Background Simulation-based medical education is central to procedural skills training, but commercial simulators remain financially inaccessible to many institutions in low- and middle-income countries (LMICs). The Centre for Innovation in Medical Education (CIME) at Aga Khan University, Pakistan, developed four low-cost, locally fabricated procedural simulation trainers to address this gap. Methods This technical innovation report describes the design, material selection, fabrication methodology, and cost analysis of a Fiberoptic Intubation Box, a Heel Prick Simulator, a Haemorrhoid Ligation Simulator, and a Caesarean-Section Laparotomy Model, developed using locally available or repurposed materials through faculty-guided iterative prototyping. Results Each device achieved greater than 95% cost reduction versus commercial equivalents, including a reduction from USD $12,000 to USD $4 for the laparotomy model, while retaining features supporting authentic procedural practice. Conclusions These devices demonstrate that LMICs can develop high-utility procedural simulators at a fraction of commercial cost, with open-access blueprints enabling global replication.
Emergency Departments (EDs) in England experience sustained crowding, affecting patient and staff experience, safety and system flow. This programme of work aimed to identify opportunities where patients attending London EDs could have been managed safely in alternative settings, and to explore what this reveals about system design, access and behaviour within the London Urgent and Emergency Care (UEC) system. A cross-sectional retrospective observational study reviewed over 2,000 patient attendances across 27 London Type 1 EDs between October 2021 and October 2023. Multidisciplinary panels assessed appropriateness and potential alternative pathways. Between 66% and 81% of patients were judged suitable for non-ED care, yet only 29% were redirected or streamed away. These findings largely reflected whole-system factors rather than the performance of individual organisations.
The evolution and maturity of quality assurance in healthcare remains largely unstudied and undocumented, in comparison to the literature about quality improvement. This article describes the development in thinking around quality assurance over the last four decades – from the first structured organisational framework that made boards accountable for quality, through the clinical governance system set up in the 1990’s. Clinical governance brought together a range of disparate components into a coherent structure, which we would largely view as quality assurance today. As practice and learning about quality management has evolved in the subsequent decades, there is an appreciation of the need to balance quality assurance with other elements of quality management – improvement, control and planning. The article presents a detailed case study from East London NHS Foundation Trust which describes how modern quality assurance has become much more patient-led, informed by improvement science, and meaningful, through reducing burden and involving clinicians in quality assurance activities.
As the NHS faces increasing pressure from an ageing population and rising multimorbidity, Internal Medicine Trainees (IMTs) are required to navigate uncertainty, frailty, and end-of-life decision-making. For many, a geriatric rotation provides the first sustained exposure to patients for whom cure is unrealistic and goals of care are complex.This opinion piece examines how geriatric training reshapes trainee attitudes towards investigation, escalation, and death. While IMT training often reinforces investigation-driven practice, geriatric medicine foregrounds frailty, predictable illness trajectories, and anticipatory decision-making. Exposure to Universal Care Planning, Treatment Escalation Plans, and senior-led conversations about uncertainty legitimises non-intervention as an active clinical decision. Strengthening education around frailty, uncertainty, and death during IMT training may reduce non-beneficial investigation, improve patient-centred care, and help alleviate avoidable pressures on an increasingly constrained NHS.
Background Duchenne Muscular Dystrophy (DMD) is a multimorbid recessive genetic disorder. In 2020, a novel one-stop multi-disciplinary (MDT) DMD clinic was piloted in Jack’s place Hospice (registered charity number 1002832), Winchester, UK. This service evaluation aimed to assess the level of National Neuroscience Advisory Group guideline adherence [NNAG, 2024], and the patient views of the clinic format. Methods Ten semi-structured interviews with patients attending the clinic were recorded, with nine subsequently transcribed and analysed using Braun & Clarke’s six-stage reflexive thematic approach. Results Participants perceived that all eleven relevant NNAG guidelines were being either fully or partially met by the DMD clinic. Participants preferred both the one-stop format of the clinic, and the hospice venue compared to hospital counterparts. This was due to superior facilities, reduced appointments and perceived better MDT communication. Conclusion The use of one-stop multi-speciality DMD clinics, utilising hospices as the forum, could improve guideline adherence, patient satisfaction, and engagement with palliative care.
