how we at Psychworks Associates approach our cases.
We know that traumatic experiences:
> present in so many different ways: anger, low mood, compliance and conformity, outbursts, disengagement, calling out bias, feeling unsafe with unfamiliar others.
> exist in the mind and body, so while we might understand the psychological effects, we also need to remember that the body also feels the effects (presenting as increased pain, worsened chronic conditions, somatisation etc).
> are intergenerational and are transmitted down the lineage, so a grandparents’ direct experience in 1947 will be experienced in some way in 2022 by the grandchild (who may be our client or grandchild)
> trigger other possibly unrelated traumas such as being bullied, ACEs, DV etc. and so what we see is an accumulation of traumatic experiences.
This is very applicable to the experiences of many South Asian people, and is something we should bear in mind not just during SAHM, but beyond that, and into the experiences of other people from other diverse backgrounds.
At Psychworks Associates, we are passionate advocates of the need to implement equality, diversity, inclusion and belonging within our daily lives. We believe developing an inclusive and equitable service must be at the heart of any organisation.
Collectively, working within the medico-legal sector, we have a long way to go in effectively challenging long-held practices and approaches - but we are proud to help lead the efforts in providing diverse, inclusive, equal care to increase a sense of belonging and cultural safety.
As a takeaway from SAHM particularly, we see that without engaging with these changes, South Asian people will be labelled unfairly as hard to engage and easy to ignore.
Here are some questions and facts about the South Asian communities that you may know personally or professionally, and a little about the stories they have lived and heard.
“From empires such as the Mughal, the Duranni, the Vijayanagar and the British, from indentured labourers forced to travel to the Caribbean and East Asia, and other migrants who travelled by choice to Africa and beyond, to the journeys that families made to the UK with just £3 in their pockets, we have all been affected by the journeys of empire.” - SAHM website
Did you know that up to 20 million people migrated to/ from India in 1947?
A huge number, making it the largest forced migration and refugee crisis in living history. Once the British left the colonies, communities were realigned according to religious beliefs and up to 2 million people were thought to have lost their lives while being displaced.
My dad was a refugee moving from India to Pakistan as an eight-year-old. He found the most upsetting part was having multi-religious communities and neighbours suddenly turn into enemies overnight.
It was frightening: many people feared for their lives and others did not make it. Rebuilding their life was not easy either, but what choice did he and others have?
27,000 of these displaced Indians went to
East Africa to start afresh. However, when ‘Africanisation‘ policies started in 60s, following independence from Britain, the same brown people who had came to seek refuge 20 years earlier, became again a persecuted group.
Many came to the UK. My mum was a survivor
of the East African expulsions. She was one of the lucky ones whose family voluntarily left only a couple of years before many were forced out. The sadness of leaving her home with whatever they could carry in such an uncertain times was masked by the relief of arriving her family in tack.
For those who stayed behind in a newly carved up Indian subcontinent, they had to start from scratch - despite being from the same original land. It became a hidden refugee experience which isn’t always recognised because migration outside of original India was not made.
What was it like arriving in the UK back then in the 60s?
For the vast majority - possibly including for
our clients or their parents/grandparents - the hardship and struggle continued.
The Brits were unwelcoming and unhelpful towards those arriving as refugees who had left their lives behind. Housing was difficult to get, employers were reluctant to offer roles to brown people who were suitably qualified and spoke English. And racism and prejudice was explicit resulting in the next generations - including me - being told directly or indirectly “to keep my head down...not to do anything to draw negative attention...don’t think people here like you”.
What does this mean for brown people in the UK today and for those of us with brown clients?
The plight of brown people in recent history as a ruled people for 200 years, who then turned into refugees, and who then faced and can still face significant explicit and implicit racism while trying to survive
is important to acknowledge and recognise.
The immediate reaction might be the overwhelming sense of loss and grief, the stress and fear of starting over, the disbelief that this has happened to you and helplessness that might ensue, let alone an overwhelming sense of injustice and anger that people can be allowed to treat others so disrespectfully. The impact on brown peoples mental health is immense.
Trauma and anxiety affects relationships, parenting, the ability to engage - pretty much someone’s entire life. This can also be heightened by the disengagement many feel through the apparent ‘need’ to confirm to Eurocentric practices.
And we also know how trauma can present and affect social interaction: wanting to stick to our own, limited trust, protective parenting, fighting for fairness/justice, sensitivity to injustice or disregard of cultural comforts. But, we now also know that traumas of the past - whether directly experienced or carried through the generations - are carried in the body as well as the mind. There is no surprise, therefore, that brown people have health issues that are linked to trauma: high blood pressure, heart disease, diabetes, amongst the classic chronic conditions.
Understanding the historic journeys of brown people in the context of a biased society is fundamental to offering a culturally sensitive service that is marked with safety, inclusivity and allowing brown people to live their authentic life without bias - because we need to work hard for them, not the other way round.
If this topic interests you, have a listen to our Psychology of Case Management podcast episode on racism on the 3rd page of our podcast listings:
www.psychworks.org.uk/podcast/?270-page=3
The importance of Independent
Living Trials in the
rehabilitation process
Natalie Mackenzie, director of BIS Services, explores the role of Independent Living Trials in a client’s journey, what success might look like, and what challenges potentially await for client and MDT alike
Independent Living Trials (ILT) referrals always elicit excitement in the BIS office, favoured by the team who revel in the setting up of a new chapter of a clients rehabilitation and recovery.
Perhaps it’s the prospect of the data collection, the buzz around finding a new home for a client, but mainly, it’s the opportunity for further growth for the client in question; the next phase in their journey.
They are not without their challenges of course, and over the years the definition of success has become more varied and complex. So why do clients engage in them, and what do they actually look like.
ILTs come in all shapes and sizes, like everything in neuro rehabilitation, they must be client specific and meet the needs of their wider community.
The rationale
ILTs often signify a shift in rehabilitation, with the focus moving from being supported to being support facilitating further improved function, moving away from the family unit or another rehab setting.
It’s a big step. Families can often be reluctant, safe in the knowledge that their loved ones are always with them and secure, and fearful of what lies outside of this. Will their loved one be safe, will they be lonely, will they be unhappy?
Conversely, it is the need to preserve the family unit that ILTs are progressed. This is often the case when the client has moved back into the family home post injury, having previously left the nest. Dynamics change, roles change, the environment can be more challenging. ILTs can restore the previous status quo, allowing a bridge back to pre injury life. This is something that has to be handled sensitively and the key here is a cracking MDT with an experienced Neuropsychologist to aid in the navigation, and of course the right timing.
The planning
It is music to our ears when we are in an MDT and the team begin discussing the potential for an ILT in four to six months; time to source property, time to gather baselines, and time to prepare the team.
Whilst still music, the calls which begin with “there’s been a change in circumstances, we need an ILT in 4 weeks” isn’t always as in tune! Teams need to be assembled (Marvel style sometimes), MDT schedules need to be accounted for, with each key therapist in place prior to the placement and vocational or educational schedules need to be factored in.
Another part of the planning is the gradual introduction into full time trial, so often they can fall apart if the team have not factored in this important element, both to allow the client adjustment time to their new schedule and environment, but also to ease the concerns of the family. This graduated approach needs to be longer than might initially be anticipated.
Of course, from a costing perspective the team need to be retained during this period of flexibility. Ideally, current RAs will move into the ILT. Ideally, but it isn’t always possible. Other conflicting client schedules, study commitments and so on may hamper that nice shift. We also often have to consider that some of the current RAs skills and task focus with the client may not be the right fit for an ILT.
A large team of skilled rehab assistants is needed, for the obvious reasons of scheduling and cover, holidays and sickness, but also for peer support and to avoid burnout. ILTs are tough. The team are observing everything, all the time.
Training for an ILT is slightly different, with a focus on graded exposure, tapering, observation, feedback to aid insight and metacognitive skills, motivating, prompting, sleep hygiene, mood, fluctuations, client sickness, impact of friends and family. And more. Multi agency working brings even more challenges, to ensure everyone is providing a consistent, holistic and empowering approach. It doesn’t always work out that way, so communication is key, constantly.
ILTs may also start out as a six-month plan, end early or extend much longer. Success can be dependent on the retention of staff and/or their ability to extend past the planned timeframe, which can be a task with high calibre staff.
The challenges
One may assume that the clients want to progress to more independence, a step closer to achieving their goals, a step closer to more autonomy and a step further away from acute settings. But it’s not always this simple. The post-injury effects on mood, anxiety, motivation and so on often ramp themselves up at this juncture. We expect it, we plan for it. But the clients often don’t know it’s coming. This anxiety, this step into the new, potentially unknown can often hit them sideways. Not often exhibited through straightforward “No” or “I don’t really want to”, the team is met with subtle resistance.
The worktops aren’t the right colour, the garden isn’t South facing, the bus stop is too far. If you have tried to source a rental property in the past two years, you will know all too well what a rarity the perfect place is. Hard to explain that to our clients.
The search can go on for what seems an eternity, and that’s even before we get to the part of explaining the up front payments to the landlord or their agent. The furrowed brows that the boxes aren’t being ticked as expected for annual earnings or guarantors. Some simply just say no, too complicated. And you can bet your bottom dollar that no is on the house with the correct garden, worktop and a bus stop 2 minutes away.
Recently, a large consideration has been the use of substances and alcohol when embarking on an ILT. Behavioural management plans, empowerment-based approaches are key here, but clients often fear what happens away from the less rigid ‘rules’ of home life. It can be a Hoover damsized barrier, and once again, a large amount of client specific flexibility is called for, just to get them through the door.
Then of course, what happens a few weeks down the line when autonomy increases, and plans begin to be pushed back against? More adjustment, more flexibility, whilst still maintaining focus on the job at hand- increased independence.
It is not straight road, that is for sure. I often allude to these trials as being akin to the Milton Keynes roundabout fest, lots of twists and turns, a number of missed exits but a general move in the right direction. The impact of substances on the success of an ILT is a big topic, and one we will revisit again.
Periods of challenge can simply happen during the summer months, when therapists are on leave, educational or support placements are on breaks, which brings a change in routine that needs to take place, but with not enough time to gradually change, and even less to taper off. You can bet that bottom dollar (if you still have it from the first bet), that most problems will rise their head. Changes to routine and structure have a big impact.
Let’s not also forget to address the potential feeling of freedom that the client can misinterpret and perceive as a period of “recreation”, shall we say. Also exhibited in sudden party invites, a sudden influx of “visitors” and potentially a slightly increased alcohol consumption, akin to the turning 18 behaviour some of us may recall.
The loss of an RA for one reason or another adds further challenges. This can be due to them moving onto another role, sometimes because the amount of time spent between client and RA is too much and both need a break.
Sometimes, because the relationship has broken down irreparably, often due to a difference or opinion, it can be as simple as that. I think we can all agree that the rigidity of some clients can be a hard mountain to overcome.
The client (and sometimes the team) underestimates the intensity of these placements, and if not adequately prepared for can prove the straw that breaks the camels back.We must all expect it and have contingencies, but this takes time, starting from scratch sometimes without impacting the ILT and the needs of the clients. From a costings perspective such inevitable changes must be budgeted for.
How do we define success?
Generally speaking an ILT is embarked upon not with the overall goal of the client living fully independently, but to determine if they actually can. Their determination of if they want to do it is also a key factor.
Success may not mean a client lives independently. Sometimes success is actually quite the opposite.
Having left the less rigid but more subtly scaffolded home or rehab environment, clients may find great success in increasing their insight about what support they actually do need, what prompts they require. Their metacognitive skill improvement is often the most sought-after outcome, whether this is coupled with a reduction in support or even an increase.
Success is also measured by the level of collaboration and communication within an important inter disciplinary team, who embark from the outset on a client centred, empowered approach, who are experienced in positive risk taking, reflective practices and overall expectant of the challenges that a complex period of rehabilitation such as an ILT brings.
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