Services A to Z

a) What s ocular surface squamous neoplasia?

Ocular surface squamous neoplasia is pre-cancerous or cancerous changes to the surface of the conjunctiva. Pre-cancerous changes can cause a condition called conjunctival intraepithelial neoplasia. This condition can turn into squamous cell carcinoma, which is a sinister tumour. This can spread onto the cornea causing decrease in vision. It usually affects one eye and is caused by sun damage.

b) What are the symptoms of ocular surface squamous neoplasia?

A fleshy pale lump is usually noticed on the surface of the eye next to the cornea. It may grow onto the cornea and, if large, can cause:

• Grittiness to the eye

• Watering

• Blurring of vision

Sometimes it can grow form the conjunctiva onto the eye lid.

c) What are the risks of getting ocular surface squamous neoplasia?

Risk factors for this condition include:

• Sun damage

• Fair skin

• Older age

• Conditions decreasing the immune system (e.g. HIV)

d) Will I need any tests?

In the clinic we may take pictures of the front of the eye. It is difficult to tell apart conjunctival intraepithelial neoplasia (pre-cancerous) from squamous cell carcinoma (cancerous). If the abnormal area is removed with surgery then it is sent to the laboratory to help confirm the diagnosis.

e) What is the treatment for ocular surface squamous neoplasia?

The main treatment is surgery (surgical excision). We may, however, use freezing treatment (cryotherapy) and Mitomycin C (MMC) eye drops as well. MMC can, however, irritate the eye. To treat this we may provide you with lubricant or steroid eye drops.

a) What is primary acquired melanosis?

Primary Acquired melanosis (PAM) is newly formed brown pigmentation of the conjunctiva. People with white skin are more likely to get this. It usually affects one eye only. There are two different types of PAM: ‘PAM without atypia’ and ‘PAM with atypia.’ PAM without atypia is benign with no risk of transformation into melanoma. PAM with atypia, however, can turn into melanoma. Around 3 out of 4  conjunctival melanomas come from PAM with atypia. If you have dark skin, brown pigmentation of the conjunctiva from birth is very common and usually affects both eyes. This is known as conjunctival epithelial melanosis and is not likely to progress to melanoma.

b) What are the symptoms of primary acquired melanosis?

Uneven, painless, newly formed brown pigmentation is usually noted on the white of the eye. If the pigment is growing quickly or changing colour then it is more likely to be a conjunctival melanoma.

c) Am I likely to get primary acquired melanosis?

If you are middle aged and fair-skinned you are more likely to get primary acquired melanosis.

d) Will I need any tests to exclude melanoma?

If it is felt to be PAM without atypia we may take pictures in the clinic to help us monitor change. Sometimes a biopsy of the pigmented area, however, is needed to exclude cancer. When doing so we try to remove all of the pigmented area. The following features make us more likely to biopsy:

• Larger than 5mm

• Increasing in size

• Has thickened the conjunctiva

• Has a distinct nodule arising within it (pigmented or non-pigmented raised area)

• Has feeder vessels (blood vessels running into the pigmented area)

• Involving the cornea

• Involving the conjunctiva under the eyelids

• Previous melanoma

e) Is treatment needed for primary acquired melanosis?

PAM without atypia can be monitored in the clinic. The main treatment for PAM with atypia is surgery (surgical excision) with or without freezing therapy (cryotherapy) and Mitomycin C (MMC).

a) What is conjunctival melanoma?

Melanomas are tumours which come from pigmented cells in our body. As well as growing on the skin, they can grow on the conjunctiva of the eye. Conjunctival melanoma accounts for 2% of eye cancers. It arises most commonly form primary acquired melanosis, or from a naevus (freckle) already present on the eye. Least commonly it arises on its own; this is known as primary conjunctival melanoma. This cancer can spread to other organs in the body, most commonly, the liver.

b) What does conjunctival melanoma look like?

Conjunctival melanoma looks like an uneven, raised, grey or pink lump growing on white conjunctiva or from a pigmented area on the conjunctiva. This may cause irritation and watering from the eye.

c) What are the risks of getting conjunctival melanoma?

The following increase your risk of developing conjunctival melanoma:

• Having pale skin

• Red or blond hair

• Blue eyes

• Over 50 years of age

• Large number of moles or freckles

• Poor immune system (e.g. HIV)

d) How likely is the conjunctival melanoma to spread around the body?

There are some features that increase the risk of the melanoma spreading. These include:

• Large tumours (large basal diameter, and tumour thickness of greater > 2mm)

• Nodular tumours (rounded and raised)

• Tumour involving the eyelids

• Tumour involving the corner of the eye near the nose (plica or caruncle)

If the tumour has grown on white conjunctiva instead of a pigmented conjunctiva, then the tumour may be more aggressive. Most common place is the liver. A liver ultrasound scan is arranged at your local hospital every year to exclude spread of disease.

e) Will I need any tests?

A biopsy may be required to confirm the diagnosis. If we decide to biopsy we usually remove the whole abnormal area. We may perform CT or MRI scan to make sure the melanoma has not spread to other parts of the body. If the tumour is greater than 2mm thick or growing in the corner of the eye we may need to consider doing a sentinel lymph node biopsy (SLNB). This is where a sample is taken from the glands that drain fluid away from the eye and analysed for tumour cells. These glands are found at the front of the ear and in the neck. This is the first place the tumour spreads to before metastasising around the body. This procedure is carried out in the Queen Elizabeth University Hospital in Glasgow with help from our maxilo-facial surgeon colleagues. If the SNLB detects cancer cells then the glands can be removed with surgery or treated with radiotherapy.

f) What is the treatment of conjunctival melanoma?

Surgery (surgical excision) is performed with or without:

• Cryotherapy

• Mitomycin C (MMC)

• Radiotherapy

• Chemotherapy

Sometimes the tumour is too big or has spread behind the eye. In these situations enucleation may be the best option. If there is involvement of the eyelids or of tissue behind the eye, we may have to consider exenteration. If there is spread of disease to the lymph nodes in the neck, we may have to remove these or treat with radiotherapy.

g) Can the conjunctival melanoma come back after treatment?

Unfortunately the answer to this is yes. Even if the tumour is completely removed there is always a chance of the tumour re-growing in the same place or in other parts of the body. For this reason, we monitor in the clinic after treatment.

a) What is lymphoma?

Lymphoma is a condition where the white cells that usually fight infection are “out of control”, keep dividing, and do not die. These abnormal cells can collect and grow in the lymph nodes. They can, however, grow elsewhere in the body including the conjunctiva. Conjunctival lymphomas are mostly of non-Hodgkin’s B-cell type. Follicular lymphoma is the next most common lymphoma. The lymphoma may just affect the conjunctiva or can affect other areas in the body as well.

b) What are the symptoms of conjunctival lymphoma?

Conjunctival lymphoma looks like a large “salmon pink” growth on the conjunctiva. This may cause grittiness, watering, or irritation to the eye.

c) Will I need any tests?

A biopsy is usually required to confirm the diagnosis. If we suspect the lymphoma is behind the eye or affecting else where in the body we may organise:

• Ultrasound scan

• CT scan

• MRI scan

d) What is the treatment for lymphoma?

After biopsy confirms the diagnosis of lymphoma, we may treat with:

• Radiotherapy

• Chemotherapy

Our choice of treatment is be guided by the haematologist or medical oncologist.

Healthier Wealthier Children is a collaboration between NHS Greater Glasgow and Clyde, Local Authorities, Glasgow Centre for Population Health and Voluntary Sector Money Advice Services.

Almost half of the children in Greater Glasgow and Clyde live in low income households, ranging from 25% in East Renfrewshire to 69% in East Glasgow [1]. Addressing child poverty is a key Scottish Government strategy for improving children’s health and well-being and is supported by the strategies, Equally Well, Achieving Our Potential and the Early Years Framework. Maximising families’ income is one element of addressing child poverty and a practical action that health and social care service providers can offer with the right support. A collaboration between NHS Greater Glasgow and Clyde (NHSGGC), Glasgow City Council (GCC) and Glasgow Centre for Population Health (GCPH) with additional support from other council partners has been successful in attracting funding from the Scottish Government Social Inclusion Division for a Child Poverty and Financial Inclusion Project.

The funding of £1,058,375 was secured for 15 months from January 2010 to provide income maximisers and development officers for all Community Health (and Care) Partnerships across NHSGGC. It builds on actions taken by NHSGGC to meet the objectives outlined in the Scottish Government Health Directorates Chief Executive Letter (CEL) 36 for improving nutrition for families living in disadvantage. CEL 36 implementation included work to improve uptake of the UK-wide Healthy Start programme and through this identified a gap in financial service provision for families attending antenatal and postnatal health services.

Building on the Healthy Start work, the Project supports the development of expertise within financial inclusion services and health structures for addressing child poverty by targeting income maximisation advice to pregnant women and families with infants and young children. The main aims of the Project are to:

•  Test out a partnership model of providing income maximisation advice at a local level; and
•  Develop a strategic approach to linking this service provision with health and other services in the longer term.

The Project is implemented through all HSCPs across Greater Glasgow and Clyde. Income maximisers in HSCPs and development officers will be employed across the whole of NHSGGC to establish referral and information pathways between health and financial inclusion service structures. The Project targets families with children under 5 attending health and early years services although some exceptions will be allowed. For example, particular attention is paid to picking up families who face additional barriers to maximising their incomes such as in the case of kinship carers, or where affordable childcare is unavailable.

NHSGGC has a Financial Inclusion Group, which reports to NHSGGC Corporate Management Team. The Healthier Wealthier Children Project Steering Group reports to the NHSGGC Financial Inclusion group[1] Low income households are defined here as being in receipt of any benefits, out of work or in work (2006 data, GCPH analysis, 2009)

What is financial inclusion?

Financial inclusion means that individuals have access to appropriate financial products and services. This includes people having the skills, knowledge and confidence to use these products and services

Financial Inclusion Guidance for staff

NHSGGC has developed Guidance for staff on money worries. This guidance includes working with patients and sources of support for staff who have money worries.

Summary Report: The Health Benefits of Financial Inclusion

Addressing financial exclusion is a priority for health service providers because it has the potential to reduce health inequalities and tackle the social determinants of ill-health. People living with long term ill-health or disability are more likely to be living in poverty, a key factor in poorer health outcomes. The NHS has contact with people as part of their rehabilitation and self care pathway and therefore an opportunity to support people’s wider social needs.

To develop an inequalities sensitive health service NHSGGC wishes to skill health practitioners to understand the social issues and structural inequalities facing their patients, support patients with these and have the capacity to refer them to appropriate services. Current evidence shows that the health inequality gap is widening and the current economic downturn is likely to worsen the situation for our most deprived communities and excluded groups; including women, black and minority ethnic people, disabled people, homeless people, refugees and asylum seekers. Financial exclusion is a growing concern in this context and so more needs to be known about the role of financial inclusion interventions in improving health.

About the Review

To date, NHSGGC has piloted a number of financial inclusion initiatives. A Financial Inclusion Group has been established to draw lessons from current practice and mainstream good practice in a sustainable way. It has developed an action plan, which it reviews regularly. To inform the work of the Financial Inclusion Group, the Scottish Poverty Information Unit (Glasgow Caledonian University) was commissioned to conduct a literature review. The broad aim of the review was to summarise the health benefits of financial inclusion identified in existing research and involved:

•  A review of evidence of the health and quality of life impacts of financial inclusion initiatives, with particular reference to collating evidence of NHS-based interventions & the health benefits of these
•  Exploring models of practice and learning to improve practice and identify evidence of the tools and barriers that exist
•  Reviewing research methods used in existing studies
•  Development of recommendations about future policy, practice and research

The research team undertook a Rapid Evidence Assessment (REA). REAs provide a balanced assessment of what is already known about a policy or practice issue. The method is appropriate for this review because the policy area is relatively new and there are few existing studies. It focused on English language sources and data, and on reports published in the last 10 years, with an emphasis on UK studies.

Key Findings

This review identified 16 key studies or journal articles which have reported health and social outcomes of financial inclusion interventions. It is clear that NHS has long recognised the value of improving access to welfare benefits and income maximisation in tackling health inequalities. Initiatives that tackle the broader issues relating to financial exclusion, such as financial awareness or financial capability are relatively recent. Many of these new initiatives remain at the early stages and few have been evaluated, particularly for their impact on health. This presents opportunities for future evaluation and research to explore the health impacts of these approaches.

All 16 of the studies identified discuss heath impacts of advice provision. Only two evaluated additional approaches including financial exclusion awareness raising sessions, money management guidance, or development activities. The studies generally focused on the provision of welfare benefits advice including income maximisation work. However, Citizens Advice Bureaux (CAB) and many other advice services advise clients on a range of social, legal and welfare rights issues (including, for example, housing, employment, taxation and debt) and several studies highlight the wide range of issues addressed and the fact that individual clients may raise more than one problem.

The main message from across the studies is that both qualitative and quantitative methods identify benefits from advice in terms of improved mental health, reduced stress or anxiety and better quality of life, but there is less evidence of improvements to physical health. Relatively short follow-on study periods and other methodological issues are suggested to have contributed to modest results in some studies.

Targeting services

Where projects have involved targeting vulnerable groups there is limited evidence of analysis of the different situations or the impacts for groups within target populations, for example, on the basis of gender, age, ethnic origin, disability or learning difficulties. Strategies that work for one group or situation can inform work with other groups but may not always be effective. Research and evaluation need to go beyond recording the characteristics of service users and explore different needs, impacts and outcomes of advice. However, this work should also be informed by a growing body of research on effective practice in financial inclusion work.

Benefits for Health and wellbeing

One assessment of work to date is that there is little need to conduct additional work to determine whether welfare rights advice has a financial effect but the potential benefits for health and wellbeing remain largely theoretical. Both qualitative and quantitative research has however identified that financial inclusion interventions can impact positively on people’s mental health and well-being. The importance and value of this has been under-played in the literature. The relationship between debt and mental health and the wider effects of addressing the stress and anxiety of debt and low income is a clear area for future research.

The review has also identified opportunities to further develop existing approaches to tackling financial exclusion. For example, in addition to welfare rights and debt advice, other linked areas of policy and practice have the potential to be considered in integrated approaches to financial inclusion because they are strongly linked to the issues of poverty and ill-health. Addressing fuel poverty is one area that has been highlighted. Prevention of homelessness and eviction and re-housing of homeless individuals is another area in which the right advice and support is essential to addressing the situation of people who are likely to have health and/ or addiction issues.

These wider issues also serve to highlight the need for a broader agenda in research that takes more account of the complexities of people’s lives. The review raised questions about whether enough account has been taken of the effects for different groups of people and different health circumstances (for example acute and chronic health conditions, mental health problems).

Evidence of effective practice exists, but this would benefit from further development. In particular advice needs, like health needs, are often not static and some flexibility in service design may be needed to respond to changing needs. For example, someone diagnosed with a condition involving long-term management or a long period of recovery may have particular and different advice needs at the point of diagnosis, when entering or leaving hospital as an in-patient and during periods of recovery or deteriorating health. Such an approach would be consistent with the aim of holistic provision and the aims of providing seamless services and the use of the pathways approach. Training and information sharing are necessary components for ensuring that health and financial inclusion professionals have the right levels of awareness and expertise for the work they do.

Financial inclusion is an area of mutual concern for local government and health services. It has much potential to contribute to better understanding of how services can help to reduce health inequalities and address any unintended consequences of the way services currently work.

Recommendations for Research

There is considerable potential for financial inclusion initiatives to contribute to an agenda for improving health. To gain a better understanding of the impact on health the following approaches to research are recommended:

• More research is needed to broaden understanding of the importance of factors such as gender, family circumstances, age, ethnicity or disability for different groups within target populations to improving health, wellbeing and quality of life through financial inclusion work
• For its contribution to be understood better and the social impacts of financial inclusion taken into account more fully, there is a need for multi-disciplinary research involving people with expertise in both health and financial inclusion
• More mixed-method and holistic, qualitative approaches should be adopted and more sensitive research tools developed for assessing the impact of financial inclusion and that is relevant for target groups
• Longitudinal studies are required, lasting beyond the one year duration of most studies in the past, particularly to understand more about the impacts on physical health and the potential for financial inclusion to contribute to reducing the physical health risks associated with poor mental health.

Recommendations for Practice

Recommendations for practical approaches to take forward financial inclusion work within NHSGGS include the following:

• Project and service monitoring should reflect both project and wider policy priorities, for example, monitoring for family situation / relationships, dependents and caring roles
• Financial inclusion development and evaluation should take account of the reach to different groups, including within target populations
• Existing research and practical guidance can inform this area of work, including adaptation of existing effective practice to reach new groups
• Consistent with holistic service provision and the pathway of care approach, projects and services should be developed in a way that recognises the importance of responding to changing needs over time
• NHSGGC should consider how addressing fuel poverty can be incorporated within its approach to financial inclusion and the linked issues of housing circumstances, including the risk of or actual homelessness, that are potentially important areas for advice and support
• There may be a need for wider links, for example with services addressing advice on homelessness and benefits, including CABs and Shelter, in a broad agenda to tackle financial exclusion
• Partnership working should involve health and financial service providers, but also service users and carers and the services that support them, for example, key workers. Consideration should be given to involving other service providers such as in housing and domestic fuel supply.
• Training, awareness raising and capacity building are needed for staff, not to become experts in new areas, but to refer effectively, for example: training for staff in financial inclusion work on issues such as health needs, or mental health first aid; for health service staff on the breadth of rights and entitlements, sources of help and when and how to refer; and for all groups, equality and diversity training may be important, particularly in projects involving screening of potential clients for financial inclusion interventions.
•  

The full report is available to download at the Scottish Poverty Information Unit website:

Health Benefits of Financial Inclusion: A Literature Review (pdf)

Healthier Wealthier Children has developed a number of guidance tools for health and money advice services staff. These have been developed, by Healthier Wealthier Children workers, as a result of needs identified by frontline staff.

Guidance – Health staff

A Quick Guide to welfare benefits for families with children (pdf) has been used extensively in the project. It fits into staff diaries and is a good reference aid for staff when working with clients.

A Quick Guide to benefits for children with additional needs  (pdf) is being piloted with Health Visitors within short awareness sessions about Child Disability Living Allowance . The project found many misperceptions about what children are eligible for DLA and application processes.

Guidance – Money Advice Services Staff

A non-engagement protocol (pdf) has been developed with the aim of providing a standard approach for managing Healthier Wealthier Children referrals across NHS Greater Glasgow and Clyde and increasing efficiency of services to respond to referrals. It is considered an example of good practice on managing referralas by NHSGGC’s Strategic Financial Inclusion Group.

Guidance on dealing with sensitive patient issues (pdf). This outlines what is expected and not expected of Money Advice Services staff when dealing with NHS clients, who may disclose complex health issues. 

Good Practice Reports

There have been a number of reports collated on innovative work in Healthier Wealthier Children.

Healthy Start Antenatal Cooking Classes in North West Sector Glasgow City CHP Report (pdf)

In Inverlcyde, Barnardos provide a groupwork programme for pregnant women with complex needs.  Healthier Wealthier Children was integrated into this approach which resulted in increased patient engagement with Money Advice Services. 

Healthier Wealthier Children partnership work with Barnardo’s Inverclyde (pdf) 

In South East Glasgow, engagement and training for nurseries resulted in better partnership working between health visitors, nurseries and Healthier Wealthier Children and improved care pathways for patients.

Healthier Wealthier Children partnership working with nurseries in Soutn East Glasgow (pdf)

An Equality Impact Assessment (EQIA) was carried out for the project overall with some local areas also carrying out EQIAs.

The project has been innovative in providing a service in 48 locations across NHSGGC.  This has been mapped against deprivation levels to inform service planning post project.

Development Workers across NHSGGC collated good practice and challenges with Healthy Start implementation.

Money worries and budgeting were integrated into a pilot project on antenatal cookery classes in North West Glasgow. This pilot was targeted for pregnant women who have complex needs. Budgeting with Healthy Start vouchers and use of Healthy Start vitamins were covered in the pilot.

Healthy Start Antenatal Cookery session Report (pdf) 

HWC Training

Development Workers and, at times, Income Maximisers have carried out a wide range of awareness sessions and training to health and other staff. It has also included innovative work in, for example, nurseries and weaning fairs of referral options for parents and training for Health Visitors on the links between employability and financial inclusion. 

Two standard presentations (shorter and longer versions) were developed on child poverty for frontline staff.

Child Poverty Presentation (short version)

Child Poverty Presentation (long version)

In addition, Development Workers and Income Maximisers themselves have shown a high commitment to learning. HWC provided induction training and an induction pack (pdf)  on welfare reform and welfare benefits for children and families and equalities monitoring. Poverty Alliance Scotland have provided Poverty Awareness Training and Training for Trainers. Child Poverty Action Group provided training on specific issues for children including Child Disability Living Allowance. 

Summary Evaluation report on Poverty Awareness Training delivered to NHS Greater Glasgow and Clyde (pdf)

National Consultations

The good practice within Healthier Children was also recognised in the Equally Well Review  and  in NHSGGC’s response to Scotland’s Child Povery Strategy:

Passported Benifits – Consultation Response (pdf)

Child Poverty Strategy – NHSGGC Final Consultation Response (pdf)

Video Resource for staff

Healthier Wealthier Children, in collaboration with NHS Education for Scotland and IRISS, have produced a video that highlights the challenges and opportunities in raising the issue of money worries with clients. 

Money Worries – A case study of how professionals in health and social care services ask and respond to client’s money worries. Rose Sloan, a special needs in pregnancy service midwife at Inverclyde Royal Hospital, talks about the importance of raising the issue of money worries with clientshttps://player.vimeo.com/video/50375916?color=ffffff&title=0&byline=0&portrait=0

Healthier Wealthier Children: Responding To Money Worries from Mindreel.

Articles/Publications/Reports/Documents: 

• Maximising opportunutues: final evaluation report of the Healthier, Wealthier Children (HWC) project (pdf)
• Healthier, Wealthier Children: learning from an early intervention child poberty project  – Phase 2 evaluation report (pdf)
• Naven, L; Egan J (2013) Addressing Child Poverty in Scotland: The role of nurses. Primary Health Care, 23: 5: pp 16-22
• Working to promote Healthier, Wealthier Children in NHS Greater Glasgow and Clyde, Naven, L (2014)  – GCPH blog post
• Shields N, Egan J (2012) “NHS innovations on child poverty: financial inclusion interventions” Health Service Journal June 28th
• Renfrewshire Healthier Wealthier Children Annual Report 2014
• Learning from an early intervention child poverty project – Exec Summary 2013 (PDF)
• Healthy Start and Child Poverty – A children and families financial inclusion project
• Setting the context for Glasgow’s respose to child poverty – a working paper (pdf)
• Developing a strategic response to child poverty in Glasgow -July 2010 (pdf)
•  Wakefield S (2008) Child Poverty: prevalence in Scotland, causes and effects and policy responses (pdf)
• Scottish Government (2008) Achieving our potential: a framework to tackle income inequality and poverty in Scotland
• Scottish Government (2008) Equally Well: Report of the Ministerial Task Force on Health Inequalities
• Women, Children and Poverty: Report of a Public Health Network seminar, jointly sponsored by NHSGGC and Glasgow Caledonian University, exploring gender and poverty 2010 (pdf)
• Health benefits of financial inclusion: A literature review (pdf)
• NHSGGC Employability, Financial Inclusion and Responding to the Recession (pdf)
• Child Poverty Seminar October 2009
• The Social Fund: a review of selected literature – Research Findings

Media Exposure

Press release in News Medical Online, following this publication entitled “Study evaluates role of midwives, health visitors in tackling child poverty” (2013) Press release by RCN Publishing Company in www.alphagalileo.org entitled “Nurses help fight child poverty in Scotland” (11th June 2013) The Herald 6th March 2011 “Child poverty project which makes a real difference” Evening Times 17th Oct 2013 “£4.5m boost for families in poverty battle” Featured in Evening Times 7th Nov 2014 “Advisors deliver £20 million health boost” and Kirkintilloch Herald 5 Nov “Income advice scheme saves £20 million” Features in Glasgow Advice and Information Network newsletter – Jan 2011; Nov 2011; Aug 2012; NHSGGC Health News – April 2011, Sept/Oct 2011; October 2014; Clydebank Post – June 2011; Herald Features Article (Stephen Naismith) – July 2012; Paisley Daily Express – Jan 2012; Children in Scotland Newsletter – Jan 2012; Herald parenting supplement – Sept 2012

Websites:

• Scottish Government
• Scottish Government (2007) Getting it Right For Every Child
• Scottish Government (2008) Early years Framework
• Scottish Poverty Inofrmation Unit
• Glasgow Centre for Population Health (GCPH)
• Engender
• Equalities in Health
• Money Advice Scotland
• Oxfam
• Save the Children
• Scottish Poverty Information Unit
• Poverty Alliance
• Growing up in Scotland
• Maternal and Early Years for early years workers
• Money made clear