5.1 - Graham Prestwich - The Patient as a Project Manager

Series 5 Episode 1

Jamie: Welcome to the Aural Apothecary Podcast. My name is Jamie Hayes. For our opening episode of Series Five, we're joined by Graham Prestwich. Graham is a former pharmacologist, a patient, and a lay member involved in all sorts of medicines related working groups. We will welcome Graham in a moment as he shares a drug for our formulary (it's like a desert island drug, but different), his career anthem and recommends a book for the Aural Apothecary library. For our micro discussion, we look at a recent article in the Sunday Times, 'the NHS is flatlining, here's how to save it right now' by the health editor Sean Linton. But first look, they never write, they never phone. Let me welcome my two fellow apothecaries, STC is in Bournemouth and Gimmo is in Cardiff. Welcome both.

Gimmo: Evening. Happy New Year.

STC: Happy New Year. Yeah. Where have you both been anyway? On the WhatsApp group? I've been responding to myself pretty much over the Christmas period.

Jamie: We've started a new WhatsApp, Steve.

Gimmo: Yeah. It gets a bit too much sometimes, Steve, when you're all excited about a new series.

STC: I know. Do you know I've often thought that whether or not groups that I'm in, that they set up a group that says 'minus STC'!

Jamie: It's a function now on Whatsapp.

STC: It should be, anyway. I know my enthusiasm, it sometimes gets ahead of me, but I have to say, I am very excited about starting series five.

I really am.

Jamie: So we've got a good series lined up, haven't we?

Gimmo: Yep. We're looking for a more patient focus for this series, so it's a good one to kick off with. What you been up to Steve?

STC: I've been really super busy actually about this whole kind of subject matter the last two days.

So just as a very quick intro, I spent a lot of time yesterday with a lot of alumni of the Aural Apothecary, so Lawrence Brad, Lelly Oboh, Clare Howard, and Professor Emma Baker, who's a clinical pharmacologist, talking all about how could we do something to help integrated care systems - so these groups within England , almost like Dorset is one integrated care system.

How do we help the leaders make decisions about how to deal with polypharmacy and over-prescribing? And so, we did that yesterday. Then today I was talking to NHS England with Lawrence Brad, about helping them with their media work around how to get the messages out about over-prescribing. And then I did a session today to a lot of diabetic health professionals who work in primary care and I was really, challenging them to not think as single-organ-ologists. They're not quite single-organ-ologists to be fair to diabetes. Of course, they're not. But I was challenging them about thinking about multimorbidity and polypharmacy and taking on people's values and preferences. So, this is our day job, isn't it? And so that's why I'm excited to be here.

Jamie: So we're three minutes into the new series and he's gone single-organ-ologists, already.

Gimmo, what've you been up to?

Gimmo: Yes. It's been Christmas and New Years hasn't it, but, it's like most people in the NHS, it's tough times.

STC: Armageddon!

Gimmo: Yeah, well, it, it is. And so, so yeah, a lot of work going on about how we can relieve the pressure and stuff, I suppose outside of work, I did my first park run for a year. In fact, it was in a long time, and I've realized I've only done one before that, so it was actually my second part run. So that was good, in the mud. So I'm gonna be able to join you and your chums, Jamie, as you refer to them.

Jamie: Welcome to the cult.

Gimmo: And I'm getting stuck into my, so I'm doing the ILM level 7 coaching qualifications. It's the coaching, executive coaching qualifications. I'm just following Jamie in everything basically.

Jamie: Leaders' and followers, STC. Leaders and followers.

STC: I'm not doing that.

Jamie: Yeah, no, don't. Look, just to help set the tone for this episode and perhaps the series, just before the festive break, the day after we recorded the Aural Apothecary Almanac, actually, I delivered my final workshop of 2022, and it was a public workshop on the psychology of medicines, joined by 30 members of the public, aged 50 to 90 years of age. The venue Porthcawl Rugby Football Club in South Wales. No slides, just me and a conversation with the public, and I have to say it's probably one of the most rewarding workshops I delivered all year.

We talked about shared decision making, describing risk and benefits, treatment burden, sustainability. We even talked about numbers needed to treat and numbers needed to harm, so I'm looking forward to doing more of those in 2023.

STC: Are you, do you wanna mention the group that you spoke to or not?

Jamie: Yeah, so it was the University of the Third Age (U3A). And they've already invited me back for more. And I can see huge potential in having conversations with that particular organization around all the stuff we talk about on the Aural Apothecary, actually. And then the other one I wanted to mention, look, I think I might have a new term for us. So I was listening to Stephen Fry on a podcast the other day, and he described sodium valporate as a “disgraced pharmaceutical” and so I quite enjoyed that term, a disgraced pharmaceutical!

STC: Is that because you're gonna need two separate clinicians to decide that you can actually be prescribed it, from now on. I think that's part of the MHRA guidance, isn't it?

Gimmo: I like that term, but that could be a new feature: disgraced pharmaceuticals.

Jamie: Yes. Ahh its not just thrown together.

STC: Oh, yes. Ooh. Maybe we should, we don't wanna stress Graham out, but maybe we should ask him for one. No, no, we won't.

Gimmo: Maybe, I know we're having an editorial meeting on air, but maybe we could have one at the end. We'll all get our thinking caps on.

Jamie: Okay. Let's move on.

It's our great pleasure to welcome Mr. Graham Prestwitch to the Apothecary. Graham's full bio will be available in the show notes. Here are some highlights: (There's lots) Graham's a pharmacologist by background with a 20 year career in the pharmaceutical industry, starting with three years in cancer research, and the mechanism of action of Tamoxifen in breast cancer.

In 2012, Graham was appointed non-exec director for Leeds North Clinical Commissioning Group with specific interest in patient and public involvement. Over the six years, the role included chairing the primary care commissioning committee and setting up and sharing a novel patient assurance group.

During this period, he developed me and my medicines, which I'm sure we'll come on to in the next 30 minutes or so. He's also involved with dozens and dozens of projects and initiatives often as a lay member. Welcome to the podcast, Graham.

Graham: Good evening all. Lovely to be here.

Jamie: There's a lot in that bundle that you supply Graham, of your extensive career and experience, but what's a medicines related matter you would like to talk about with us on the podcast?

Graham: Well, my passion and hobby is really helping the person on the receiving end of the medicines to have a much bigger and important role in the choice and use and getting the support that they need to do their job properly. I've likened the patient in many instances to the project manager. We get landed with the job as the prescription is handed over to us.

Jamie: So Graham, very quickly before Steve comes in, look, it's almost seven years to the day that you publish that piece in the BMJ, I think, isn't it on the  project? What did you call it? Management opportunity. We'll put it in the show notes. And it is a very clever, great read and so true and at halftime in my talk to the public, several people came up to me, and that's what we got talking about really , navigating the system and having a project manager either for yourself or your loved ones.

STC: Oh, I've just remembered. You mentioned halftime, it made me think, please don't tell me that you needed to peel a load of oranges before you started for the halftime interval.

Jamie: I didn't . They did have tea and coffee on cups and saucers, though.

STC: What I was gonna say though, so I, I've met Graham. I've known him for a while now and I think I met him for the first time at the very first meeting of the national over-prescribing report that Keith Ridge was in charge of, which is pre-pandemic, believe it or not.

And I've heard Graham, you give that example many times now and every single time he says it, I think to myself, he's absolutely nailed it. And that is really what we are talking about. And so that's why we had to open up series five of the Aural Apothecary with you, Graham, because we want to engage patients and patient advocate groups to say, yeah, it's okay to ask, which is part of your remit isn't it, in relation to “Me and my Medicines” ?

Graham: That has been the whole theme of such a simple piece of work that, , came out of about 60 plus, nearly 70 conversations with people from around West Yorkshire about how they were getting on with medicines and some of the challenges that they faced. Everybody came up with a similar theme, really, that they have unresolved issues to do with their medicines. If that issue is not resolved, taking a course of action on your own every day, reordering every month, it's not gonna happen enthusiastically. If you have an underlying issue that's filling your head with doubt and concern and it's sorting out that issue, whatever it is, that makes all the difference.

Gimmo: The way you've described it, it really puts across beautifully the, the responsibility that we are suddenly handing to the patient, and I've never, until you said it.

I mean, you know, we've talked about shared decision making a lot but I never really thought about it in those terms. I mean, if you, if you gave anyone else a dangerous piece of kit that, that could harm them, whether it was Tech or something else, you'd spend a lot of time making sure that they could use it correctly. But we're not doing, or, or not that they're using it correctly, but they had the support that they needed to use it properly. Yet we just don't do that with medicines, do we?

Jamie: That's why I'm not allowed to have a chainsaw.

Graham: But if you look at the top 200 medicines used in the United States, 80 of the top 200 have a black triangle warning, pointing out that they're actually quite dangerous. 80 out of the 200 most commonly prescribed! So it's exactly as you describe it, Gimmo, we are giving people something quite dangerous with no support or very little support to handle dangerous goods.

STC: I like your counter analogy, Gimmo, because actually we might say, if you bring home a bit of kit that you buy, you might think some people would read the instruction manual, but lots of people wouldn't, would they. They would think that they could use it without reading the instruction manual.

And so we've got the same plethora of, you know, different types of people, haven't we using medicines? We've got the people who get the patient information leaflet out of the box, which is completely indigestible to most people and read it and circle it and then phone up the next day to ask you like 4 million questions.

And then you've got the other extreme where they would never bother and they would just take it. Or the person who just shoved it in a cupboard and didn't take it.

Jamie: If they can read.

STC: Yep. Quite. Yeah, good point.

Graham: Or if, if they can find the version that's in English. Cuz there are so many versions on that leaflet.

STC: Yeah. Or they don't speak English and they want the version that's not in English. So yeah, lots and lots of reasons. So it's a great analogy.

Gimmo: So, so I think we all really love the “Me and my Medicines”  website. Um, me and my medicines.com, I think it is, but we'll put the link in the show notes, but I mean, .org sorry. And I guess, what are you trying to do there that addresses that question, I suppose would be my question?

Graham: Well, it's got some way to go, yet. And, it's events like this that inspire me to get my finger out basically and, work harder. But the website is there as a free for anybody to use and make use, to sort of think through some of the issues that, are presented by, by such a theme and to think about how they can take that idea and put it into their own practise. Within the boundaries of what an individual can do. So it's for a patient to be able to do what a patient wants to do, it's for whoever to pick it up and say there's something in there that I could go into the office tomorrow and do differently. Encouraging people to, to think differently about that conversation between the patient and the clinician. So it's designed to just open up that thinking and behavior.

Jamie: Graham, you've listed lots of things, initiatives that you're involved in with expertise and lay membership, et cetera. What's your gut feeling for the medicines agenda out there. Let's go for the last seven years since you first wrote that project management article, what sense do you get from these committees and working groups that you spend your time with?

Graham: I don't think much is changing. I think primary care is still built around a machine that's designed  to write, produce, and reproduce prescriptions that are then dispensed in the same way that they always were, and at my own practice they've still got Lloyd George envelopes lined up. I can see through the window, the edge on view of Lloyd George envelopes.

Gimmo: Well, “ Room for review” was, that was one of the points I came into this sort of pharmacy, this side of pharmacy, and it was fantastic at the time. And it, you know, it talks about different levels of medication review and around the same time was the "Ask About Medicines" campaign and that's why the www.meandmymedicines.org  website I like because cuz it's, it's like you say, you're not, in some ways, you're not doing much more than we did back then 20 years ago. It's about encouraging people to inquire and ask questions and to build up a relationship with their healthcare professionals.

I mean, I would say some things have changed but it's not 20 years on as you imagine it to be in 20 years from now.

Graham: Sadly guys, sorry Steve, but sadly, I've got my name on “Room for review” at the back as one of the contributors. So that's really embarrassing, isn't it?

Gimmo: Well, Jonathan Underhill's got his name on that, so I don't, I think, hasn't he, so it's not that embarrassing.

STC: What I was gonna say Graham, though, is if you had to put your flag on the on the mast. What is that thing that we need to do to unlock it ? What is the one thing that you think that is the reason why the progress seems to be slow? Is it time? Is it resources? Is it it the public / patient? Is it the professional? What do you think the one thing is that you think could move this along more quickly? And I think the future of the healthcare system has to look at how it's grown since 1948, wasn’t it? And say that people now live over pension age. At that time, we, we expected a year or two out of people who retired and that was it. It's completely turned on its head. And we need to redesign the system around keeping people involved in that health so that health becomes part of daily life, not as an add-on that somebody else does. It's gotta become part of our day, not somebody else does it for us, and that's a long haul, but we have to get there.

STC: You're right, and we mentioned it in the Almanac episode, the David Haslam book, which is about the side effects of healthcare and where we went wrong, that point is very strongly made within the book.

I know the others have read that book and it is an excellent read. But the other thing I was just thinking about, you know, I love podcasts, so I've gotta give a podcast shout out to the Reith Lectures this year. Well, from 2022, did anybody listen to those? They're the four freedoms, and they're based on Franklin D Roosevelt's famous four Freedoms from 1941.

And it's about the freedom of speech, freedom of worship, freedom from want, and freedom from fear. And as you might expect, they're incredibly clever and intellectual and make you think a lot. But if I'm honest, and there were some very highbrow people, including Rowan Williams, the ex-Archbishop of Canterbury. But the one I would suggest that people listen to, and I'm gonna tell you why I think it's highly relevant, was a chap who I had never heard of, his name is Darren McGarvey. He's Scottish, and he spoke very eloquently about freedom from want, but his angle is that he grew up in a very, very deprived area. He was a drug and drink addict. And he basically talks about, and that's why I think this is key, he talks about the welfare state. So same sort of time as the NHS, the welfare state was brought together to help people. Okay. And actually, even though he came and needed it when he was younger, he's realized ,and he uses the word “agency”, and that seemed to be a word that went through the whole of the Reith lectures, is that there's, you need Agency.

In other words, what Graham has just said. The individual, who's the one putting it in their mouth, has got to take some responsibility. But the system has got to help them to be able to do that. You can't just rely on the system, and it was a brilliant lecture, really, really good.

Graham: That's a terrific point, Steve, cuz a number of the patients involved in putting “Me and my medicines”  together talked about their willingness to take some responsibility if they could understand what that responsibility involved.

So it sounds like a really good listen.

Jamie: I mean, that's, that's going back, I remember if I said it last time, but it's a Sir Michael Marmot quote, isn't it? "Don't blame the patient, blame their poverty."

Graham: If I could be allowed, guys, I was reminded today of an encounter, an encounter, that doesn't sound quite right. A meeting or several meetings with a respiratory consultant from Newcastle, who passed away some eight years ago now. But that guy, I met first in 1979, he was a respiratory consultant at the Royal Victorian Infirmary in Newcastle, and we were talking about the management of asthma and Alistair Brewis talked to me about him feeling personally responsible if one of his patients landed on his ward, suffering from acute severe asthma. He considered that to be a failure on his part for not teaching them and convincing them how to use the blue inhaler and the brown inhaler properly and appropriately to manage their asthma.

So, he took it fairly and squarely as his responsibility to make sure that they understood and could do it for themselves. And that stuck with me right the way through the last 40, ump-teen years as, as that's what patient involvement is all about, is that agency and, but being supported to be able to do that.

And when I sat in the waiting area, waiting to see him, I would ask patients how they felt about having to wait so long to see the doctor. Even in 1979, people waited a while to see doctors, you know, and it was lovely to hear, that the folks in that waiting area while I was sat with my briefcase, hoping to go in and having a chat, by the way, I never sold him a thing, but I think they were some of the best conversations I ever had. But when I asked the patients what they felt about waiting, they said, "who cares? I'm waiting to see the best doctor in Newcastle. It's well worth it." Says it all.

Gimmo: But I wonder if there's something in, you know, we're seeing in the press a lot now, aren't we?

That people are saying there's a lot of people ringing ambulances and going to GPs who don't really need to ring the ambulance or go to the GP. Now, I don't know if that's true or not cuz it could be hyperbole, but there is something about, has there been a shift in people in terms of them placing more responsibility in the hands of the people treating them as opposed to taking responsibility for themselves? Cause our health minister in Wales said something similar this week in response to the, the growing crisis in NHS was, look, “the NHS is just gonna have to do less”. And I think what she meant was that, that people are gonna have to start taking more responsibility for their health. I just wonder if we, if that is, if that's just, if that's an easy excuse or whether there's any truth in it.

STC: Well, I would agree with that. Sorry, Graham, go on.

Graham: I was just gonna say, I think we have to have fresh eyes looking at some of these things because if somebody's ringing up and they've got an issue let's give them the benefit of the doubt that that issue matters to them.

It might be cuz they weren't organized, it might be cuz they didn't organize their repeat prescription and therefore they've left themselves in an awkward place and so they just ring up. But are we giving people sufficient support or options or alternatives to be able to find out different ways of doing things?

And I know we've got some telephone based things and what have you, but we need to make sure that people understand what their options are for getting help. Cuz if you don't, if you're unsatisfied, you're just gonna keep going 'til you get there. If you can't get a GP appointment, people are just gonna go to the next port of call down the line, aren't they?

And that's natural enough to do, so I think we just need to think about what people's needs are, first of all, and see if we are, we're doing our best to meet those needs where people are, and then take on these other broader issues about appropriateness. But there's lots of people with real need who are not ringing as quickly and as soon as they should as well.

And we, we've gotta be very careful not to put people off getting that help when they really, really need it.

STC: You're dead right, Graham? But on the flip side, of course, is that if you can stop people doing things that are then taking practitioners away from things that really need to be done.

It's like everything ,in whatever work you've ever worked in, there's never enough time, there's never enough resources. You have got to decide, like the health minister there, I say this all the time. I could do that, but what am I not gonna do if I'm gonna do that? And so sometimes, I don't often get irate, but I sometimes get very irate when the same people constantly run out of their medicines, if you like. And they're always the same people that come back. And I'm not talking about where we know that they've got a complicated picture as far as we know. But jokingly, I used to say sometimes to the, to the staff, we will do it.Okay. Because you don't want them to be without, but can you remind them that PR equals PR?

So we need some personal responsibility, otherwise, you're gonna end up with a PR, which is not a nice thing. But do you see what I'm saying? So, there's both ends of the spectrum, as there always is and we need to meet in the middle, which I guess is the whole point of what you are saying, and it's okay to ask and it's not good enough for a health service to say we haven't got time to talk to you." We wanna encourage people to ask, but we also need to work together as equal partners to help you, cuz you need to manage your, your condition and your health.

Graham: Absolutely. Steven. I fully appreciate that.

Jamie: You sound like his dad there. Graham.

Graham: Oh, sorry. Did that sound condescending?

Jamie: No, no, not at all. Just called him Steven.

Graham: Oh, right. But I think listening to the way you described that, you described that as telling the patient that they're gonna have to do something. And my angle really is-

STC: He was pointing his finger, as well, Graham

Jamie: I told you, I don't get irate very often, but yes I'll, I'll listen.

Graham: Ah, yes. Once the finger wagging starts we're sunk, aren't we? But there's something about, investing the time in those few people who take up most time is turn it round into an investment and say, right, sit down. Let's talk about what the hell's going wrong, here. You are messing up the system, you're not doing some things, and I think that you should be, and you think that I should be doing this, so let's have a, let's have a proper chat. It's like, you know, it's all but make a cup of tea and say, let's have a proper conversation about this and sort something out together. And I think those are the people where there's probably a dozen if that in a big practice.

STC: I certainly accept that. Okay, Graham, I think you're warming up now. You said you were a bit nervous when you came on, but I don't think we're not seeing any sign of that.

So you can relax now. Okay. The main bit is over. So one of the pleasures of coming on the Aural Apothecary as a guest is you get to give us three things, and the first one is a drug that simply evokes a powerful memory, either from your life or your health journey so far. Uh, what would you like to offer us for the Aural Apothecary formulary?

Graham: Okay. The list was very long and I started jotting a few down and thought it could be all sorts of things, but I've arrived at one that for me, captures so many different aspects of, of medicines generally that, that people could relate to and work through. And it's a great exemplar of all the sorts of things that we talk about.

Jamie: Before you name the drug, just go through the list a little bit for us, Graham, of what you've discounted. Just give us a couple of ones that were on the list but didn't make the, the final…

STC: Ooo, Jamie, that's very good. Normally you get really arsey if people want more than one.

Jamie: Well, he's not having more than one is he?

Cuz he's discounted them.

Graham: Well, it started off with Tamoxifen. Cause that was the one that kind of shaped, a lot of aspects of my life. But it was really quite character building, in the sort of stuff that, that happened in and around tamoxifen and the stuff that I learned as a person, really.

So that drug still being alive, today. The guy I worked for in 1975 wrote to me at Christmas, wishing me a happy Christmas and asked if I'd bought his book yet, which is about the, the life story of Tamoxifen, cuz he's now some a big wig in the States and still championing the Tamoxifen story. So that was him.

And, so that was, that was really special to me. And with all its ups and downs and all those things with it, it's fascinating. The second one that I had on the list was Warfarin, because it was an important exemplar of the fact that we need to tune things to individuals and people.And I like the whole notion of tuning it. And my father, who's now long passed away, was prescribed Warfarin. I remember he was a hospital pharmacist, chief pharmacist in a hospital. And, in his latter days, he absolutely refused to take Warfarin because to him it was simply rat poison. And so it wasn't coming on the list, so that one was an example, but then I arrived eventually at the one I've chosen and, and that one, if I may, is Alcohol.

Jamie: We used to prescribe it back in the day on the wards, didn't we?

Gimmo: Yeah, we've talked about that with, Mark, didn't we? Mark Taubert. It also fits with my choice right back in episode one cuz there's a nice chemistry to alcohol.

Isn't there a nice simple chemistry that appeals to? The appeals to the chemistry nerds.

Graham: CH 3 CH 2 OH or something, something like that.

STC: C2H5OH, I think, right? Excellent choice. No one's picked it before either Graham, so that's straight into the Aural Apothecary Formulary.

Excellent. Next up is, what about an anthem for your life or health? For the Aural Apothecary Spotify playlist, which really is on Spotify.

Graham: Really is on Spotify, right. Well, my formative years were in the seventies and it was just like, I still think the seventies was just amazing. I think I was too young to appreciate how good the music was in the seventies, but as time moves on, you look back and you think that was bloody good that, so I just had to make a choice out of some of those.

So I've ended up with a little bit of Pink Floyd. I love the album cover and I've just, I've gone for "Us And Them" as the number. I just think that it was just nice. It's got a, some real deep meanings, some big issues in there. Those issues are just as current today: wars, people on the street, and racism - they're still just as ripe. And it was way there, back in '73, was it released or something?

It's just amazing just how topical that still is today and there's beautiful music in there. So yeah.

"Us And Them" - Pink Floyd.

Jamie: Quiz question.

STC: Yes, I know what you're gonna ask.

Gimmo: It was very recently, wasn't it?

Jamie: No, no, it's, it's Pink Floyd now becomes one of the third, maybe fourth to have two entries on the playlist.

STC: Three?

Jamie: I think four.

STC: Oh, you think four? Yeah. So Jamie Brewster picked "Comfortably numb" by Pink Floyd. Yeah.

Jamie: Okay.

STC: And Oh, Phil. Phil Howard.

Jamie: Of ,course he did

STC: also picked a Pink Floyd track.

Gimmo: Yeah he picked an album, didn't he?

STC: "Shine on you, crazy diamond"

Gimmo: I love that Graham said about the 70's as well. Cuz my dad's record collection is all from the 70's and it's all Pink Floyd, the Stones, you know, the later Beatles, Thin Lizzy. So I'm, I've definitely got my name on that.

Jamie: So the quiz question is, what are the artists that have more than one entry, and there's four of them, on our playlist. So Pink Floyd, you got three.

STC: Bach

Jamie: Bach, Bowie.

STC: Bowie, yes.

Jamie: Is Christina Aguilera?

STC: Christina Aguilera. There you go. Well, another, something else to add to the eclectic mix.

So thank you for that, Graham. We'll definitely take that. So, and the third thing is a book that has influenced your life or your health journey or thinking for the Aural Apothecary library.

Graham: Okay, well it's here. I've not finished it yet, but I was inspired to read it, encouraged to read it by my brother. My brother took early retirement. He's a much younger man than me, and, he enjoys cycling. And with the fact that my mitral valve leaks like a bucket with no bottom, the notion that I can still ride for two or three hours on the bike and do 30 or 40 miles does perplex my cardiologist, and my brother was fascinated by all that, so he recommended that I have a read of the Midlife Cyclist by Phil Cavell, and this is about high performance cycling, but also encourages us, as we move on in life, to keep going and the confidence with which we should be having a go at things that are quite physically demanding and how healthy that is.

It is very healthy to keep doing it, and it's not damaging. So, just talking to my brother has, has inspired a lot of keep going on the bike and he, we sort of had this informal agreement that whilst I'm 70, I've got to do 70 miles in a day on the bike, whilst I'm 70. And I've not quite got there yet, I've managed 40 miles a day, but not reached the 70 yet.

So I've still got a few months left while I'm still 70 to see if I can hit 70 miles a day. So that's the book and hopefully that'll keep me healthy. It'll either that, or kill me, one or t'other. We'll just have to see. I'll keep in touch, Steve and let you know which way it goes.

Gimmo: Well you, you're looking at a couple of midlife cyclists here, so , yes.

Graham: Oh, excellent.

STC: Yeah, just signed up for the Dragon ride in June. There are, there's a very long one and a very very long one. I'm doing the hundred mile one, but it's tough enough, but I think you are brilliant because I think I'm right in saying that there is evidence, people who cycle and continue cycling into their seventies and eighties, they definitely have…, unless you get hit by a car, obviously , you're likely to do much better. So yeah. Okay. Excellent. So that's in

Gimmo: That's on my list. I'm gonna read that

STC: The Midlife Cyclist by Phil Cavell.

Jamie: Very good. Okay. Micro discussion next. Looking at the recent article in the Sunday Times, titled "The NHS is Flatlining. Here's How to Save It Right Now." And it was published in the Sunday Times on the 1st of January by Sean Linton, who's the health editor for the Sunday Times. And it contains 10 suggestions that we've touched on a few of them already, perhaps, and certainly watching the evening news, tonight, it looks like from the way it's been portrayed in the media, certainly that we are in desperate need of some of these potential actions.

Did you have a read of it, Graham? What were your thoughts?

Graham: My initial thought was how underwhelming that list is. How boring and what we're already doing is included in that. And if we are gonna rely on that sort of thinking, we will gradually go down the plug hole. Apart from that, I thought it was quite good

 I think, I think if we, if we are gonna put up things like "let pharmacies do more", I don't think we are helping anybody to achieve anything, because it's not a case of letting pharmacies- the pharmacy is a building, it doesn't do things. It's other people that work in it that do things. So, it just got my back up to start with.

 The notion of curbing multiple medicines, I don't know quite what that means, but that just strikes me as driving around, scuffing your expensive alloys was what I thought curbing was about, but it's just, just a bizarre thing to put in. You know, "better follow up care". Well, crumbs if- yeah. Well, anybody can say these things, can't they?

It is just totally underwhelming and "embracing genetic testing" Oh. You know, it's just not inspiring at all. And that's what worries me is it's clearly not had the input from the sort of group of people that you were talking to in South Wales the other day, Jamie. The students of the third age could add a lot more interesting stuff to that.

Top of the list I think is actually make good use of 65 million people who are there sitting and waiting to be good project managers if you could just help them to get there.

Jamie: So on that, Graham look, they knew their stuff, the 30 people I had the pleasure of spending a couple of hours with, boy did they know their stuff, they knew what was going on. They were a little bit stunned when I mentioned my "most medicines don't work in most of our patients most of the time". And so, I had to sort of repeat that for them and then explain that a little bit for them. But yeah, you're spot on, Graham and so they certainly would have something to contribute to an article such as this.

Gimmo: Yeah. Cause I think, I think what it said that relates to what you just said there, Graham, wasn't it, it says something like, "utilize the community to help." Cause one of the big problems, as everyone knows, is getting people out the back door.

And so they use the horrible term “bed blockers”, which I don't like at all. But, the issue is, as we know, that there are people who are healthy in hospital, healthy enough to go home, but there's no way for them to go to. And, we've been thinking about this. You know, part, a lot of the needs that these people need met is medicine's needs.

So they can't go home because their medicine's support needs can't be met. How can we get, instead of relying on the statutory services, how can we get the community to better support these people? So they can go home or they can go to their place. Cuz we just haven't got the services to deliver what we need to, yet, we don't trust the community or utilize the community enough to support them. Don't know the answer to that, but that was one I did like. Even though, as you say, the way he's explained them is a bit simplistic, but I think there's really something in that that we probably perhaps haven't tapped into yet.

STC: So in my grandiose moments when we read this article and I said to the chaps on WhatsApp, of course nobody answered. And I said, oh, we don't wanna let a good crisis go to waste. Why don't we use this article with, perhaps all of our guests who are patients or patient advocates in series five and ask them which ones they disagree with? And I think you've done a fantastic job, Graham at explaining why, perhaps it needed a little bit more thought and I sort of said, well, maybe we could come up with the Aural Apothecary tonic list for the NHS for 2023.

Jamie: One of the things I highlighted in the first couple of paragraphs was the advice trap.

They've gone straight into giving advice, and you've just mentioned the word coaching Graham, which, all different types of coaching out there, but within coaching there's a trap. And so telling people what to do, we know is not gonna help improve the situation often.

Graham: Yeah. It's that that whole concept of doing that, I think is really important to this. So that would be one. I think the second thing I'd like to put into that list, if I can, guys, is something about making better and good use of all the data that the NHS collects about us ,in a constructive way to be more, more specific about what works and what's effective and what's safe and what's dangerous is ineffective and unsafe. And we could do that if we used much more of the data in a wise way to be able to identify what's good and not so good. Thinking of older people, for example, where medicines are not studied in trials, cuz you couldn't just, you just can't do that in 80 / 90 year olds.

STC: It fits beautifully though, under your support, then trust.

So in other words, support people to make decisions using the BRAN acronym, you know, the benefits, risks, alternatives, doing nothing, and then trust and respect that we've had the decision, we've had the conversation, we've listened, and this is the current way forward that still fits under your support. Then trust, doesn't it?

Jamie: What was the 'i' that Lucy Pollock added to 'bran'? She turned it into brain, didn't she?

STC: She did.

Graham: I thought you were gonna say she turned it into Brandy! Haha.

Jamie: So she suggested adding instinct and individuality into the 'bran' conversation.

Gimmo: But I suppose my point, this is all still about the individual.

My point was about that within communities and within families, there are people who are experienced in taking medicines, or other aspects of healthcare that can help as well. So, we're still relying on it being healthcare professionals doing the support, whereas I think that support can be provided from within the community and we need to get better at that.

STC: Yeah. Which is the bit that we talked on last time about community pharmacists being within their communities and are a bit more accessible than perhaps trying to see their GP. But we want them to be able to see their GP for things that are complicated and require the continuity of care with a full set of records.

But that's what we said really in the Almanac, wasn't it? When we foresaw that 2023 was the year for community pharmacy.

Jamie: Okay. A big thank you to Graham for joining us on the Aural Apothecary and for sharing his stories, his Desert Island drug, his career anthem, and his book for the Aural Apothecary Library. Coming up next time, we'll be joined by Deborah Duval, patient and managing editor of Kidney Care UK.

Join us next time. You can contact us via Twitter @auralapothecary. We're on LinkedIn. Email us at auralapothecarypod@gmail.com. Over to Gimmo for the Final Ingredient.

Gimmo: Thanks, Graham. I really enjoyed that. And just a reminder, I think it was www.meandmymedicines.org , if people wanna have a look at the website, I recommend that they do.

Okay. So, we always try and be nice to each other here on the Aural Apothecary. But did you know that civility saves lives? So, thank you to one of our listeners, Alex Farmer. She's a pharmacist who works in emergency medicine. She sent us in an email a link to an organization called Civility Saves Lives.

So there's a group of healthcare professionals aiming to raise awareness of the power of civility in medicine. They maintain that civil work environments matter because they reduce errors, reduce stress, and foster excellence. They go on to say, almost all excellence in healthcare is dependent on teams, and teams work best together when all members feel safe and have a voice. Civility between team members creates that sense of safety, that is a key ingredient of great teams.

So what happens when someone is rude? Well, there's an article in the Harvard Business Review in 2013, and it says 80% of recipients lose time worrying about the rudeness ,38% reduce the quality of their work , 48% reduce their time at work and 25% take it out on service users. And that results in a 20% decrease in performance. And for those service users or patients themselves, they report 75% less enthusiasm for that organization. So, there we have it Incivility or being rude affects more than just the recipient, it affects everyone. So be nice to everyone. Civility saves lives.