SMN Annual Report€¦ · In 2016/17 the Scottish Muscle Network has: Built capacity and capability in Scottish neuromuscular services by delivering a comprehensive programme of professional

Scottish Muscle Network

ANNUAL REPORT 2016/17

Lead Clinician: Marina Di Marco

Network Coordinator: Laura Craig

Programme Manager: Carsten Mandt

SMN Annual Report 2016/17

Contents

Executive summary ...................................................................................................................................... 2

Introduction ................................................................................................................................................... 4

Aim/ Purpose/ Mission Statement of network ................................................................................................ 4

Report against Workplan .............................................................................................................................. 5

Plans for the year ahead ............................................................................................................................. 11

Network governance ................................................................................................................................... 12

Detailed Description of Progress over Reporting Period ............................................................................. 13

Proposed Work Plan for 2017/18 ................................................................................................................ 18

Appendix 1: Network membership .............................................................................................................. 21

Appendix 2: Finance ................................................................................................................................... 22


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Executive summary

This report gives an overview of the key achievements of the Scottish Muscle Network, a nationally designated managed clinical network, in the financial year 2016/17. It also sets out the main work priorities for the network for 2017/18.

In 2016/17 the Scottish Muscle Network has:

Built capacity and capability in Scottish neuromuscular services by delivering a comprehensive programme of professional education in neuromuscular disorders, including an annual conference, a study day for allied health professionals and two Muscle Interest Group meetings;

Expanded the recording of neuromuscular patients on the Clinical Audit System to include additional neuromuscular conditions with a view to enabling the network to better utilise data to inform its work and evidence the impact on services and patient outcomes;

Updated guidance on the management of adults with myotonic dystrophy to reflect current best practice;

Revised care standards for myotonic dystrophy in support of ongoing audit of the quality of clinical care for this patient group;

Produced additional patient information resources on the network website to support effective self management;

Supported the development of increased capacity in Scotland for neuromuscular research, by developing expertise and infrastructure for research and by creating effective links with neuromuscular research centres elsewhere in the UK, most notably Newcastle and London;

Fostered a common approach in Scotland to new drug treatments such as Translarna in Duchenne Muscular Dystrophy to ensure equity of access between services. Funding to support patient access to Translarna has subsequently been announced by the Scottish Government.

In 2016/17 the network was also recognised as one of the very first “networks of excellence” by Muscular Dystrophy UK, following the charity’s UK wide audit of neuromuscular services and networks.

The main work priorities for 2017/18 will be focussed on:

Strategic planning for the future direction of the network, linked with the scheduled review of the network reporting to the National Specialist Services Committee (NSSC) in 2018

Patient/carer engagement, including: a myotonic dystrophy family event, a bone symposium in collaboration with MD UK and a joint patient/carer event in collaboration with SMA Support UK

Professional education programme, including: Annual Network Conference, Muscle Interest Group meetings, Myotonic Dystrophy study day for anaesthetists and an International Bone Symposium with Endocrinology


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Audit against the myotonic dystrophy standards in Scotland

Audit the level of neuromuscular inpatient admissions, readmissions and length of stay to investigate concerns that patient discharges may be delayed due to a lack of community support available to them post discharge

Work with the North of Scotland Planning Group to quantify the demand for care advisor support in the north of Scotland

.


4

Introduction

The Scottish Muscle Network (SMN) was first established in 1999 and originally funded by the Muscular Dystrophy Campaign now known as Muscular Dystrophy UK. In 2004 it was designated as a national managed clinical network (NMCN), commissioned by NHS National Services Scotland on behalf of NHS Boards and Scottish Government Health and Social Care directorates (SGHSCD) Since its inception the network has been effective at progressing evidence based, patient centred care for children and adults with neuromuscular conditions, through the development and implementation of clinical guidelines, patient pathways, clinical standards and information resources. It is estimated that there are more than 6,000 children and adults in Scotland affected by inherited and acquired neuromuscular disorders. Examples include muscular dystrophies, myopathies, mitochondrial diseases, peripheral neuropathies and disorders of the neuromuscular junction such as myasthenia gravis. Although much progress has been made in the diagnosis and management of these diseases, neuromuscular conditions are largely progressive, debilitating and can frequently be life shortening. Patients commonly require complex and long term management. Services for those affected by neuromuscular conditions are delivered across Scotland through a collaborative networked approach. Care is routinely delivered as locally as possible but travel may be necessary for diagnosis and to access specialist expertise or specialist facilities.

Aim/ Purpose/ Mission Statement of network

The network’s aims are:

To raise awareness of neuromuscular disorders

To promote the delivery of an equitable, high quality service to all patients in Scotland with neuromuscular disorders regardless of where they live


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Report against Workplan

A detailed report on progress with the agreed network workplan for 2016/17 is available on page 10 of this report.

The main work priorities for 2016/17 include:

a. Build Capacity and Capability in Neuromuscular Services through Education for Healthcare Professionals

An annual multidisciplinary educational conference was held on 2nd September 2016 in Dundee. 73 delegates attended the event, 53 of whom completed the event evaluation. Participants rated the education provided as being of high quality, relevant to their work and effective for their continued professional development.

Figure 1: SMN Annual Conference Evaluation

Following the success of previous events, the network held “Muscle Interest Group” meetings on 20th May 2016 (Aberdeen) and 17th November 2016 (Edinburgh). The aim is to provide a forum for discussion of challenging neuromuscular cases, professional peer support, and dissemination of medical knowledge. The two meetings were attended by 21 and 25 delegates, respectively. Figure 2 below summarises the evaluation responses received by delegates of both Muscle Interest Group meetings in relation to the perceived relevance, quality and effectiveness of the meeting, as well as the importance delegates attach to the meeting for supporting their clinical practice.


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Figure 2: Muscle Interest Group Delegate Evaluation Feedback

An Allied Health Professionals (AHP) education day was held on 25th April 2016 in Glasgow. Whilst this study day is open to all healthcare professionals, the focus is to bring together allied health professionals who have patients with a neuromuscular disorder in their caseload. This meeting takes account of case studies, sharing practice, new research and opportunities to develop treatment and management strategies for the neuromuscular population. The event was attended by 57 delegates with 4 rural and remote Health Boards linked in via video conferencing. Delegates have rated the event very positively as providing relevant, practical education to support good clinical practice (please see graph below) for more detail on evaluation responses). The availability of videoconferencing (VC) was welcomed although some technical challenges were noted that impacted on some aspects of the meeting for VC participants (e.g. video clips not playing over the VC link).

Figure 3: AHP Day Evaluation Feedback


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The network has also revised the way it gathers feedback from delegates at its education events. Historically, this was limited to event evaluation forms completed on the day. As a result it has been difficult to gauge any sustained impact network education events have on clinical practice. To address this the network is now also surveying delegates six months after attending an event to ask them about changes they have implemented in their practice since attending the network event. Results from this additional layer of evaluation will be available in early 2017/18.

b. Support Self Management through Patient Education and Information

Self management is an essential part of the ongoing management of neuromuscular conditions. To enable patients to self manage effectively, the Network has been developing a range of patient information leaflets, as well as videos demonstrating physiotherapy exercises. In 2016/17 these resources have been expanded and two additional videos were produced. These resources are all available via the network website: www.smn.scot.nhs.uk. c. Build Capacity for Utilising Data to Inform Service Delivery and Planning

Throughout 2016/17 the network has continued to develop the neuromuscular patient register using the Clinical Audit System (CAS). This now includes demographic and diagnostic data for the following patient cohorts: Duchenne Muscular Dystrophy (DMD), Becker Muscular Dystrophy, Charcot-Marie Tooth, Spinal Muscular Atrophy, and Fascio-scapulo-humeral Dystrophy.

The network developed a specification for changes to the CAS to allow clinical assessment outcomes to be recorded for patients with DMD. The change request is currently being considered by CAS System Developers for inclusion in a 2017/18 schedule of developments.

The system has a total of 445 live patients registered as of 31 March 2017. The map below

shows the number of neuromuscular patients on the register by Health Board of residence. Please note that in order to maintain patient confidentiality, this map cannot show patient numbers for areas with very small neuromuscular patient populations. This affects NHS Borders, Dumfries & Galloway, Orkney, Shetland and Western Isles, which collectively have eleven individuals recorded on the system.

http://www.smn.scot.nhs.uk/


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Neuromuscular Patient Register Mapped By Health Board of Residence Figure 4 below illustrates how the patient population on the register is spread across the various neuromuscular conditions recorded on the database. It is important to note, however, that patients are recorded on the CAS as part of an ongoing process to build up capacity within the network for collecting and utilising data to inform the network’s programme of work. To date, progress has been steady but incremental and as a result, there is as yet not a comprehensive register of the Scottish neuromuscular population. Figure 3 therefore is not a complete representation of the neuromuscular population in Scotland and recording for some conditions, such as DMD, is more complete than others where recording on the CAS began more recently, e.g. myotonic dystrophy. It is also important to note that not all people with neuromuscular conditions in Scotland are known to specialist services, in particular in the adult population, which in turn impacts on the completeness of the neuromuscular patient register.


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Figure 4: Neuromuscular Register by Condition

The Myotonic Dystrophy Subgroup of the network updated its service standards with a view to carrying out a further audit cycle in 2017/18. In the reporting year 2016/17, the group started to audit liver function test (LFT) results for patients with DM1. Results from this audit are expected to be available later in 2017 and will be used to develop and share best practice across the network.

d. Support Service Planning and Development

Network members worked collaboratively to ensure a consistent approach was followed when considering patient access to new and unlicensed treatments, such as Translarna for use in boys with DMD who are still sufficiently mobile. This has subsequently been superseded by the Scottish Government’s decision to fund universal access to Translarna in this patient group. The network is continuing to monitor patient outcomes for this treatment to contribute towards building up the evidence base underpinning its effective use.

Original plans for 2016/17 had included a review of the network’s strategic vision for neuromuscular care in Scotland to ensure that its work priorities continue to focus on those aspects of neuromuscular care that add value to the experiences of patients, their carers and families as well as to healthcare professionals and NHS organisations. This was postponed until June 2017 and will be undertaken as part of the national commissioning review process.

For some conditions such as DMD the typical disease progression is well understood. Figure 5 shows the number of children with DMD by Health Board of residence who will be aged between 10 and 17 over the next five years. This information can be used by services to anticipated demand for specific interventions and additional support associated with key milestones in the patient pathway, e.g. referral to adult cardiology and referral to community physical disability teams from age 15 onwards, as part of the SMN transition pathway. Given


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that SMN data for DMD patients is deemed robust, it is useful to NHS Boards to plan services to meet local demand and will be used to inform the strategic planning work to be undertaken by the network as part of its review.

Figure 5: Children with DMD by Health Board due to reach age 10 to 17 years in 2017 – 2022.

e. Facilitate Best Practice through Guideline and Pathway Development

The Myotonic Dystrophy Subgroup of the network updated its existing guidelines on the management of Myotonic Dystrophy (DM1) in adults and on the anaesthetic management of DM1. In addition, the group developed guidance on the use of Modafinil in DM1 patients with sleep problems, aimed at ensuring consistency in the prescribing of Modafinil across Scotland.

The network published its updated transition care pathway, which is available from the SMN website: www.smn.scot.nhs.uk.

f. Patient / Carer Engagement

Muscular Dystrophy UK (MD UK) have recognised the SMN as a “network of excellence”, following the charity’s first national audit of neuromuscular networks. More detail about the “network of excellence” award is available on the MD UK website: http://www.musculardystrophyuk.org/news/news/first-ever-neuromuscular-networks-of-excellence-announced/.

Patient clinic experience questionnaires were developed by the network and piloted in NHS Greater Glasgow and Clyde to assess patient satisfaction with the services provided to them.

http://www.smn.scot.nhs.uk/

http://www.musculardystrophyuk.org/news/news/first-ever-neuromuscular-networks-of-excellence-announced/

http://www.musculardystrophyuk.org/news/news/first-ever-neuromuscular-networks-of-excellence-announced/


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The initial pilot evaluated well and the network had planned to roll out the questionnaires to all clinics in Scotland in 2016/17. The questionnaires in the pilot were administered by the network co-ordinator and replicating this approach across the wider network proved too resource intensive to be viable. The Scottish Paediatric Epilepsy Network adapted the same questionnaire to be completed by patients/families themselves and subsequently administered it successfully in epilepsy clinics across the country. The Scottish Muscle Network now plans to roll out its revised questionnaire using a similar methodology in 2017/18.

Following a successful patient and carer event in collaboration with Muscular Dystrophy UK, held in January 2016, the network liaised with other third sector partners to hold further patient and carer events. A joint event with SMA Support UK for people affected by Spinal Muscular Atrophy is scheduled for September 2017. A DMD family event for children with DMD and their families, in conjunction with MD UK and the Developmental Endo Research Group Glasgow, is being arranged for 17 June 2017.

g. Support the Development of Scottish Research Capacity

The network has built up relationships with UK centres of neuromuscular research, namely Newcastle and London, and has been supporting services in Scotland to build up their capacity for neuromuscular research. A number of relevant studies are now being carried out in Scotland including, for example, the DM1-Neuro study of brain changes, cognitive deficits and sleep disorders in myotonic dystrophy and a range of studies in DMD, such as the ScOT-DMD study into bone health in DMD. Glasgow is now integrated into a UK-wide network of research centres for interventional studies in DMD, facilitating the sharing of best practice and access to UK wide trials for Scottish patients.

Plans for the year ahead

The network’s key priorities for 2017/18 are:

Strategic planning for the future direction of the network, to be undertaken as part of the national commissioning review

Patient/carer engagement, including: a myotonic dystrophy family event, a DMD family event in conjunction with MD UK, and a joint patient/carer event in collaboration with SMA Support UK

Delivering a professional education programme, including: Annual Network Conference, Muscle Interest Group meetings, International Bone Symposium and Myotonic Dystrophy study day for anaesthetists

Audit against the myotonic dystrophy service standards

Auditing the level of neuromuscular inpatient admissions, readmissions and length of stay

Quantify the unmet need for care advisor support in the north of Scotland


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The main issue for 2017/18 is that the current Lead Clinician will reach the end of her term of appointment in November 2017 following a one year extension last year. To date no intimations of interest have been received from network members to take on this role.

Network governance

The Network operates as a Managed Clinical Network (MCN) in accordance with the Scottish Government’s core principles of an MCN. The Network is overseen by a multidisciplinary, multiagency Steering Group.

The Network Lead Clinician is Marina Di Marco, Principal Neuromuscular Physiotherapist, NHS Greater Glasgow & Clyde. The network is supported by Laura Craig, Network Coordinator and Carsten Mandt, Programme Manager.

In the reporting period the Network had the following subgroups:

Adult Subgroup

Paediatric Subgroup

Myotonic Dystrophy subgroup

Educational and Editorial Group

Neuromuscular Physiotherapy Group

All the above groups have an agreed remit and terms of reference.

An information governance framework has been agreed and implemented for the network.

See CEL (2012) 29 for the most recent statement of these principles:

www.sehd.scot.nhs.uk/mels/CEL2012_29.pdf

http://www.sehd.scot.nhs.uk/mels/CEL2012_29.pdf


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Detailed Description of Progress over Reporting Period Objective Number

Smart Objective Linked Dimensions of Quality

Planned start/ end dates

Detailed Plan Available / Owner

Description of progress towards meeting objective

Anticipated outcomes RAGB status

2015-07 Agree shared approach to new, emerging and currently available medications

1 March 2017 Steering Group

Following Scot Gov decision to fund Translarna, access to Translarna now available for all eligible patients. Prior to funding decision, shared best practice within network to facilitate consistent approach taken by all clinicians.

Myotonic Dystrophy Subgroup developed Modafinil guidelines to ensure consistent use of Modafinil for sleep issues in DM1.

Consistent and appropriate advice given to patients

B

2015-11 Audit care against standards for the paediatric management of Duchenne Muscular Dystrophy

3,5 January 2017 Paediatric sub group

Standards never finalised so no basis for audit. New guidance now being developed based on the International Care Standards. Agreed to remove audit from work programme until new guidance has been ratified and implemented.

Improved care against agreed paediatric DMD standards

R


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Objective Number






2015-17 Develop CAS: record clinical outcomes for DMD patients on new drug treatments

2, 3, 4, 5 January 2017 Laura Craig

Change request proposals in the final stages of agreement. Awaiting response / action from NISG.

Ability to audit care provided / effectiveness of new treatments

A

2015-19 To strategically work with UK counterparts towards improving Scotland’s research capacity in neuromuscular disorders

Built up additional capacity within Scotland to carry out research. Relationships established with other UK research centres for ongoing collaboration.

Increase research activity in Scotland with better access to trials for Scottish patients

B

2016-01 Ascertain patient / carer views on service delivery and re-design:

(a) Roll out patient/carer experience questionnaires across all clinics

(b) Deliver joint patient engagement event with third sector partners

(c) Action plan from patient interviews on Facio-scapulo-humeral Dystrophy (FSHD) care experience

1, 2, 3, 4, 5, 6

Jan 2017 Steering Group

(a) Following the pilot in

RHC Glasgow clinic,

roll out agreed to all

paediatric clinics in

Scotland. Similar work

undertaken by SPEN

has informed a change

in approach to deliver

the questionnaire more

efficiently and quickly

across the whole

country.

(b) Engaging with SMA

Support UK to identify

Clear understanding of patient/family priorities for service improvement/ development

A


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Objective Number






a collaborative

approach for a patient

event. Date for event to

be confirmed for later

in 2017.

(c) Action points to be

reviewed as part of the

strategic planning day

in June 2017

2016-02 Analyse audit results against the Myotonic Dystrophy standards and develop action plan to improve services for MD

2, 3, 4, 5, 6 March 2017 Myotonic Dystrophy Group

Audit results reviewed – overall very positive. Areas for improvement, esp. re target for annual review. Agreed to collect additional data about patient engagement / access to service to establish a more accurate picture. Additional audit data on liver function tests being collected also.

Improvements in care provided against agreed standards

G


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Objective Number






2016-03 Investigate number of patients who stopped engaging with specialist services during transition to adult services

1, 2, 3, 4, 5, 6

March 2017 Karen Naismith

Total number of patients identified, awaiting clinical review of patient list to ascertain disengagement from service. To be carried forward to 2017/18.

Better understanding of scale of patient disengagement A

2016-04 Facilitate healthcare professional education on the latest information/ developments on neuromuscular disorders:

(a) Hold annual educational meeting for Scottish healthcare professionals

(b) Hold annual educational meeting for Allied Health professionals

(c) Hold two bi-annual Muscle Interest Group meetings to provide a forum for discussing challenging cases and peer support

(d) Evaluate impact of HCP education

4,5 March 2017 (a) Education and Training sub group

(b) Physio Group

(c) Maria Farrugia; Laura Craig

(d) Education and Training sub group

(a) Successful event held on 2nd September in University of Dundee.

(b) Successful event held on 25th April in Teaching & Learning Centre, QEUH, Glasgow

(c) Successful meetings held on 20th May at Aberdeen Royal Infirmary and on 17th November in Edinburgh.

(d) Follow up evaluation questionnaires issued to delegates 6 months after education event. Low number of responses. Analysis to be carried out following further post-event evaluation in early

Increased healthcare professional knowledge to either confirm existing good practice or leading to improvements in clinical practice.

B


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Objective Number






2017/18.

2016-05 Agree strategic outcome and quality improvement measures

December 2016

Steering Group

Postponed in anticipation of strategic planning part of upcoming SMN review

Long term strategic plan for achieving network aims and objectives

A

2016-06 Continue to develop patient information resources on SMN web site.

Develop a video on stretches

Develop a video on passive movement

Audit uptake of patient resources

1,3,4,5 December 2016

Marina Di Marco

Physio Sub Group

Videos on passive movement and stretches available on SMN website. Further videos planned for 2017/18. Reviewed Google analytics on website usage.

Improved patient support and self management

B


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Proposed Work Plan for 2017/18 Objective Number






2015-17 Develop CAS: record clinical outcomes for DMD patients on new drug treatments

2, 3, 4, 5 January 2017 Laura Craig

Change request proposals in the final stages of agreement. Awaiting response / action from NISG.

Ability to audit care provided / effectiveness of new treatments A

2016-01 (a)

Roll out patient/carer experience questionnaires across all paediatric clinics

1, 2, 3, 4, 5, 6

June 2017 Steering Group


A

2016-01 (b)

Deliver joint patient engagement event with SMA Support UK

1, 2, 3, 4, 5, 6

Dec 2017 Steering Group


A

2016-03 Investigate number of patients who stopped engaging with specialist services during transition to adult services

1, 2, 3, 4, 5, 6

March 2017 Karen Naismith

Total number of patients identified, awaiting clinical review of patient list to ascertain disengagement from service. To be carried forward to 2017/18.

Better understanding of scale of patient disengagement

A

2017-01 (a)

Healthcare professional education:

Hold annual educational

4,5 March 2017 Education and Training

Increased healthcare professional knowledge to either confirm existing good practice

G


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Objective Number






meeting for Scottish healthcare professionals

sub group

or leading to improvements in clinical practice.

2017-01 (b)


Hold two bi-annual Muscle Interest Group meetings to provide a forum for discussing challenging cases and for peer support

4,5 March 2018 Maria Farrugia; Laura Craig


G

2017-01 (c)


Hold neuromuscular study day for anaesthetists

4,5 November 2017

Cheryl Longman; Laura Craig


G

2017-02 Support the NSD review of the network / develop strategic plans for the development of the network in the future

1, 2, 3, 4, 5, 6

October 2017 Hugh Kennedy; Laura Craig

Ascertain network performance and refresh network strategic aims and objectives

G

2017-03 Develop further video content for the SMN web site.

1,3,4,5 December 2017

Marina Di Marco

Improved patient support and self management

G


20

Objective Number






2017-04 Quantify unmet need in North of Scotland for care advisor support

1,3,4,5 October 2017 Marina Di Marco; Hugh Kennedy; Ken Mitchell

Evidence need for service change / investment and identify potential solutions

G

2017-05 Audit inpatient admissions, length of stay and readmissions for the neuromuscular population

1,3,4,5 October 2017 Hugh Kennedy; Laura Craig; IMS

Evidence base for perceived challenges around prolonged length of stay and delayed discharge due to lack of appropriate support in the community / at home.

G

2017-06 Audit service provision against myotonic dystrophy standards

2, 3, 4, 5, 6 March 2018 Myotonic Dystrophy Group

Improvements in care provided against agreed standards

G

2017-07 Hold myotonic dystrophy patient/carer engagement event

1 November 2017

Cheryl Longman; Laura Craig

Increased engagement with patients and carers and better understanding of their priorities to address in future

G


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Appendix 1: Network Steering Group Membership

Name Designation Health Board Area

Dr Anthony Bateman Consultant in Respiratory Medicine NHS Lothian

Dr Alex Baxter Consultant Paediatrician NHS Lothian

Laura Craig Network Coordinator National Services Scotland

Dr Scott Davidson Consultant in Respiratory Medicine NHS Greater Glasgow & Clyde

Dr Phil Davies Consultant Paediatric Respiratory Physician

NHS Greater Glasgow & Clyde

Marina Di Marco Lead Clinician / Principal Neuromuscular Physiotherapist

NHS Greater Glasgow & Clyde

Jen Dunne Neuromuscular Clinical Nurse Specialist NHS Greater Glasgow & Clyde

Dr Maria Farrugia Consultant Neurologist NHS Greater Glasgow & Clyde

Dr Helen Gregory GP NHS Grampian

Dr Iain Horrocks Consultant Paediatric Neurologist NHS Greater Glasgow & Clyde

Dr Shuko Joseph Clinical Research Fellow NHS Greater Glasgow & Clyde

Dr Cheryl Longman Consultant Clinical Geneticist NHS Greater Glasgow & Clyde

Carsten Mandt Programme Manager National Services Scotland

Dr Catherine McWilliam Consultant Clinical Geneticist NHS Tayside

Dr Kenneth McWilliam Consultant Paediatric Neurologist NHS Lothian

Fiona Monaghan Orthotist NHS Borders

Dr Karen Naismith Consultant Paediatrician NHS Tayside

Denise Oxnard Genetic Counsellor NHS Greater Glasgow & Clyde

Gill Paton Neuromuscular Liaison Nurse NHS Lothian

Yvonne Robb Genetic Neuromuscular Nurse NHS Lothian

Karyn Robertson Senior Programme Manager National Services Scotland

Tracey Sharp Project Manager NHS Forth Valley

Lesley Snadden Genetic Counsellor NHS Greater Glasgow & Clyde

Wilma Stewart Neuromuscular Care Advisor NHS Greater Glasgow & Clyde

Robbie Warner Parent representative/Muscular Dystrophy UK rep

n/a


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Appendix 2: Finance

The annual budget for SMN expenditure (not including staffing costs) is £5,000. Spending against this budget for 2016/17 was £3,086.77, covering costs for network meetings and education events.

Documents

SMN Annual Report€¦ · In 2016/17 the Scottish Muscle Network has: Built capacity and capability in Scottish neuromuscular services by delivering a comprehensive programme of professional