Episode 2 - Clare Howard and Multimorbidity

Aural Apothecary Episode 2

Jamie: Welcome to the Aural Apothecary podcast, authentic chat about medicines, pharmacy and healthcare in the UK.

Steve: Pharmacists Jamie, Gimmo and STC take on topical and controversial stories, but keep it edgy, yet lighthearted.

Gimmo: Podcasts, share their 'desert island drugs' and joyful patient stories. Thanks for joining us.

Jamie: Hi everyone,

I hope you're all well. Welcome to the Aural Apothcary podcast. My name is Jamie Hayes. I'm a pharmacist and executive coach from South Wales. As usual, I'm joined by my fellow apothecaries 'STC' in Bourmouth and Gimmo in Cardiff. For those of you that joined us for the first episode, thank you and welcome back. It was good to get the first one in the can.

Difficult to believe, I know, but we've been recommissioned for a second episode, and so here we are.

To our first time listeners, a warm welcome to you, too. What is the Aural Apothecary podcast and why have we started it? Well, it's one of those projects and ideas that's been on the list for a while. You know the list, the one that says, "write a book, do a triathlon, join a choir, learn how to vaccinate, start a podcast."

And so here we are. We're aiming to bring you some honest and authentic chat about medicines, pharmacy, and healthcare in the UK. It's the type of continuing professional development that takes place in the pub, the type of pub based CPD that doesn't get you struck off your professional register. We will take on topical and controversial stories, but keep it edgy yet lighthearted.

Over the coming episodes, we will welcome guest speakers from the world of medicines, healthcare, and pharmaceuticals. On all occasions, we'll be looking to bring our guests down to our level. As you will discover, it's work in progress. We have lots of fun pulling it all together. We record it live in one take with very limited editing.

We hope you like it, but we are not really here to be liked. It's been great to hear from you with all your messages of support and how much you enjoyed episode one. Plus, thank you for all your suggestions for our continuous improvement program. We are working our way through them. Gimmo has got himself a new microphone.

The "it's a bit blokey" comment is proving a tricky one, though. If you didn't enjoy the first episode, wait until you hear this one. So coming up in today's pod, we will hear from our special guest who will share their desert island drugs, select a career anthem to add to the Aural Apothecary Spotify playlist and add a book into the Aural Apothecary library.

We will also have a brief discussion on the latest thinking evidence on multi morbidity and polypharmacy. That's the CPD bit. So welcome STC and welcome Gimmo. STC, what have you been up to since we last hooked up?

Steve: Well, actually this week I've been looking quite a lot into the new English NHS discharge medicine service, which is due to start in February.

So we've actually been learning from Wales, cuz you boys have been doing it since 2011 actually, I think, haven't you?

Gimmo: Yeah, the discharge medicine review.

Steve: Yeah. So it's gonna be an essential service in England. So there isn't any doubt that we need to do it and it'll be great for patients, but I don't think there's any doubt there's gonna be quite a lot of bumps in the road.

I think it's gonna really test the PCNs as in locally for the communication that's required between the community pharmacists and the general practitioners and the, hopefully the pharmacy teams that work in there. So I'm absolutely confident it's gonna work eventually, but I'm absolutely sure that there'll be some local issues that need to be sorted out.

So hence why we're starting to look into it now.

Jamie: Okay, thanks, STC. Gimmo, what have you been up to?

Gimmo: Mostly Covid work, but, um, been looking at Valproate this week as part of a piece on safety I'm doing. But actually the thing I'm most proud of today was, sat down with my daughter and, and we did one of her physics tests together, and I got 12 outta 12.

So, um, I just wanted to put out there that, that I, I still haven't lost my scientific background. It's year, year seven, but I, I was, I was pretty pleased with that.

Steve: How many did she get?

Gimmo: 12, Ask me anything on forces.

Steve: Well, there's a reason why I didn't go into optometry. You know, it's cuz I was rubbish at physics.

Jamie: Okay. Thank you both. Welcome again. Right. Let's move straight on. We promised you pace on these podcasts and so I'm gonna hand over to STC, who is going to welcome our first guest on the Aural Apothecary

Steve: Yep. So I would like to introduce to the Aural Apothecary, Clare Howard, who I've worked with quite a bit since I moved down to the South Coast, and she has a long and distinguished career in pharmacy, which she might not want me to say, but I know she does say that she did start working in a pharmacy when she was 16.

So she has spent a lot of time working in a pharmacy. Obviously, you never mention a lady's age, but she has worked in community pharmacy, hospital primary care and was actually the deputy chief pharmaceutical officer for  a while as well in England, and she now is essentially the head of medicine's optimisation and clinical director at Wessex Academic Health Science Network.

And that's really where I first came upon Clare, and we've worked together on things around polypharmacy and deprescribing. So, Clare, welcome to the Aural Apothecary.

Clare: Thank you guys. I'm, delighted to be here and honoured to be your first guest.

Steve: Well, it was essential for us after three 50 something blokes, we needed to make sure that we balanced up the books.

It was an easy choice that we wanted to have, uh, a lady on, but. Come on, let's get Clare on. She'll be great. So what we are gonna ask our guests, as well as the idea of the Desert Island drugs and the book, and the song is bar-Covid, what is your number one thing in your inbox? At the minute.

Clare: Steve, I think for me it's a little bit related to Covid, but, but all of the patients, particularly the older patients out there at the moment, on high risk medicines or multiple medicines where we know that prior to covid through the work, particularly we've been doing in, in Wessex, we've got a fairly accurate snapshot that of, you know, over 200 practices, that we had over 31,000 patients already that were potentially at risk from clinically significant medication errors. So due a medication review or due a blood test. And that was pre covid. And I think we know that over the last year or so many of those older patients are at home.

Phlebotomy services were stood down in the early days, uh, and we've not been routinely calling those patients in for review. So I think as we emerge, it's gonna be really important for primary care to have systems in place, not just to find the patients. That's kind of straightforward with tools like pincer and the polypharmacy comparators.

But how are we gonna prioritise those patients? How do we make sure that vulnerable patients. Patients from deprived backgrounds, for example, are prioritized for our support as well as older patients and those who we know are clinically at risk. And I think that's gonna be enormous challenge because we won't be able to see all of those patients on day one when we, when we start to get normal services back up and running.

Gimmo: Yeah. So I mean, you mentioned PINCER there, and that was one of the things I was thinking of when you said that, you know, we haven't, we haven't exactly had it in Wales else, but we looked at some similar stuff. Is that, um, is that a thing where you are, is that, is that something that's being thought of?

That sort of risk stratification tool seemed to be what you want.

Clare: Um, yeah. So across, England, the academic health science networks who were, put in place in England to support the system to develop innovation and, and scale and spread, uh, evidence-based practice. So across the AHSNs, over the last. Uh, two, three years we've been working to deploy pincer, across all of those practices.

And it, it's still patchy. We've still got a lot of work to do, but, certainly in my part of the world in Wessex, we've got about 94% of practices now using it. So that snapshot is really pretty accurate in terms of the volume of work, and I'm keen that practices, do another baseline post covid. So we get a really.

Picture. And then we work with our PCNs, our primary care networks, to say, okay, this is a big workload. We need to address this and we need to do it in a fairly systematic way, understanding that we just won't be able to see everybody straight away. So how do we, how do we get that priority and risk stratification done really well, really accurately.

So we see those most in need.

Steve: So I don't think I'm breaking any confidences by saying that where I'm working and I can confirm. As you might have expected, we were doing really well before covid in the numbers of patients, for example, who were on the pincer hazardous prescribing list, and when I looked at it only last month, of course it's gone up again quite significantly because as you've said, People can't come for blood or the blood services are not available.

So I know that you and I share this view that yeah, we are gonna need to get back on the horse in relation to that and all the stuff that certainly in England we're trying to do around structured medication reviews. Again, we have continued that, but people are less willing to come in, even though we've then turned to doing some on video.

On telephone, et cetera. But I think it, it is the role of clinical pharmacists in general practice to what I call keep the well, well, and I think the gps agree that the longer we don't try to keep up with that, then we go into have those additional strains on the NHS service. Yeah, it's, it's a really big challenge and I don't have all the answers.

Gimmo: And it's interesting that pincer might, this is something that might give us a measure of, cuz obviously it's a worry, isn't it? How, how much general healthcare has been missed during Covid and I, and I wonder if this is something that can give us an indication of that

Clare: And as Steve was saying, you know, before covid it, so, so in my neck of the woods, we'd reduced that at-risk list by over three and a half thousand.

So we'd made big inroads into that list. But yeah, I, I'm looking at. The practice, you've done a second, uh, download and you can see that things have, have gone backwards. So , an evidence-based tool like that that's been used in hundreds and hundreds of practices now feels like a very good place to start as opposed to everybody creating searches and we don't get that big picture. Because systems will have to commission phlebotomy services differently in light of some of this data and think about, uh, how, how we sort of put some of that together. So it's big picture stuff and you need really good data to support those decisions.

Jamie: While we've got clear on And can I ask you about your polypharmacy action learning sets?

Claire, without putting you on the spot too much, I've heard little bits about them from Steve. What's the background to those and, and they sound like a success.

Clare: Yeah, yeah, sure. We're, we're learning I think Steve, Zoe, and I, that teach on them would say, you know, it's an evolving process. But essentially we took a, a gem of an idea that came from Yorkshire and, and evolved that.

And we've now got, well over a hundred, GPs and pharmacists who've been through the process. And we've evaluated that. And essentially we take them on a journey of three action learning sets. We talk to them about what data is available to find patients at risk from problematic polypharmacy. We then, Quite a lot of work on shared decision making and things like Montgomery rules and how do you help patients decide when to take a medicine, but also understand what's important to, to patients in order to reduce some of that pill burden.

And we take them through that process. And by the end of the third action learning set, we we're joined by local geriatricians to talk through really giving confidence to clinicians to stop medicines. I think a lot of time clinicians know that either the patients aren't coping with the volume or they're not really taking the medicines or don"t understand it, but that nervousness to stop a statin or it's a real barrier and, and hopefully this work is starting to, to make some chipping away at that.

Jamie: So that treatment burden that you mentioned, that's, that's a term that is just recurring more and more in the literature now, isn't it? Um, can I just take you back to the actual action learning for our, our listeners, can you just explain what action learning sets are for those of them that aren't familiar with it? So, action

Clare: learning is a type of learning that's particularly geared up to complex problems where there isn't a, you know, you do X, Y, and Z and you'll solve polypharmacy.

So, so polypharmacy really lent itself to action learning sets. You take a group that work together that get to know each other there’s peer support, as well as some didactic sessions. And, and you see in the cohort, they move along this journey from not feeling very confident to stop medicines, to feeling more confident, but it's, it's perfect for something as complex as polypharmacy because there isn't a silver bullet for this. This is about changing systems, learning from one another and doing things differently with patients. And that's big stuff for, for, for prescribers.

Steve: Okay. So, hey, enough of the heavy stuff Clare. The reason for coming on obviously onto The Aural Apothecary is to give us your 'Desert Island Drugs' and as you know, this is something that we'd use in the polypharmacy learning set, and I know you loved it when I first suggested that we might do it. So what would you like to offer up? and as you know, it's about a drug that would evoke something quite powerful for you. So what would you like to offer The Aural Apothecary as your desert island drug?

Clare: Thanks Steve. So, God, this is really difficult when you actually have to do it yourself. So my first choice is methadone. So I was a community pharmacist in the mid-90's and I was running needle exchange schemes, and I was working in Stratford-upon-Avon, which, you know, you might think of as kind of middle class market town without a heroin problem, but you'd be wrong. And it was a really, really big issue. And I think for me, doing needle exchange and starting to get involved in substance misuse services, you just sort of realise it, especially in, at that period of time, you know, middle 1990's, those patients, HIV patients, patients with substance misuse problems, you know, they just weren't afforded the same sort of support and care that other groups of patients were. Yeah, and so in my little community pharmacy, I had a consultation room, you know, well, well, well before it was mandatory. And so being in a confined space, swapping needles with those patients and supervising their methadone, you get to know those patients pretty well. They weren't a massively different age group to me. And so you just sort of get this sense of, you know, nobody wakes up in the morning to, you know, to become addicted to heroin. And so some of them I worked really carefully with. And at the time when I inherited some of them, they were, you know, they were taking the methadone, they were selling it around the back and they were still injecting the heroin.

And I think what I'm really proud of is that by getting to know some of those patients and working with them, I moved them from a position of injecting to not injecting anything and taking the methadone orally and got some of them down to quite nice low maintenance doses. I didn't ever get anybody off and clean, but I do hope that there are patients out there from that group that, that are living healthy lives now, because of some of that work.

So that had to be, my first choice.

Steve: Well, absolutely brilliant.

Gimmo: Yeah, I mean that's great cuz I can remember you said sort of the nineties and I can remember sort of in the early nineties and we started to do needle exchange and, and actually it's one of those things that pharmacy's quite a conservative profession and, and some of the attitudes around that time towards people taking drugs was, I would argue not very professional.

So those of us who are doing those services were often on our own because lots of people just didn't want to do it and thought it was the wrong thing to do. So it, that's a nice sort of description of how far we've come because it would be deemed unprofessional for saying that now and rightly so. Back then, I mean, I remember setting up a needle exchange thing and it was, you know, it was, um, people really sort of had, had views about.

People involved in it that, that weren't very nice.

Clare: Absolutely, and I'd started out, as Steve said earlier as a 16 year old Saturday girl in Wigan. And I think you get a real taste of, of life in, you know, a pharmacy in Wigan at that age that actually, you know, some of this stuff, people's lives are tough and difficult and, and they're not there out of choice.

And who am I to sort of judge, like, why don't, my job is there to look after their health and make life a bit easier. So I think some of it was probably youth in inexperience and other, it was just, you know, these are patients they need the same service as everybody else. And it was a lot of fun. I have to say, some of them were brilliant, brilliant people that I had a huge amount of fun, you know, with in the couple of years that I was there.

Steve: Okay, that's great. We'll definitely accept methadone into the desert island drug list. So also we are looking for a soundtrack to your career.

Clare: Yeah, this was really hard because clearly I'm from Wigan,  I've worked a lot on polypharmacy, so the Verve, "the drugs don't work" was just so much of an obvious choice, but I'm not gonna go down that route.

Gimmo: Good cuz I picked that last week.

Clare: So my choice is a song by Johnny Nash and it's, “I can see clearly now”. And it was released in 1972, which is the year that I was born. I don't care that people know what age I am.

Steve: I didn't give it away.

Clare: No, no, no. I don't care. I think hopefully for me, so you'd ask me to sort of pick something that you think typifies your career and, and I hope those that kind of work with me would recognize that I am an optimist, not in the sort of “Pollyanna” way. Don't get me wrong, I can moan with the best of them and I do on a regular basis but in terms of work, I'm not a sort of pharmacist who has to have ironed out every obstacle first.  I do like to give things a go and I'll try new things and I can sometimes quite clearly see in the NHS, we've got a lot to be proud of, but there's an awful lot that with a bit of organization and a bit of common sense could be an awful lot better. And I think that song for me is about, you know, it's been a bit rough, but here, let's have a go at this. And you know, the clouds are departing so let's try so, so I just felt it sort of summed up, hopefully my attitude to try new stuff in the pharmacy world.

Steve: Well, I can, having worked with you for four and a half years, I would totally accept that. Absolutely. Spot on. Good choice. So, and the last idea is for something to go into the Aural Apothecary Library. So, a book if you like, that you would like to recommend to others. That may have meant something to your career.

Clare: Yeah, sure. This was really difficult. I'm a big fiction reader, but not masses of kind of management books and things.

But after much deliberation the book that I've chosen is “Invisible Women- Exposing Data Bias in a World Designed For Men” which is by Caroline Criado-Perez. Ina nutshell, this book describes that the default human is a male and the female of the species is sort of established as a kind of subversion of that and everything, the way everything's set up, the way all data's collected and there's a particularly brilliant section on  healthcare is predominantly looking at males and women are a kind of add-on.

Or just ignored altogether. And I think having been a female, you know, pharmacy's a female dominated profession in terms of the numbers, but as a female kind of working my way up through the ranks and, and you realise some of the stuff, you're, you're up against a book like this, which is relentless in the examples of how the world is not set up for, for women with caring responsibilities and I know now on social media the guys that will have a challenge with that, but I would, I think, I would argue if you are not gonna read it for the likes of me, your peers  have got daughters, grand-daughters that have gone through this stuff ,and I as well have gone through this stuff.

So I think there is some really important stuff in this book that hopefully the male of the species could benefit from. So I hope that wasn't too controversial for you, but that was my choice.

Steve: Absolutely brilliant and we agree wholeheartedly. And of course, the female of the species is, the song by Space that comes to mind for me, is more deadlier than the male….

Gimmo: Yeah, no, I was just gonna say, well, I mentioned very briefly that I've been obviously looking at Valproate for the last couple of weeks for, for various reasons, but that's a joke that sort of highlights what you're talking about really, because cuz obviously I'm looking at it in terms of it shouldn't be taken in women of a childbearing age and the system just isn't geared up to support that sort of thing.

That sort of exclusion whereby you've gotta identify and do something that is,in favour of those women. So, so you know, you saying that has just highlighted something I've been dealing with this week when looking at the system. So good choice.

Steve: Great first guest, excellent choices, all.

Jamie: Yeah.

Thanks Clare. Fantastic first interview for us. Let's move on then with our first current issue that we are going to chat about. And so I did promise you in the introduction that we would open up a discussion on Multimorbidity and its importance and the link with treatment burden and polypharmacy.

Interestingly, I did highlight a paper for my fellow apothecaries to look at this week in preparation, and I think our guest might have even had it as well. And I thought, well, that's a new, that's a new message from a new paper. I think it was a Lancet paper. 10 minutes before we were due on air tonight, it was highlighted that the paper was nine years old. But interestingly, the message is still the same.

Gimmo: Stop trying to make excuses Jamie

Steve: The pedant amongst us is Gimmo. Well done, Gimmo, you spotted it well

Gimmo: A pendant that I checked the date of a paper!

Jamie: worryingly I've read the paper twice from start to finish . I thought, oh, that's interesting. So,  what do we think multi morbidity, hand it over to somebody else to, to start us off, Gimmo?

Gimmo: Well, it was just the obvious point that once we sort of realized we'd picked a paper that was nine years old, but it was interesting that none of us realised because it's still a big issue.

I would say polypharmacy has probably come on leaps and bounds since this was written, but multi morbidity and how this talks about how we still sort of treat diseases as a single entity. I'm not convinced that's changed much.

Steve: No, it definitely hasn't. I mean, you look at NICE and it knows it needs to work harder to do this, but actually I even wonder who are they gonna get on those panels to be able to actually do that because Clare and I know that there's this lovely term that came up in one of our polypharmacy learning sets. It was in Cornwall, if I remember rightly, no, Devon. And it was this idea that, well, we've got all these singleorganologists and it's actually really hard for them to keep up to date, if you like. Not only in their own area as the actual expert, but to expect them to be able to keep up with everything else.

So I work as an advanced generalist, which I think a lot of clinical pharmacists do, and I've always argued that even if you become the cardiology pharmacist or the mental health pharmacist or the respiratory pharmacist, woe-be-tide, if you think you can then not keep up to date with all the medicines and the disease states that all of those patients are going to suffer with, a COPD patient being a classic example. And so yeah, I think Britain probably has followed the American model really, hasn't it? In moving towards single-organ-ologists and specialists. And we hear this a lot, don't we, Clare?

Clare: Yeah. And it, and it presents massive challenges for the patient and for the clinician to look at their medicines in the entirety on work, work out what's going on, and what's important to the patient. We had a patient on one of our groups that described two of her consultants having a row and each of them thinking they were more important and nobody thinking about the patient at the bottom of  all of that. I think the bit for me in the paper that was interesting , you know, in the discussion when it talks about you know, age deprivation and being female as being  big driving forces around your likelihood to have multiple long-term conditions. And yet, like we just said before, the services are just not geared up, uh, to support that. And I think post covid, the deprivation angle to this is really, really stark, isn't it?

And the health inequality, so, so yeah, maybe 12 years old, but we're still grappling with all of this now.

Steve: Jamie, isn't that your famous inverse care law? At work.

Jamie: It certainly is.  And, and we haven't got time on today's pod, but I, promise you , a story for a future pod. It's the day I spent with Julian Tudor-Hart , and it is one of my most memorable days.

And you know what, I was on my way to a drugs and therapeutics symposium in July, 2000. And I got on the train and I sat opposite this old looking guy who turns out was 73. The day I sat opposite him. He passed away when he was in 91 a couple of years ago. But yeah, that story is for another time.

Steve: So do you just wanna explain to the listener though , who he is?

Jamie: So, yeah, he's a GP from Swansea in South Wales and he published the Inverse Care Law in 1971, which suggested that those in need of healthcare get it least, and those who don't need it get it most.

Steve: Yeah. So it chimes very strongly, doesn't it? And I know Clare, when you look at the NHS BSA data for England you often pick up this, don't you, around the social deprivation. You cannot ignore it.

Clare: It's so stark. I mean, saddo that I am, I spend ages looking at that data. And if you, it's interesting cuz the volume stuff, so the volume of medicines people are on, it's Blackpool, it's Portsmouth, it's the North-East.

They are the places with the biggest problem in terms of volume of medicines. Interestingly, when we look at some of the therapeutic comparators, so the sort of, you know, things that we know when you give them together are more likely to cause harm. It isn't always the deprivation factor there. So we're getting it wrong for the more affluent populations in terms of drug choices.

And then we're dishing out all of this stuff, and the drivers are around deprivation for the volume comparators and, and you know it’s static, however, which way you look at it.

Jamie: Just to let you know that despite sort of calling out a paper that was nine years old for our current affairs section in front of me, I have got 1, 2, 3, 4 papers from the British Journal of General Practice in the last six weeks.

All on multi morbidity. So primary care consultation, length by deprivation and multi morbidity in England, enhancing self-management of multi mobility in primary care, impact of multi morbidity on healthcare costs and utilisation and treatment burden for patients with multi morbidity. So as Gimmo said, you know, a nine year old article but is still as current and as you know, difficult for us today , STC?

Steve: And I think listeners are always gonna want to think about, well, have you got any solutions then?

And I think what that paper points to is what I see, and Clare and I have seen this when looking for data around how do you most successfully manage to reduce polypharmacy? And it is through multi-professional teams. So whether that's community geriatricians and GPs or GPs and pharmacists or community matrons and pharmacists, or community matrons and GPs.

It's a multidisciplinary professional team effort . That is the response and that paper , even though, as you say, it's nine years ago, that's what it talks about. You need to have a generalist primary care team and primary care I think wants to do tha , but it's become increasingly hard. And so, who is going to fill that void?

And I think they are the right people to do it, but they're probably gonna need a bit more specialist help from say community geriatricians. And as the paper says, what do you do for the loads of people who under the age of, as the paper identifies lots of people under the age of 55? Well, geriatricians generally, they don't see those patients, but they're one of the few people left that will do a all-encompassing medical review of a patient. It's really hard.

Clare: It is. And, and it'll be interesting in, in England where we've started to put these social prescribers in. So Steve, you're right. You know, the multidisciplinary team is the answer to some of this, but it'll be very interesting what the role of social prescribers is in terms of the non-drug support  for some of these patients.

And will that have an impact on, on some of our more deprived populations, where that is the answer around sort of support that's not really linked to a prescription at all. I guess we, we'll have to wait and see.

Steve: We'll have to get a single-organ-ologist on, I think to re-ask this question again and see from their point of view. I think that would be really helpful. I'm sure the listeners would, would listen and take note of that.

Jamie: And we've still got eight years because we know it takes the NHS 17 years to implement anything . So we're a clock ticking , but we are on track? Okay. So thank you. Thank you, thank you all.

Gimmo: Well, that was a good chat, but I don't think we should let you off the hook, Jamie. Must do better, next time. We'll be discussing that famous paper on vitamin C and its use on British naval ships next week.

Jamie: But I must, I must get a chance, I must get a chance to tell you my day out with Julian Tudor Hart story when properly for a future session.

It is extra bonus POD, it's a stunner. Okay, thank you all. Let's move on. What, have we got coming up next time. Well that's me as well now, I think. And so just to let you know that our next guest on our next episode will be joined by Dr. Amira Guirguis.  Amira is a pharmacist and international expert in the field of substance misuse and infield detection of novel psychoactive sub psychoactive substances.

She's now the MPharm program director at Swansea Medical School and she was recently identified by the Pharmaceutical Journal as one of their women to watch , 2021, one of 12 outstanding women that will change the face of pharmacy. So, we look forward to hearing from Amira. In our next episode, I'm gonna hand over to Gimo, who is gonna go through the different ways people can get in contact with the POD.

Gimmo: So we're on Twitter @aural apothecary and this new-fangled social media thing called Instagram #auralapothecarypod . And you can email us at auralapothecarypod@gmail.com. Thank you.

Jamie: We look forward to hearing from you.

Steve: I was just thinking, actually, you better tell Amira that methadone is already gone for Desert Island drugs.

Jamie: She told me what her Desert Island drug was. It's Okay.

Steve: That's all right then. Okay.

Gimmo: And to finish. The final ingredient. Do you guys lack motivation  at work this week? An early warning for dementia, apathy in middle-aged could be a predictor for some forms of dementia, scientists have warned . While easily mistaken for laziness, a loss of motivation, and interest in life has long been associated with frontotemporal dementia.

So, potentially a serious matter, but it was the last line that that caught my eye, particularly given what Clare was hinting at in terms of the tidal-wave of work that's heading towards GP practices at the moment. But the researcher said, people who lose motivation in middle-aged should seek medical advice.

Jamie: You've been listening to a 'Three Apothecaries' production,

Sound and production by Jimbo Slough.

Music by Jamie Brewster.

Artwork by David Baker.

Thanks for listening to the Aural Apothecary Podcast where we, always, dispense with accuracy….