3.1 - Dr Louise Newson - The Menopause Doctor. Prescription charges - fair or a tax on the sick?

Aural Apothecary 3.1 Transcript

Jamie: This is the Aural Apothecary podcast. My name is Jamie Hayes. Coming up in today's episode, we are joined by Dr. Louise Newson. Louise is a GP and menopause specialist. We will welcome Louise in a moment as Louise gets to share her desert island drug, her career anthem, and recommend a book for the Aural Apothecary library.

Gimmick, or serious bit of policy? Our micro discussion will look at the place and future of prescription charges in England. Gimmick was how opposition parties and critics described the abolition of prescription charges in Wales back in the day with Scotland and Northern Ireland following suit. And who says we are not edgy? Hello to our listeners in the UK, Hong Kong, the States, New Zealand, Canada, Kenya, Singapore, Australia, Ireland, Spain, Belgium, France, Portugal, and Germany. And if that list doesn't include you, we would love to know where in the world you're enjoying the Aural Apothecary podcast. We hope you're all well, and have had a nice couple of months since the end of series two. Before we go any further, it's strange, but I have to say I've missed them, which is a little bit weird and slightly unsettling.

Let me welcome my two fellow apothecaries, STC is in Bournemouth and Gimmo is in Cardiff. Welcome both. Evening all. What have you been up to since the break?

Gimmo: Been a long summer, hasn't it? When you've got three kids at home. They're glad that they've gone back to school. But yeah, a weird summer, I think.

STC: No sun!

Gimmo: Yeah, yeah. No sun either, but managed a trip to Cornwall. That was fantastic. Managed a trip to Tenby. I went to the Green Man Festival, which was brilliant. That's my first festival in about 15-20 years. First one as an old man, as opposed to a young person.

And there was a talk in the science tent and guess who it was? It was Professor Mark Taubert, who was one of our fantastic guests in episode six. For those who remember, he's a palliative care consultant from Velindre, here in Cardiff. And you know, interesting talk in the middle of a festival when everyone's enjoying themselves was about the importance of talking about death.

But, Mark being Mark, he managed to make it funny and uplifting. And so yeah, if you haven't caught that episode, then make sure you do cuz he's well worth the listen.

STC: Did you vomit while you were there, Paul?

Gimmo: I didn't, no.

STC: I thought that's why they called it the green man, you know. No, no. So, I also was in search of the sun down in the southwest, went to South Devon, really enjoyed it. Stayed in this big old house down in Thurston, south of Salcombe. And I gotta tell you this funny story. So big old house, massive bedrooms, like huge beds can't even see your wife. Anyway, I wake up one morning and I think, that's odd. I've got this sticky thing on my calf. I was like, what the hell is that? Anyway, so I got up, turned the light on. I looked down on my calf. Almost perfectly, no curl or anything wrap was a Butrans patch. Which is an opiate patch if you're not a healthcare professional. And I'm like, how on earth has this got on me? And I can only assume that the person who'd last slept in those beds, they'd obviously be laundered, but you know how they stick to stuff and it. It must have somehow.

Jamie: No. No. No.

STC: Yes, yes, yes.

Gimmo: That's like seeing a plaster in the swimming pool, only worse. So, did you have some weird dreams that night?

STC: Well, I can't remember. So that was very strange. And I must just say that, while I was away, I finished the Lost Connections book by Johann Hari. Do you remember the one that I got instructed , and was told I must read it because it was about biochemical, psychological and social causes of anxiety and depression.

And it's a fine read and it dovetails beautifully with the book that Jill gave us about “a crossroads between should and must”. And he talks about, you know, the lost connections and needing to treat the fire, not the smoke. And it was fascinating and I really enjoyed it, but there was one little term that I really liked, I'd never heard before.

And he said that people who had lost their way, and he talks about they described themselves as having a karaoke life where they are singing along to a song that's written by someone else, which I thought was really powerful. What you've been up to, Jame?

Jamie: So my staycation was in North Devon, so we've given the Southwest a good economic boon. Park run is back, so that means I've picked up injuries already. And last week I went to Taunton to become a certified civil and commercial mediator at Normanton Chambers in Taunton. And it was a cracking course, a week's course. It was like role play immersion therapy all week. Role play ,after role play, after role play.

So you have to get over yourself quite quickly on the first morning.

STC: Did they have actors?

Jamie: No, that was us.

STC: Oh, right, okay. Because I’ve done that sort of stuff with actors and it's brilliant when the actors do, you know when they're pretending to be patients.

Jamie: Very good. Let's get on the important bit.

We have another impressive line up of guests for series three and to get us underway it is my great pleasure to welcome Dr Louise Newson to the pod. As I mentioned, Louise is a GP and menopause specialist. You can read Louise's full and impressive bio in the show notes.Some highlights from the bio: Louise runs a menopause and wellbeing centre in Stratford upon Avon, which is the largest menopause clinic in the world. She has developed the menopause information website, www.menopausedoctor.co.uk . She's authored the Haynes Menopause Manual. She's the founder and a trustee of the menopause charity. She's also set up Newson health research and education as a not-for-profit company, she does lots of media work. And finally, Louise hosts a weekly podcast for women, which is often number one in the Apple Medical Podcast charts. Welcome Louise.

Louise: Thank you. Hi.

STC: Lovely to have you on the podcast. You say it's a podcast for women. I've dived in and done six episodes already.

Louise: I don't say it's a podcast for women. I just, it's a podcast for anyone that will listen, actually.

Jamie: Welcome to the podcast. Lovely to have you here. What's going on with you at the moment, Louise?

Louise: Well, it's always menopause actually. I constantly spend my life thinking about how to reach more women. But it's not all work, as you were saying, I've got three children as well. So, it is the end of the summer. Two have gone, one's just off to university, one's upper sixth and she goes to a boarding school. So I've just got one child. I feel like I'm cheating really. It's quite easy having one.

Jamie: Yes. I've got another one out to the nest, off to uni as well. So that's one remaining.

Gimmo: When I told my wife who was coming on, I said, anything you'd want me to ask her or say? She said just say thanks. Oh, I think she's the right sort of target audience, age, I don't wanna give away, don't wanna say her age, but, she said thank you. And she's enjoyed the book and she's enjoyed the app, I think you've got as well, haven't you? You didn't mention Jamie.

I was just gonna describe an experience that happened to me at The Green Man actually. And it was when we were in that tent watching professor Taubert and someone passed us a card or a leaflet and it was for a talk on menopause or there was a menopause doctor there. And it was funny for me with a small laugh watching the reaction because on the one hand there was sort of, Why are you giving it to me?

Is it so obvious that I'm that sort of age and almost, you know, insulted, but on the other hand, but I'm going to this because I really need to know more and it's something I'm really interested in. And then when we were telling our friends afterwards, all the women, they had a similar reaction.

It was like, oh my God, they pass you that card. and that's what this topic emotes, isn't it, I suppose is, I don't know, it emotes those weird sorts of reactions. We don't really talk about it, I don't what to say.

Louise: Yeah, I think it's changing. I certainly think things are changing as in the past people have just laughed about the menopause.

"It's just an annoying, menopausal woman who's just taking up space and don't go near her. She's a bit hormonal" sort of thing. It's a butt of jokes, isn't it? Actually, even the economy has been described as menopausal at some stage which is a shame actually because it means that it's really hard for those women They are not listened to and they are not understood and they often don't understand themselves actually often what's going on.

Jamie: I've listened to a number of the podcasts now and find them excellent. I've learned a stack in a very short space of time. One of the things that comes up a few times is you've pointed out the lack of content in medical, nursing and undergraduate education, has that improved in the last few years?

Louise: I wish I could say yes. I think things are improving. Certainly, there's a lot of thirst for improving education. I, as you've probably heard me say, had no formal menopause training, as an undergraduate or postgraduate. I suppose I'm quite unusual because I'm not a gynaecologist. I'm a physician. Before I was a GP I was a hospital physician, so I've got MRCP as well, but I've also got a pathology and immunology degree, so I'm very interested in the way our cells and our bodies work.

I'm very interested in how important oestrogen and testosterone actually are for the way our bodies work and prevent diseases. But all my work has been self-taught actually. There's very little formal training. People think there is, but when you talk to them, it's probably half an hour from a gynaecologist in the clinic, one afternoon sort of thing.

Through my not-for-profit, we've created a menopause education program, and I did it because, I was just sick of spending a lot of money, taking a lot of time off work, spending a lots of money, sitting in lecture theatre thinking, oh, I know this. And then I sat in clinics and I thought, actually, I don't know this, this is what real patients and real stories are about.

So we filmed some actresses, one of them is my mother, actually, the older patient and then some are professional actresses. We gave them stories about patients, and we filmed them and we did 10 minute consultations in them.

We've got lots of links to evidence. And we've also filmed lectures as well. So, we put it all together and we initially were going to charge but make it very cheap, £135 pounds a year. But that still felt uncomfortable with me because as you know, if you have to spend money, you're less inclined to do something.

So when I founded The Menopause Charity, I said let's just make it free. And my financial director went mad because the not for profit company is so in debt. And I said, look, it's in debt anyway so let’s get it out there. So, we thought, well maybe if we could have a hundred downloads it really be amazing, wouldn't it?

We gave one free license to every GP practice knowing that there's 10,000 GP practices. Anyway, we've extended it so it's free to every healthcare professional, and we've now had over 14,500 downloads of the education program in the last three months. So that shows that people want to learn. They really do. But it's been very hard. Menopause has been a bit of a Cinderella specialty, actually. And everyone thought it's a bit boring because why would you want to treat menopausal women? As they go on a bit and they're a bit anxious and they might take 20 minutes in a consultation sort of thing. But it's transformational medicine if you get it right.

So it's worth investing in these women.

STC: It's a classic case of endocrinology at work though, isn't it Louise? So, I trained with an endocrinologist and I remember him saying to me, what's beautiful about endocrinology is that if we get it right, if we get the diagnosis right, we can fix it.

Louise: Yes, totally.

STC: So that's a really good example. And the other thing is, we first were alerted, if you like, on the first series, I think when Davina McCall's program was on and lots of people were talking about it. And that's when Paul mentioned it as something at the time. And that's when I got thinking and like Jamie, I started listening to your podcast and thinking, this is great, we should get you on. And , I don't wanna make you blush, but you have done a fantastic job because everybody I speak to, even in the practice, you're gonna love it. This is so funny. This is absolutely genuine. I was late home tonight because one of the GPs, not partner, one of the salaried GPs, said, Steve, I need to talk to you about something, I think it's gonna come up tomorrow. And I said, okay, so that's why I'm late. So, she phones me up and she starts talking about HRT and she said, oh, there's this thing about, you know, women who are on continuous combined HRT and the fact that they can have daily Utrogestan and the license doesn't actually say that.

And she said, and I sat there, beginning to sort of smile to myself thinking, oh, I know a little bit about HRT. And then she said, I'm on this brilliant thing she said, called 14 fish, with this HRT specialist. And I, then I started really laughing and I said, oh, yeah and what?

And she said, and I wrote to her and, and she wrote back to me and she said, yes, that's fine. It's a good question about off license treatment, et cetera, et cetera. And I said would you be happen to be talking about my menopause doctor, Louise Newson? She said yes. So, you know, there's this thing about six degrees of separation.

I'm gonna say that in a menopause world, I think you're probably within three degrees of separation. And so, you've taken it a long way in a very short period.

Louise: Yes, I have imposter syndrome. I don't think about what I've done, I think about what I need to do. Really.

STC: That's a good message. What do you think you need to do more?

Because I know that when I spoke to you offline you said, well, like take the NICE guidance. So, we've talked a lot on here about shared decision making. Again, this is a beautiful example of shared decision making. You know, do you want a pill ? Do you want a tablet? Do you want a patch? Do you want a gel or, or whatever it might be. So where, where do you want to take it?

[00:12:29] Louise: Well this is really grand, isn't it? My mission is to improve the global health of women because actually it's a car crash, isn't it? For women. They have low hormones that last forever, but there's health risks associated with it. But only the minority women are allowed their hormones back, and some of it is because they don't understand, they don't realize how safe HRT is. For a lot of women is actually that they are refused it.

You know, in my clinic today, I see people and they come to see me because they can't get HRT. It's like, well, why not? You are 49. You are menopausal. You haven't had a period for three years. You are wanting to give up your job, your memory's gone. You are shouting at your children every day. You can't sit down because you've got such bad vaginal dryness. So why aren't you getting any hormones? Well, my doctor said I can have antidepressants, that's all I'm allowed.

You're like, what? What's going on? It's a real injustice to women actually, and I feel I'm more and more feminist with time, but I feel it's no one's fault because women haven't been given right information. The media certainly haven't, but us as healthcare professionals have been given wrong information.

You know, you look at the MHRA, what they're telling us about how dangerous HRT is. No wonder people are scared about it. Well, it's interesting you talk about endocrinology because endocrinologists are amazing. They're so clever, far cleverer than me, but they don't get taught about sex hormones.

I had someone recently in my clinic who's had a pituitary adenoma from early on, so she's been amenorrhoeic, so she's not had a period for 25 years. She's on every single hormone. But I said, what about oestrogen? Oh, no, no, no, because my mother had breast cancer. I can't have it. And she's under an endocrinologist and you think, oh dear this is such a shame. She's now got osteoporosis.

Gimmo: I've never forgotten my mum, if she's listening, always brings it up because

STC: Of course she's listening, Paul, she's our number one fan!

Gimmo: And she was put on HRT years ago, and it was at the time when there was a big scare, as you've said, and that they're sort of episodic, aren't they, these scares around HRT and I sort of advised her not to take it, you know, exactly as you've just described, and she's never forgiven me because all the symptoms came right back. And I think it is an area where learning the guidance around heart disease feels easier than learning the guidance around this sort of thing, and I don't know why, I dunno if that’s our own biases and how our background or whether we're just not interested, you know?

Louise: Yes. I think it's because we've been scared away from it actually. And if you are scared in medicine, you sort of think, well let's just say no and it doesn't really matter because it's “only the menopause”. And I think also people have thought about menopause as something that causes symptoms. And if you look back when the hormones were found, when insulin was discovered, if you like, people call it a disease. Diabetes, of course it is a disease. Thyroxine -hypothyroidism. Oestrogen, when they discovered oestrogen, it was hot flushes.

It was never a disease. Whereas if then they said, well, the menopause is a disease because it should be thought of as a disease. If you think hypertension is a disease, is obesity a disease? We don't know. But it increases risk of so many diseases. And it's the same with the menopause, but no one thinks about it.

So, they think, well, if a woman doesn't have a hot flush, then does it matter? And in fact, I had a very awkward conversation recently with a gynaecologist who wants to report me to the GMC because how dare I prescribe HRT in someone who's 60 without doing her oestrogen level because how do I know it's low?

It just doesn't make sense. So, I had to justify myself to him, like a naughty school child. And he was saying, well, she didn't even have any hot flushes, so why would you give it? I said, I'm just looking at the clinic letter, because she was seen by another doctor, and she's got low mood, memory problems, she's feeling very tired, she's got muscle joint pains and headaches and they all improved when she was given oestrogen, so I'm sure they were related to her oestrogen deficiency. He really didn't like that, and I think it's because people have thought menopause equals hot flushes. And that's it. And I think also it's been made very complicated.

I mean, I can't keep up with all the different combined oral contraceptive pills cause they keep changing their names. You look in the BNF and I'm thinking, oh my goodness, which progesterone, which dose? And I think with HRT, if you look in the BNF, there's all these synthetic hormones and I don't know what half of them contain.

And that's why I wrote the Easy HRT Prescribing Guide. And if you prescribe body-identical hormones that are available on the NHS, you keep it really easy. Then it makes it very simple in the way that endocrinology should be, and then you can tailor it to the patients. And once you start doing it, it is, as I've said, transformational.

Not only do women come back and say, thank you, my life's come back. I can keep my job. I can function as a person, but actually more importantly, I'm sitting there thinking, wow, do you know what? I've given them something and it reduces their risk of heart disease, osteoporosis, diabetes, dementia. I can't think of any other treatment in medicine that does that. It's really quite incredible.

[00:17:06] STC: You're right about too much choice, Louise. So, I would give you the analogy of inhalers. GPs, likewise with asthma, they're almost like afraid of it because there are so many different combinations. So, I think you're right about that for sure. I must just say one more thing before I forget.

Otherwise, Kara who works with me, who's one of the prescription clerks, will tell me off for not mentioning this cuz she once brought a letter to me and she said to me, Steve, look at this letter. And it was from a gynaecologist and she was describing this lady who was in the perimenopausal and she used this word that I had never seen before. And the lady used it herself to describe her mood with her husband and her children. And the word was verminous! And I was like, oh my word, I've never heard of that word. I mean, obviously I worked out, it was vermin and, but that's how she described her mood and that was in the letter and Kara said to me, have you ever heard of that?

I said, no, but I think I can gather what, how she felt, and how the others are around her were. So, that is the most sort of extreme version I've ever seen written.

[00:18:02] Louise: I mean, I've had women, and in fact, more than once, who said to me, if I had a knife in my hand, I would kill my husband. There are times that I feel so awful. And I get that. You know, even I had symptoms for a few years and I didn't care if I was shouting at my husband. I love him dearly, but at times I just thought, I really don't care. He can walk out. I don't need him. And of course, I need him. But it's like you've got this demon in your head telling you that you can be really angry and cross, but it's quite frightening.

And actually, it's very frightening when these women actually think about suicide themselves. You know, I had someone came to my clinic a few weeks ago and she'd been sectioned straight after having her ovaries removed. She phoned her husband from the recovery room and said, something's happened, I'm really scared about myself.

And she then tried to kill herself by banging her head against the wall and was sectioned and kept saying to the psychiatrist, I think something's missing. I think it's my hormones. And they said no, I think you've got a acute psychosis, you are depressed. You need to have heavy drugs and it went on for about six months. And then one of her children actually read about me on my Instagram and messaged me and said, I'm really worried about my mother. And so obviously I saw her as an emergency and she's already improving on her own hormones, unsurprisingly.

[00:19:18] STC: Well, I think even though we are three men, of a certain age. I think we could probably still talk about this for quite a lot longer. But I think in the interests of the rest of the podcast, it has been absolutely fascinating. But as you might be aware, when you've perhaps listened to some of the podcasts, we like to ask all of our guests a couple of things.

And so, the first one is we're very interested in a desert island drug, which is something that evokes a very powerful memory for you. So not something you take to a desert island because it will save people's lives. Would you like to offer us up your desert island drug? And I'm not gonna take any guesses what it might be.

Louise: Well, I quite like to say testosterone, if that's alright. Am I allowed to?

STC: Yeah, of course you can. Yeah.

Louise: I thought everyone would say oestrogen, but actually.

Gimmo: Everyone was guessing oestrogen.

Louise: Yes, I know. Do you know what? If I'd met you six years ago, I would have said oestrogen, but actually testosterone.

We produce, as women, three times more testosterone, than oestrogen. It's a really powerful hormone and it's been neglected for so long. And actually, personally, I take testosterone and if I didn't, I would have given up my job as a doctor. There's no doubt about it. It's really good for mood, energy, concentration, stamina. People will say, it's just that sense of wellbeing comes back, that sense of self-worth of just being happy, actually. And there's also some evidence that it reduces risk of osteoporosis, heart disease, and probably dementia as well, so it's very important. But it's not thought about, is it, for women?

STC: I listened to your podcast with Dr. Jeff Foster actually about the, can we say the 'Manopause'? Does that exist?

Louise: Well, he doesn't like that term, but yes, certainly testosterone deficiency in men is, and I've done a lot of work with the British Society of Sexual Medicine where Professor Mike Kirby, who you might know, has spoken about the benefits of testosterone in men.

And I've just talked about benefits of hormones in women, testosterone and oestrogen and it's very similar, but it doesn't affect all men, as you know, it's probably about a third of men have low testosterone.

Jamie: Your latest episode Louise is on testosterone as well, isn't it? So that's worth a listen for all our listeners as well.

Louise: Yes, so I've done one with the most amazing professor, Professor Isaac Manyonda, and I've got one coming up in a couple of weeks with one of my colleagues, Dr Zoe Hudson. Again, talking about testosterone. We are trying to make a noise, because I think it's important that women know about it, but we are also really hoping that it becomes licensed for women, soon. Because as you know, it's not licensed for women anywhere in the world other than Australia at the minute.

Jamie: So he mentioned foggy brain, better sleep, better energy, and better libido as his take home messages for your listeners.

Gimmo: But it's not part of any mainstay guidance, is it? I mean, I'm out the loop on this.

Louise: Yes, it's in NICE guidance. So NICE menopause guidance from 2015 say that if a woman has oestrogen replacement, so has HRT and still has reduced sexual desire, then you can consider testosterone. And it's also mentioned in the International Menopause Society guidelines.

STC: But there's no licensed product at the minute, is there?

Louise: No, but as you know, we prescribe lots of things off license. If you think of all the things we've prescribed for children, and also medication like amitriptyline for migraines, for example, is prescribed off license.

STC: So I was struck though by Dr. Jeff Foster, being very clear about not using it ,in men anyway, if it didn't meet the strict criteria.

[00:22:22] Louise: Yes. I think it's different somehow in men. I've certainly seen lots of private clinics that give testosterone to people who, you know, want to body build or, you know, haven't got low levels. It's very different in women, women who are menopausal will have low testosterone. So, we give it in really safe doses and monitor their levels so they're always within female ranges.

STC: Well, we'll definitely accept testosterone as your desert island drug into the Aural Apothecary Formulary, as we like to call it. What about a song then? So we like to think of an anthem that might mean something to you.

Louise: Yes. This is bit awkward actually because my oldest daughter's a musician, she plays the trombone and she's just gone to the Royal Academy of Music, and she listens to music all the time. My husband's really into music and I've just got one of these brains that just listens to music because I like it, but I can't remember anything.

So, I was thinking hard about this actually. And so I decided this is a bit geeky so you might laugh at this - Toccata and Fugue in D minor by Bach. I tell you why is that I used to play the organ and I went to boarding school from very young. Actually, I was only 10 when I went to boarding school because my dad died when I was nine, when I was sent off to a really horrible strict boarding school.

And I learned to play the piano and then I learnt to play the organ. Not particularly well, but this is one piece of music that I really, really wanted to learn. So I learned it and I played it once in assembly and it's the most amazing feeling of power when you are playing the organ. But actually, you can't make a mistake because if you do, you can't hide it. With a piano, you can just as it just fades very quickly. You can't with the organ, and it makes me very happy when I listen to it because it is a very uplifting piece of music. But I also, when I'm thinking about what I'm doing with the menopause and my career, any little mistake I make is amplified.

 You are all giving me all these lovely compliments.

And I don't want to tell you the number of people that write emails, phone me and complain about what I'm doing. The horrible things that have happened to me over the last few years, and, you know, the more I get out there in the public domain, the number one thing is I'm a clinical professional person and my clinical integrity is really important to me and that this piece of music makes me think, oh, Louise, if you get one that small thing wrong, they will remember.

They won't remember the beauty of the music. They'll just remember that note played wrong. So yes, so I don’t know whether that's a bit awkward or geeky, but I just, it just made me think.

STC: That's almost as powerful as the piece of music itself, cuz I also love that piece of music. Oh good. You cannot, you cannot miss it when you, if you hear it in a church, it's unbelievable, isn't it?

Jamie: And that's the emotion we are after Louise.

STC: Yeah. Very much. Oh good. You've nailed it. Okay, so we've got your desert island drug. We've got your career anthem, so no pressure, but we are also looking for something for the Aural Apothecary library. Would you like to offer anything to listers in regard to this?

[00:25:11] Louise: Yes, of course. So, this is where oestrogen comes in. So, a book called Oestrogen Matters by someone called Avrum Bluming, I don’t know if you know of him. He's a professor of oncology from the University of California in America. And about three years ago I was presenting something at the Royal Society. And it was about patient choice. Which is very pertinent for your podcast, of course. He was talking about HRT for people that have had breast cancer. It was actually, the whole day was about breast cancer. There were different parts, and he was talking about his own experience, so his wife had oestrogen positive breast cancer. His daughter had had oestrogen positive breast cancer, and they'd both chosen to take HRT. And I thought, that's a bit risky, isn't it? And he'd written this book about how oestrogen matters and how important oestrogen is for our future health as well as us to function.

And it's written for anybody, but it is very heavily referenced, very scientific as well. It's the most amazing book. And once I listened to him, I thought, gosh, you're telling me all the things that I've been thinking about the last 20 years.

And then he talks about how little evidence there is that oestrogen actually causes breast cancer. And oestrogen, as you probably know, used to be a treatment for breast cancer and it can induce apoptosis. So actually there is some studies that giving oestrogen to women who have had breast cancer, they do better.

So, it is an incredible book and it's done very well for him, but I really feel that every woman and probably every healthcare professional should read it. He's got the most amazing brain. He's really clever. I've listened to him talk a lot and I've invited him to talk to our doctors recently.

And the other thing that he recently said was, do you know what, Louise? I'm not there to be their doctor. I'm there to be a patient's advocate. And I think that's a really great word, isn't it? Because I think, you know, gone are the paternalistic days where we just give people the green piece of paper and say “off you go”.

I have really tried to be an advocate and making our patients being listened to, enabling them to be listened to. So, I've learned a lot from him as a mentor, but I think his book is just brilliant.

STC: So it's Oestrogen Matters by Avrum Bluming, have I got that right?

Louise: Avrum Blooming? Yes

STC: Yeah. Okay. Excellent. Well, we'll definitely accept that.

Louise: Oh, good. I'm doing well. That's good.

Jamie: "We'll accept that."

STC: What? We accept, everything, it's a personal choice. It's about personal choice.

Gimmo: This isn't room 101, Steve.

Jamie: Our micro discussion next, STC, that’s you as well.

[00:27:38] STC: So yes, our micro discussion for the first episode of Series three, we thought we'd try and make it meaningful and edgy, and so you may or may not be aware that there was a consultation that's now closed in England only.

As Jamie said, it's already free for prescriptions in Wales, Scotland, and Northern Ireland. This was about whether the upper age exemption should change so that it's in line with the state pension. So, we don't wanna get, we will stray into some form of politics, I'm sure. But this was purposefully about should it move from the age of 60 to 66 in line with the state pension.

It just sparked, I suppose, a thought process around that. Let's have a debate about prescription charges because you know, they contribute about 600 million pounds a year. I'm reading now from the document that was quite intense that came with it that most people probably didn't read, but it contributes about 600 million pounds in revenue, which I suppose is not a huge amount, really.

And they were saying that actually if the government went with what they think is their preferred option, which is phase it in like everything else. So, in other words, if you are 61 now, it won't affect you, but everybody that's gonna be 66, it'll be phased in and that it would raise £174 million per year over the next 10 years.

So, they actually talk about in the wider document about why they didn't consider any other radical options. And the reason why I guess I, in particular, wanted to discuss it was that this does come up a lot and I think we'll maybe talk more about this issue about, well, why is it, and I know that Louise has a view, and that's partly the reason why I brought this in here, is that actually, maybe that's not the big issue.

Maybe the big issue is why do we have one list for certain conditions and other conditions, and it's never changed, pretty much, since it was first enacted, anybody got a view on this? Louise, do you wanna kick us off?

Louise: Obviously I can only think about HRT, but, every other hormone or treatment is on it, isn't there?

So, if I had an underactive thyroid gland or if I had diabetes, I would have free prescriptions. And we know a study that came out last year showing that women from low socioeconomic classes are about 29% less likely to receive HRT. We know these women are more likely to have cardiovascular disease, more likely to have mental health issues, more likely to be obese, so actually more deserving of HRT.

One of the things that I'm also doing is working as an NHS advisor for the National Menopause Programme, and I've been pestering them for a long time and they're finally listening because I'm selling it to them as a health economy problem because we know that if women don't get the right treatment, they're more at risk of these conditions.

If you think about an osteoporotic hip fractures, it costs the NHS £3 billion a year. We did a study of 5,000 women and we found that for 10% of them, it took nine GP appointments just to get the diagnosis of the menopause. If women can make the diagnosis themselves, for example, using the free Balance app, then we could free up 750,000 GP appointments a year.

So that's quite a lot of money actually, that is just saved. So, giving something that costs four quid a month. Even though potentially that's for the majority of women. You've got to be a bit patient. But 10, 20 years’ time, you've made your money very easily. And I think this whole postcode lottery has to change, we've been doing some mapping of who gets HRT and it's completely wrong.

And then we did some deprivation scores of who comes to my clinic. And you can see on my website, the fees are eye-wateringly expensive to come to the clinic, and 10% of our patients are from the lowest deprivation. It's shocking. You know, we see people that they come and they've been given £10 from every family member to come because they just want their lives back.

So, this shows how desperate women are. So, I think it's really wrong that they have to pay.

[00:31:21] Gimmo: I'm in agreement with that. I mean, first of all, the specific thing about the list, it's a nonsense that there's two lists. It's an absolute nonsense. Why is one chronic condition trumping another one in terms of what you get for free?

Well, I suppose I'm in the mindset and you know, I live in Wales where we've had no prescription charges for, I think it's over, over 10, 15 years. They're a false economy. They contribute to health inequality. They don't save money in the long run. £ 600 million sounds a lot, it's not, in the grand scheme of things.

Louise just said about the knock-on effects of women not taking their HRT end up costing you a lot more money. Well, that was the subject of a report in 2017 and organisations like the National Rheumatoid Arthritis Society and I think Parkinson's UK produced a paper that showed clear evidence of this, that people were not taking their medicines.

Now you can imagine the consequences of not taking your Parkinson's drug because you can't afford it. You are gonna cost the NHS a lot more money. So, it's a false economy. I think it's a historical/political thing that is in anachronism in a modern health service. And the clear answer is scrap it.

And if you're worried about increase in prescription numbers, then sort out your repeat prescribing system?

[00:32:31] Jamie: Yeah, I mean, I find it hard to get excited about this cuz again, it hasn't been an issue for us in Wales for so long. When it happened, I remember taking call, it was 2007 or 8 and we reduced prescription charges, hadn't we, over the previous years.

And then they were abolished in 2007 or 8 and I took a call and they said, oh, can you supply us with the evidence. And I said, oh, I said it would be nice, but we don't have the evidence. And it was a political decision at the time, I think, but since 2010 and where we published a few papers and David Cohen was one of our health economists who published the papers to say, actually, nothing to see here.

You know, the big reaction to getting rid of the prescription charges is gonna drive prescribing in other directions. It never happened. And so, all of a sudden those health inequalities that Gimmo is describing, it's just so nice to have those conversations without cost of prescriptions coming into the equation for us.

[00:33:21] STC: Mmm. It's really interesting that you say that, that there was no evidence at the beginning when Wales decided to do it, because I did say at the beginning that I have a slightly controversial view about this, so I'm gonna give it to you and then hear what you will have to think about this. This isn't based on evidence, this is based on 30 years of working in the NHS, but I'll give it to you anyway. And so, this has been going on and there isn't any doubt that the system, as it currently stands is bonkers. And what we need is a system that's simple, fair, and easy to administer. And I also think that to seek to engage patients as partners in taking their medicines to improve adherence, reduce adverse effects, and reduce waste.

 And we also need to encourage people to use their community pharmacists, for self-limiting conditions and that will provide overall value, better money for the taxpayer and reduce burden on GP services. I also think, and this is the controversial bit for which I have no evidence other than my own personal view and experience, is that people don't value anything that is free.

So, all patients, in my world could pay a nominal fee. And by that, I mean nominal, I mean 50p or a pound or whatever it might be. So that, and then there would be a limit to what that would be. So, in other words, even if you were on 20 medicines, the limit would still be five pound, let's say.

Okay. I'm talking nominal amounts because I'm sure Louise would agree with me from a GP background. There are so many things that get done where people have only requested them and want them, because they don't have to pay for them and they create a lot of burden in the system. Now, I also think that there are obviously, and there are big issues in here like cancer for example, and this is political about why they wouldn't make any changes about cancer patients, for example.

But I've just had this feeling that, you know, there are certain exceptions that might be too emotive, so patients with cancer, for example, people who have got conditions that if not treated, it puts the public at risk. So that would be sexually transmitted diseases, HIV, TB, notifiable diseases, schizophrenia.

And other than that, my view is that everybody should pay a nominal amount. And that that would actually, you know, people would value more what they were doing.

[00:35:28] Louise: I can see where you're coming from, but actually I think again, it comes down to education of our patients actually. Because I think if they're educated, empowered, they're less like to come asking for help for the things that, like you say, you could get elsewhere.

There's been so much sort of misinformation, not, not just about the menopause, but everything. And then now it's so hard, isn't it? It's such a strain on primary care. Oh and secondary care with Covid. But I think if patients know what they can and can't get, I don't think they'll take the mickey Actually, I feel it really uncomfortable charging people because I think, I mean, my daughter has intractable migraines and it has been horrendous. She's under four different Neurologists and as a mother, who has migraines herself, I feel doubly guilty cause I've given her the migraines through my genes. But, you know, it's really hard and I think God, five pounds for every medicine that I've given her. It's a lot of money for her as a student.

Yes, okay. You can argue they are free, but when she's earning money as a musician, she's not gonna be paid much and she would end up not taking some of her medication. And I just look at people, five pounds isn't much for some people, but actually it's a lot If you're feeding your children and you've got other things going on.

STC: I was talking about a nominal fee until like 50p. But if you were taking lots of medicines, there'd be a cap on what the maximum would be. We pay for dental treatment, and I know we'll get into this whole NHS politics and we probably haven't got time, but that's my view and I just wanted to put it out there. Come on, Paul.

[00:36:48] Gimmo: I think you're right about, we need to get better at working with patients to help them understand not just the financial value, but understand their medicines and what it means to have them and to take them. And we've talked about that a lot, we've also talked about behavioural science and economics.

And so, I struggled out of Lidl this evening, with the load of shopping in my hand cuz I didn't wanna pay the 20p for a carrier bag. And that's what you're doing there. You're introducing a friction cost, so the impact of what you are suggesting will be that people, the charge doesn't matter, but the act of paying will mean that people will err on the side of not taking over taking.

So, I think it'll have the same impact as prescription charges, whatever the value is. And I think I agree with Louise as well that any sort of cost, even if it's nominal, will impact the disadvantaged hardest. It'll have less of an effect, I agree, than six pounds, but it's still gonna have an effect on health inequality.

So, I would still, I get what you're saying about value it. I've heard this argument loads of times and I think, you know, it's worth thinking about.

STC: But remember it's nearly 10 quid an item now, guys, not five and six squid. It's nearly 10 quid.

[00:37:49] Louise: I also think we've all been on house visits where we've looked at this polypharmacy especially, it's worse, isn't it as people get older and these people often don't pay any prescriptions and you say to them, oh, what are you on? And they, you open the cupboard and then you just, it's fallen on top of you, isn't it? All the bisphosphonates that they don't want to take as they get side effects. All those analgesics, everything like that. And often it is because they're too scared to tell their doctor because they don't want to upset them because, oh, but that doctor was so nice when she gave it to me and she said it would really help me.

STC: But that's where the nominal charge would help with that.

Louise: But I, well, they're not paying for it, so they'll just...

STC: yeah, that's what I'm saying, so if you have a nominal charge, in the same argument that Gimmo has just given, that's my point. If you're not using it right, you're not gonna take it. You're not gonna ask for it.

Louise: I don't think it would make any difference.

Jamie: Can I cut in here with my mediation training please? Can we have one person speaking at a time, please. Anyway, Louise, I was gonna come back to you on your episode with Dr Sarah Hillman, and we nearly got through an episode without mentioning the inverse care law, but what was the figure from the research that Sarah did, was it 29% lower prescribing?

Louise: And actually these people were more likely to get oral HRT, so oral oestrogen, which has risk of clot with it. And actually, when you talk to some doctors, they're like, do you know what? I'm too busy, I can't do menopause as well. But then you actually say to people, well just ask every woman you see when their last periods were or whether their periods have changed.

And you can get menopause into every single consultation or perimenopause to every single consultation to all women, actually. My youngest patient is 14. She only had one natural period, so you don't need to stop asking at a certain age either.

STC: Jamie, can you enter the prescription debate or should we, should we draw to a close?

Jamie: Oh, do you know what I was thinking? Listening to Louise's last podcast, you immediately invited your guest back on.

Louise: Yes, he's coming back.

Jamie: So that's something that we should do. We should invite Louise back on for a future series to continue the conversation.

Louise: I'd be delighted.

Jamie: A big thank you to Louise for joining us on the Aural Apothecary and for sharing her stories, her Desert Island drug, her career anthem, and her book.

Coming up next time we'll be joined by Dr Chris Martin. Chris is a pharmacist by profession and is currently the chairman of the Life Sciences Hub Wales and co-vice chair of the Bevin Commission in Wales. His interests include innovation and of life care. We will look forward to catching up with Chris next time on the Aural] Apothecary.

You can contact us via Twitter. That's at @AuralApothecary, LinkedIn and email auralapothecarypod@gmail.com. Over to Gimmo now for the final ingredient.

[00:40:11] Gimmo: Okay, so thank you Louise. That was fantastic, I really enjoyed that. I want to talk about a colleague who's a consultant physician in Cwm Taf Morgannwg Health Board, Dr. Helen Lane. She was on the frontline during covid, obviously like a lot of people were, had a tough time, really tough time. And so, to help her cope, she turned to writing poetry. And so she just published a book of poems and the collection is called Reflections Through the Waves, poems of the Pandemic , and I just wanted to mention it because I know she's very passionate about it, she shared it with people and actually the proceeds from the book, you can get it on Amazon, go to Young Minds, Beat and wish upon a star and we've never done it before. And it breaks our sort of, not talking about Covid reel, but are we happy for me to read out a poem from it?

So, it's good to talk, I pray he survived. I rushed to the ward, he tries to smile. My greatest reward. His family's so grateful, so precious, but faceless.

Such emotion and fear, his survival is priceless. I return to the office, I'll get through today, then flowers from the caring.

Perhaps I can stay, but all staff around me still struggle each day, they suffer in silence and dare they to say, such supportive staff, vital cogs in the team, the grief they have witnessed, the things they've seen.

Who asks the porters, who hope for the best, who cradle the sick, then carry them to rest?

Who asks the domestics, who clean every space. After those who kept leaving, having lost life's race, who cares for the caterers who keep us all going, exposed to a risk, but carry on knowing that we all need each other now more than ever, and we may just survive this, but only together.

Jamie: This was a 'Three Apothecaries' production.