Tipping the balance: Chronic superior vena cava thrombosis resulting in an aberrant and inefficient venous circuit.

Given there was no direct flow into the right atrium from the SVC, we deemed this inefficient venous circuit responsible for her breathlessness, with a small reduction in cardiac function 'tipping the balance' and producing symptoms this late in life. The patient opted for conservative management with the risk of intervention outweighing her currently manageable symptoms.

Richmond Wellbeing Service Access Strategy for Older Adults.

IAPT (Improving Access to Psychological Therapies) is a national programme aimed at increasing availability of evidence based psychological therapies in the NHS. IAPT is primarily for people who have mild to moderate, common mental health difficulties such as depression, anxiety, phobias and post traumatic stress disorder (PTSD). The programme seeks to use the least intrusive method of care possible to treat people at the time when it will be of most help to them. Individuals are able to self-refer into most IAPT services or alternatively can request to be referred by their GP or other services in the community. Richmond Wellbeing Service (RWS) is one such IAPT Service and this research is based on our work to promote accessibility of the service to one of the harder to reach population groups - older adults. We know that IAPT services could have a positive impact on older adults as it is believed on average, 25% of over 65 year olds face common mental health problems. However, only a third of these people discuss this with their GP and so are less likely to be referred to an IAPT Service. In relation to the above, this project was designed to look at increasing access for older adults into Richmond Wellbeing Service (RWS) specifically to improve access to the RWS by older adults by 100. The overall goal was to increase older adult (65+) referral rates by 20% over a year, in raw number this would translate to an increase of 100 over a year period, and in percentage terms an average of 8% of total referrals. Results yielded an increase of 39 referrals between baseline and test period. The majority of this increase had occurred in the final five months of the projects duration(31). Interestingly the number of older adults in the older age band (85+) almost doubled within this period (from 12 to 21). In total, in percentage terms this translates to an an increase of OA referrals from 6% up to 6.7%, as above we are aiming for 8% or an additional increase of 61 patients. Thus during the duration of the project there were signals of an increase in the desired direction, as the number of OA referrals increased following the period of time the interventions were implemented. However referral rates did not fully reach the target set. The authors concluded that sustainable and meaningful change in improving access for older adults into an IAPT service is possible but does take time. (Alongside the increase of referral a continous assessment of quality is required and where neccessary improve upon the appropriateness of the service offered to Older adults).