Episode 5.3 - Professor Alf Collins: No decision about me, without me

Aural Apothecary Episode 5.3

Jamie: Welcome to the Aural Apothecary podcast. My name is Jamie Hayes. For this episode, we're joined by Professor Alf Collins. Alf is NHS England's clinical director for personalised care. We will welcome Alf in a moment as he shares a drug for our formulary, his career anthem, and recommends a book for the Aural Apothecary library. For our micro discussion, we continue our look at the recent article in the Sunday Times, "the NHS is Flatlining, here's how to save it right now." Before we go any further, let me welcome my two fellow Apothecaries. STC is in Bournemouth and Gimmo is in Cardiff. Welcome both.

Gimmo: Evening.

STC: Evening.

Jamie: What have you been up to?

Gimmo: I'm embroiled in pre-holiday planning at the moment.

So, I can't really think. It's been a busy couple of weeks and then I'm in that pre-holiday panic phase.

STC: I'll give you a couple of quick ones, a couple of negatives, and then a very, very big positive. So, a couple of negatives, as in personal negatives for me. I got feedback from two people who are avid listeners of the podcast, one telling me off that mentioned Amazon as to where to get your books from and that we should be pushing local book sellers Apologies for that, Sarah.

I got some good feedback from Liz Lamberton, who's a renal specialist pharmacist who really, really enjoyed the Deborah Duval episode, but said that I, with too much glee, said, "take note, secondary care."when Deborah was talking about how she didn't think that they were listening to her views about her own life. And the big positive, nd it couldn't have come at   better episode for us, with Alf cuz, hey-ho, it's not just thrown together! Dr. Julian Treadwell GP, an academic who's been working apparently for six years on this, and this is this new website called wwwgpevidence.org . And it is “fabulous darling”, and I'm sure we're gonna talk about it later, but basically there is, you know where to go for good evidence that puts it into a patient decision aid So smiley faces, risks and benefits. It's fabulous

Jamie: Very good, Gimmo?

Gimmo: Yeah, like you say, not much. We went on a date, didn't we?

Jamie: We did. STC went up to Scotland to watch the rugby, so Gimmo and I sneaked date night in, we had a little podcast summit in Cardiff. While he was away in Scotland. We went to TEDx Cardiff.

And in between one of the speakers, they asked to speak to somebody in front of you. And so, the lady in front of us tapped on the shoulder. I said, oh, you have to speak to us. Sorry. And I, and so I asked, I said, if you had to give a TED talk, what would it be on? And she replied, patient safety.

STC: No!

Jamie: She did. So, a big shout out to Marlene Perez-Coleman, patient safety and environmental advocate, Argentinian plastic surgeon, moved to Wales, resilient and resourceful is how she describes herself. So, yeah, we had a great conversation with Marlene and it was lovely to meet her.

STC: That's just a stop from "positive and pacey", that.

Jamie: Yeah. So, what would your Ted talk be? Steve, if you had to give a TED talk, I'll come back to you on that and then look from me, maybe a first for the Aural Apothecary, but I've been sent a gift.

STC: Well, hang on. I sent you a gift.

Jamie: No, no, no, no, no. From a listener. Oh. Oh, hang on. Can you see that is, do you know what?

STC: Is it a Tom-Jones-esque type gift?...

Jamie: So, thank you to one of our super fans, Fiza , who sent me an orange peeler.

STC: Don't even ask.

Gimmo: Hold on, Fiza’s my friend.

Jamie: Ah, well, yes. But, you know... Anyway look, congratulations to Aural Apothecary alumni, Dr. Pete Turton, who I saw on social media, has just got his consultant post.

STC: Yes. Congratulations, Pete. Absolutely. We took him all the way as an anaesthetist there. Jamie: And then look finally, before we welcome our guests for tonight. Thank you to our listeners in Belgium, the Philippines, Estonia, Mongolia, for keeping us bouncing around the charts in those countries for the last five or six weeks.

STC: Ulan Bator  we'll be going there for the next live show.

Jamie: Your support is much appreciated. Let's move on.

Gimmo: Are we allowed to mention that we're off to Lisbon?

STC: Oh, yeah. We should.

Jamie: Go on, then

Gimmo: We're off to Lisbon. So well, do you know the name of the conference, Steve? So, you give the details.

STC: So, the European Association of Hospital Pharmacy, have invited us to do an Aural Apothecary live at the EHP conference this year in Lisbon.

So if you're gonna be there, Check it out.

Jamie: Very good. It's a great pleasure to welcome Professor Alf Collins to the Aural Apothecary. Alf was a community consultant in pain management for many years, and in parallel worked for a decade with the Health Foundation helping lead applied research and implementation programs in person-centred care.

He has researched and publicized widely on all aspects of person-centred care and has a particular interest in changing the relationship between patients and healthcare professionals. He has honorary fellowships from the Royal College of Physicians and the Royal College of General Practitioners, runs a visiting professorship in healthcare policy at Coventry University.

I've had the pleasure of welcoming Alf speak at a couple of conferences. One was from a studio in Bristol during lockdown. The other was at last year's PrescQIPP  conference in November, 2022. Welcome to the podcast, Alf.

Alf: Well, it's absolutely wonderful to be here. Such a delightful company to be with at, quarter past eight in the evening.

Lovely, lovely to be here.

Jamie: Thursday Night Pod. So, Alf, look changing the relationship between patients and healthcare professionals. How's that going?

Alf: Slow. Slow, but sure. I'd reckon actually, Jamie, we've been talking about it haven’t we for decades actually, this stuff? And I remember 20 years ago when I was really kind of getting into grips with this, changing the relationship stuff, and I was getting a bit down about it, but I do think there's many, man more of us now talking about it.

There's many of us knowing it's the right thing to do. In policy terms. It's I think, probably as high profile as it's ever been, certainly in England. And I think we do some good stuff generally, across the country. And I think pharmacists, I would say this, wouldn't I? On a podcast led by pharmacists.

Jamie: Not a pharmacy podcast though, Alf. Okay. Not a pharmacy podcast!

Alf: Thank you very much for reminding me that. I think they are probably are leading the way. Pharmacists probably are leading the way actually. Physio-therapists, pharmacists, nurses, probably. Doctors, eh, possibly not so much. With some honourable exceptions, of course, of course. Yeah.

STC: Why do you think that is, Alf?

Alf: We've got our heads full of knowledge, haven’t  we? Especially doctors, we like to pride ourselves in how much we know, really. And actually, we feel it's our duty, if we're being person centred to tell patients all the stuff we know.

And that, I think is probably getting in the way of us developing a genuine curiosity to know more about them. Of course, it's a vast overgeneralization of course, but you know, there's quite a lot of research that doctors struggle a little bit more than other healthcare professionals to work in a person-centred way.

Gimmo: So, so I've sort of been involved in, I say teaching, that's probably not the right word, but we're running a few sessions on shared decision making and actually I think using some of the King's Fund stuff, that you were involved in, was the King's Fund? No decision without me.

STC: Hang on a minute, we should just make a very big point, not just because Alf is here, because that is a seminal piece of work.

So for listeners, and the reason why you might think,we were having patients and advocates on in this series. Well, we are because you gonna have no better advocate for all of you than Alf Collins. So Alf Collins and Angela Coulter are the godfather and the godmother of shared decision making in the UK and their King's Fund document from 2011, which was called Making Shared Decision Making a Reality: No Decision About Me without Me is absolutely seminal in everything that anybody ever says about shared decision making. Jamie : Let the guest speak now.

Alf: Well, that's lovely. That's really lovely. Yeah, we wrote that 12, 13 years ago, didn't we? It's funny, isn't it? And. We are getting there though, aren't we?

People like Nadine Montgomery, it took her years to go to the Supreme Court to actually get the Montgomery ruling, and I think she's done as much as anybody actually to change our perception of the value and importance of shared decision making.

It's there in GMC guidance. It's there across all the professions in terms of their statutory regulations. I don't hear people now saying, oh no, that's not a very good idea. People generally say, yes, of course, important. And then they say, yes, of course. And I do it. And of course, we know that perhaps not everybody does do share decision making as well as we might

STC: Alf just for the non-health professionalcould you just very, very quickly explained then the Nadine Montgomery law? Cause it is important. Alf: Yeah. Yeah. So, it used to be the case that when we were signing a consent form to proceed to a surgical procedure, then it was encumbered upon the clinician, it was called the Bonlam Principle, to tell patients what a reasonable clinician would tell a patient about the benefits and harms of the procedure.

And Nadine Montgomery, it was a dreadful case. I won't go into the detail of the case, but it was a, maternity case which really didn't go at all well. And she argued that actually it was her that ought to be making the decision about how much information she would want to have herself to make a decision about what she, what's called in legal terms a material risk, a significant risk.

It's only us as individuals who really know what a significant risk is. We kind of make sense of it in terms of our own context. So, it turned the Bolam case on its head and the Montgomery principle is now that we should tell patients about the benefits and harm and procedures that a reasonable patient will want to know,not that a reasonable clinician would want to divulge. So it's turned it on its head. STC: Yeah. Thank you. Thank you. Alf. So sorry, Gimmo, I know I jumped in, but you were gonna talk about, you were doing some teaching about shared decision making.

Gimmo: Well, no, it was more we were musing weren't we on what impact this had.

You know, that paper was 10, 12 years ago and there's stuff before that I just remember. It's always stuck in my mind. One of the things that used to come back for people at those sessions was, people were generally in favour of the principles. They were always worried about the time and effort that was involved in doing it and how they'd fit that in to what was then a busy sort of schedule and now is even busier. And I often, and we used to try, we used to say, well, if it's done right, it will save time. And it's better for the relationship. So I just wonder if that's true. If, is it easy? Is it easy to do? You know, or if we slightly mis-sold it in terms of, it is actually a more difficult processIt's just more worthwhile in the long run.

Alf: Yeah. I mean the evidence is, reasonable that it probably does take five to 7% longer. That's what the Cochrane Review from a few years ago said. When I was part of the Health Foundation, we ran a program called Magic, it was a big quality improvement program.

And what we demonstrated there was if patients know stuff up front so if they're given decision support tools upfront, if they're encouraged and supported to think about what matters to them upfront, either in the hospital letter or when they see the receptionist, when they walk into the waiting room, or when they're waiting for the online conversation to happen.

If people are prepared, start to understand what their options might be and start to think about the questions they might wanna ask, then that actually does kinda reduce the amount of time that's needed to do it really well. So you have to actually change the way you do processes and the service to do it.

STC: Yeah, and just to add to that, as you guys know, being a clinician that I am, and I've had a couple of excellent consultations today actually, that really detail what it is that we're talking about here.Having spent seven years now working in primary care, having spent 25 years in secondary care and bemoaning some of that stuff in secondary care, cuz I always used to say, well, I didn't really get to know the patient and you know, they're not in their own habitat.

You know, I was thinking today as I cycled home, it's a bit like an analogy with a zoo animal. Okay, so if you are the patient in the hospital, you are not in your own habitat, are you? So you're going to do what your keeper tells you and the keeper thinks that you, the animal, are complying with what you, the keeper are doing.

Well, that's because you hold the keys quite literally to the compound, whereas now in primary care, I feel I'm seeing those animals in their own habitat and so it's much easier to have these conversations cuz the chances are that they're really gonna tell me what they think because they're in their own environment and their own values and preferences can come through. Hopefully that analogy makes sense.

Jamie: Did you check that analogy with anybody before coming on?

STC: No. No, that's literally how my brain works. About an hour ago I came up with that. I think you quite liked it. Anyway, what I wanted to say was that, the other thing I've noticed in primary care is that, and again, there are always exceptions aren't there, but I find that  I have to prepare. Okay, now I do get half an hour appointments because I'm dealing with people with multimorbidity and lots of medicines , like 10 plus.

But, I challenge anybody to be able to have a shared decision making process without some preparation of what you know about that person before they come through the door, so that you then spend the time with them listening to what they think and it's sort of like, now I'm like, oh, but it's so obvious and yet it's this kind of almost like prevention versus cure, isn't it?

Surely prevention's better than cure, but we still do too much curing. And it's like surely if you proactive rather than reactive. Cuz if you're reactive, the chance is are you're gonna get it wrong. Both from your point of view and the patient's point of view. And I see it clear as day, but I realized that it's about changing behaviour.

Alf: And it's interesting, Steven you were talking about seeing people in their natural habitat. About a month ago, our boiler broke, at home, in came the plumber. I understand nothing about plumbing. He was fiddling away for about 10 minutes. came to me, gave me a plain English diagnosis. This is what's happened. It is stuffed, plain English diagnosis. And then he said, here are your options 1, 2, 3. Here are the benefits and here are the risks as associated with these options. And here are the costs. What do you wanna do? Honestly, it was absolutely perfect shared decision making.

It's not an unnatural conversation to have, is it? It's a, an everyday negotiation, it feels to me.

Jamie: Alf, tell me about the term : Activated consumers.

Alf: Right. I don't like the idea of patients as consumers. I really don't. I fervently believe in co-production. I, we've had a far too paternalistic system for far too long.

What I don't want us to move is in the opposite direction towards a consumerist society. And I genuinely believe that co-production where we meet in the middle and we share our own expertise is the place to be. However, there's been an awful lot of talk, particularly in the States about this concept activation, and activation is having the knowledge, skills, and confidence to manage your own health and wellbeing To take part actively in conversations about your healthIt came from a colleague of mine, Judy, Hibbard, University of Oregon, about 20 years ago. I've done some work with Judy on Activation but I just don't like the phrase consumers, cuz I, as I say, I fervently believe that it's a conversation between equals that comes to the best possible decision for both parties.

Gimmo: Well, a few years ago when we were doing some work looking at the Nuka system of healthcare, that was very fashionable for a while, a  place in Alaska, where they had a very multidisciplinary primary care model. And they used the word think I've got this right, “customer owner”. So instead of patients now, I think anyone in the NHS, as you just did, Alf, gets antibodies when we start talking in those sort of terms, but actually it was quite a useful phrase cuz it, I thought it, it, in a way it laid out the relationship quite well in that the patient was both the customer and an owner of the service that they were getting.

So I'm with you, but I think there is some use in reminding ourselves that the patients aren't just users of the health service, they the owners of it and the payers of it.

STC: But isn't that, going back to Graham's point about being project managers? I mean that's exactly Graham's point, isn't it?

From the first episode in, in this series?

Jamie: Yeah. You use the term Healthcare Navigator, I think, Alf. I've seen in one of your taks , which is the same premise, isn't it? Yeah. Can I give you two quotes, Alf that I picked up on Twitter? " We need to do much more de-implementation, but it's hard." That's one of yours. And "agree and would add that confidence to share our reasoning and our uncertainty seems to come with experience / age,  would be fab to explore this from an ethnographic point of view."

STC: Is it age or is it experience?

Alf: Yes. Maybe wisdom, isn't it? Somewhere in between age and experience.

Yeah, that was Richard Layman who started that. Richard Layman used to write a wonderful column in the BMJ for many years about evidence-based healthcare. He's a very wise person and he, it was Richard that started that Twitter trail off. We're full of uncertainty, aren't we?

We've no idea about healthcare. Makes us feel anxious, as clinicians, why aren't we much more open with patients about, about I'll use the word patient here, just to be, rather people, just to be clear, why aren't we much clear with people about our uncertainty? I must say, towards the end of my clinical career, there was nothing in my head that I wasn't sharing with patients.

I wasn't holding stuff back. I was just very genuinely and openly being the person that was inside my head with them.

STC: It does come with, as you say, it's confidence, it's wisdom. I was talking to someone the other day about, being, talking about judges of character and I said, the thing is, I said, when you work in healthcare, I worked out one day, roughly I think I've spoken to and helped a quarter of a million people so far in my career. And there are only certain, we've all got values and preferences, but there are certain gross types aren't there of , types of people. And so if you've had lots of practice at that's, that 10,000 hours kind of thing, isn't it?It does become easier the more you've done it. So whilst earlier I was talking about, I see it and it's easier, I guess what I'm saying is that came through training, okay. Being trained, and then being prepared for when people come through the door. And I honestly do believe that, but if you haven't got the training and you haven't got the understanding, then of course you're gonna find it difficult.

Alf: Yeah, exactly. Exactly. And I would, and if you haven't had the experience of saying to patients, I don't know, and having the confidence to say it and realizing that time after time, when you say that, patients genuinely, they really that, that they get it. They really do. They don't go, oh my God, you're hopeless.

 They kind of generally kind of, they'll engage in a conversation at a much, much deeper level, I think, if you display that humanity and uncertainty.

STC: Yeah. Jamie, I'm just gonna beat you on your quotes. Well, I think I'm gonna beat you on your quotes in that seminal Kings Fund document.

How about this? “Shared decision making is the principal mechanism for ensuring that patients get the care they need, and no less, the care they want, and no more”. Who knew that you had Al Murray in your fun document? The pub landlord! No, it was actually Al Mulley. But anywayI'm always thinking it as Al Murray when I read it.

Jamie: So along that, no more the de implementation side of things. Alf, what does that. Look like for you?

Alf: Yeah. It's a rubbish word, isn't it? It really is. And it's...

STC: Like deprescribing, that's a rubbish word too!

Alf: I was looking through some office of budget responsibility papers...

STC: Having difficulty sleeping?

Alf: Yeah, I know. That's boring, isn't it? It's so boring. People have been saying why does the NHS keep costing more? Why, why, why? And I also looked at a fantastic paper. It was called “ What the Nobel Prize Winners ever done for us?” , in the HSJ a few years ago. It was essentially saying that the increasing spiralling costs in the NHS are due to increasing complexity and intensity of clinical practice.

In other words, when we get more research, we add it onto what we're already doing. We don't substitute the new research and stop doing stuff, we just add it on. So, we accrete more and more and more and more processes, many of which are low value processes onto the way we go about doing our jobs. So, we frankly ought to be de-implementing stuff, at least as fast as the rate at which we implement.

In order to, to maintain some sort of equipoise in the NHS, we're just actually, we're burning out our staff, we're doing too much to patients, and there's gotta be a time when we just say, look, we've done enough. We've done enough. We've gotta start, taking an awful lot of stuff off the menu and we're not doing it, we're not doing it enough.

Gimmo: Yeah, I was gonna say, it's the first rule of process mapping really is what can we take away?

Alf: Yeah, exactly.

Jamie: And one more from me, Alf before I let Steve come on with the important bit. But on one of the groups that we are all on, I think there's that talk of the time needed to implement.

That debate that's taken place the last couple of months hasn't it, about that, if we are to follow the guidelines that actually our clinicians just don't have the time to be able to implement everything that's thrown at them.

Alf: Yeah, it's all the same stuff, isn't it? 27 hours a day I read from America.

If you use, if you did all the American guidance you'll be spending 27 hours a day, seven days a week. Yeah, Tim Wilson was the name of the chap who wrote that really good article in the HSJ about four years ago? And it really is about, we're doing too much.

We are doing far, far too much.

STC: If you send that to us, we will put it in the show notes.

Alf: I will

STC: okay. Excellent. Great chat as ever. Sounds like one of those that we could spend all night here in the pub of the Aural Apothecary, but we must move on.

So, Alf, one of the benefits of coming on the Aural Apothecary is to give three things. The first one I'm sure you're aware of, this is a drug that really evokes a powerful memory for you, either from your working life or through your health journey so far. So, what would you like to offer us for your desert island drug?

Alf: Well, it's a class of drugs and it's pretty boring, I'm afraid, but it's statins.

STC: Oooo, Jamie will force you to pick one of them!

Jamie: You can start with statins and we'll, yeah, we'll ask some clever questions in a moment. We'll get you down to one.

Alf: So the reason I chose the statins is I remember I was in Oxford when evidence-based medicine took off in the mid-eighties, and we started talking about numbers needed to treat and numbers needed to harm.

I did some work with some people who were running a little magazine called Bandolier do you remember?

STC: Oh yeah.

Jamie: Remember it well, remember it Well. Really good, wasn't it? Bandolier.

Alf: Was really, really good. And I remember hearing that these new drugs were called statins and the number needed to treat was 40. I remember that so well, was about 1987, something like that.

And I remember thinking, why are we giving people drugs if you were give it to 40 people before one gets a reasonable effect and we've had that debate on and off for years, years and years, decades. Tell me about statins. There's the kinda trade off between, you know, the public health good and the fact that, you know, until recently we've not really thought they do that much good on the whole for individuals.

Something, a small number of individuals that they do actually help, would I, it made me really think about statins for this podcast is, I've just been sent the new NICE decision support tools on statins, they’re a damn sight better than I thought, actually. They do look very much better than I actually thought, it's made me think, God, I think I probably need to do my Qrisk again and reconsider whether I take statins myself.

So that's why I bought it up.

STC: I was gonna say, it links very well to Julian Treadwell's resource that we mentioned earlier, www.GPevidence.org, and he tweeted, I think yesterday to say however many people have looked at it so far. And the three top areas that people have gone to is statins, anticoagulation in atrial fibrillation, and, Louise will be happy, HRT. Those are the three that most people have gone to so far. Excellent. Well, if I tell you that one of the previous guests picked Simvastatin, could you pick another statin for us so that you can have it unique to you?

Alf: So I'll go for Atorvastatin in that case.

STC: Ok. It was Mahindra Patel, by the way who picked Simvastatin? I know, I know. The listener was shouting out at their radio. I know we're not on the radio.

Jamie: It just shows you though, after that decision not to take a statin or to take a statin is a dynamic one, isn't it? And it changes, it changes, doesn't it?

Alf: Isn't it? And it makes you think an awful lot about adherence and yeah the difference between preventative medications and medications that you use to treat symptoms. Yeah. It's all, it's very interesting. It can trigger a lot of debates.

Jamie: And so it's not a once only is it that's, you know, it's, it's, oh, I made the decision not to take a statin then I can't review that. I can't change my mind. I can't, you know, that's important to note, isn't it?

STC: And do you know what? We get that all the time. So, you know, we say to people, absolutely fine. Here's all the information. Yeah, I've heard what you've said. We'll document that. We can come back to it whenever you like. A week later, "I've decided I've changed my mind. I will. I will go with it." Absolutely fine.

Alf: Yeah. It's an old chestnut, but yeah.

STC: Yeah. Okay. Atorvastatin, and yet Statins probably have the most data of any class of drugs on the planet. Atorvastatin is then into the Aural Apothecary Formulary.

Well, next up, Alf, I don't know what your musical taste is like, but we take everything on this podcast. It's very eclectic. So what would you like to offer for the Aural Apothecary Spotify playlist? And yes, you know what I'm gonna say next? It really is on Spotify.

Alf: So two came to mind, but I'm gonna, I'm gonna tell you the one.

The two that came to mind are number one, Kashmir by Led Zeppelin. A number of reasons for that. One of which was Robert Plant went to my school. Ah, he's a lot older than me. But he was in the sixth form in school in Stourbridge, and he was always hanging about around the town centre driving his silver Aston Martin DB5.

When I was a 15, 16 year old, and it was quite impressive. So I really got into Led Zeppelin's music and Kashmir is one of their finest tracks. But actually the one I would take is from Pink Floyd and it's "Shine on you crazy diamond", just it's a banging tune and probably the best guitar from Dave Gilmore that I've ever heard.

And every time I hear it, look at it live on Pompei from a few years back. It's absolutely blistering. He was about 73, 74 at the time, fingers are a little bit on the chunky side, playing like a God. Yeah. There we are, Shine on you crazy diamond.

STC: Wow. Well, go on Jamie, I know you want to

Jamie: No, not at all.

No, I just, we're being dominated by Pink Floyd.

STC: Pink Floyd has now got the most number of picks from Aural Apothecary guests. Is that right, Jamie? Yeah.

Gimmo: Well, I think we've had "Shine on you crazy diamond", that’s our first duplication, isn't it?

STC: Phil Howard had it. Yep. So there we. But we've had three we've had three others as well.

I think there's no rules though. No rules. Yeah. And it is a great track, a very good friend of mine. Jamie and I, we've known for 35 years, Darren Cooper. That's one of his favourite tracks as well, so "Shine on you crazy diamond". An absolute belter. Excellent. And the third for the Aural Apothecary Library is your book choice for the listener.

Alf: Well, again, I'm slightly, I'm a bit of a maverick, aren't I? It's actually the Lady Bird books.

Jamie: You got my attention.

Gimmo: You're at Jamie's level.

Alf: The reason for that.

STC: What about Brexit? Sorry!

Alf: The reason for that,

Jamie: Is it the Sly Fox?

Alf: It's all the Lady Bird books and I'll pick one. The six Wives of Henry VIII  is the one that comes to mind. But I grew up in a very, very poor family. And we had no books in the house at all, apart from Lady Bird books. And, it was a council house in the, Midlands and, and you know what? You could pick up and you could read about the six wives of Henry VIII. Then you could pick up another one and learn about calligraphy, and then you could pick up another one and learn about Polynesia, honestly, I mean, just, they were incredible and in fact, I've got a collection of them now, in my library.

Jamie: Is the “Magic porridge pot” in there, Alf?

Alf: Yeah.  and they're still brilliant reads.

Absolutely brilliant reads. I commend them. I commend them to this podcast.

STC: Well, I think that's genius. And you're dead right! It's a bit like Horrible Histories. You know why Horrible Histories on the TV was so successful was because, unlike everything, it's a bit like, you know, communicating risk. If you've gotta  understand it, you've gotta be able to put it into a format that people you know, can digest. Yeah. So that's genius.

Gimmo: Maybe we need to write the Lady Bird Book of medicines.

Alf: There we go. Well, do you know, I was, as I was thinking about this, I was thinking that is a format that is so engaging, It's a wonder that nobody's really caught onto it now.

STC: Yeah. So the, because they have done some modern ones.

But they've done very tongue in cheek, the new ones. Yeah, lots of parodies about Brexit and stuff like that. But you're right, Gimmo. Cuz we have talked, maybe it was offline, but about the Haynes Manual. It's another one, right That I really like. And Louise Newson, who's the HRT guru ,who we've had on here, She's written a Haynes manual for HRT, and I said to the boys, we should do a Haynes manual on medicines and deprescribing. I honestly think that we could get a chapter out of every single one of you that's been on as a guest.

Jamie: So that brings me on to ,look, my read for this week was, is called "Medstrong”  Okay. And it's from the States. "Aging Well through Deprescribing" by a Pharmacist called Donna Bartlett featuring a five step medication optimization plan. And it's a great read, actually. It's a really good read and it's not far above Lady Bird book level, to be honest with you.

You know, it's just it's a bit thicker than a Lady Bird book, but it actually talks through in a very nice way. Aging well through Deprescribing and the whole emphasis and focus in the book. Yeah. It's worth a read.

STC: Is it aimed at the public?

We could plagiarize it, turn it into the Lady Bird books in the UK.

Joking, joking. Yeah.

Jamie: That's a plan, that's a plan. Alf, before we go on, look I was serious about the question earlier. What would be your TED  talk if you if you had to do a TED  Talk?

Alf: It would actually be about the application of health psychology to healthcare,  my wife's a psychologist.

Many of my best friends are health psychologists. There's this whole discipline of the way we think about the way we understand health, healthcare, and medicine. Which drives our behaviours, which most of us are not aware of. And frankly, I think health service should be promoting this work.

most of my work has been driven by a sort of an amateurish understanding of health psychology. So it would be about health psychology. Although, as I say, not being a health psychologist , I wouldn't do as good a job as some of the people who are health psychologists.

Jamie: STC, what would you be?

STC: I think we, I mean we say that, don't we? We are not psychologists. We do  like cod psychology, but we talk about it like almost every podcast, don't we?. So my TED Talk would basically be called One Less Pill. Because, and I'm not just saying this and I think it's cuz of my tens of thousands of hours of practice , and my attention to detail and my preparation , is that I've always prided myself on that, you could pretty much ask me about any patient and I could probably suggest that at least one less pill that person didn’t need  to take

Jamie: Gimmo ?

Gimmo: I don't know. You put me on the spot there. There's something about how cognitive bias plays into our thinking, cuz I think we, we underestimate it.

And so that heuristic approach to how we make decisions, I think would be mine.

STC: Which actually goes back to Alf's very first point when I pushed him about why does he think that doctors perhaps are not quite as good at, on mass, as other professionals about moving to shared decision making. Is that possibly some of it in relation to cognitive bias as well? Isn't that because they've seen the way that they've always done it and therefore it's more difficult to do it because it's different , as well as the issue you raised about, you need to be confident in, in and want to be able to offload everything that you know, sort of thing.

I dunno?

Alf: I'm sure that's right. I think there's quite a lot of work being done in general practice around the fact that we, what we tend to do is we tend to prescribe courses of action, including medicines that seem to have worked in our own practice. And that's what the bias is. It's the last patient we saw that did really well or really impactful in some other way.

You remember them and you remember that, oh, Amitriptyline work for them. I'll give it to the next one. Yeah, it's everywhere, huh?

STC: Yeah. So, Jamie, come on. What was your TED talk?

Jamie: So my TED  talk and my TED Talk has been submitted cuz I watched TEDEx on Saturday night in Cardiff Saturday.

Gimmo: I knew, I knew you were gonna send one in.

I could sense it

Jamie: And I thought. Right. So mine is “Medicines, Rivers, and the Sea”. And it starts off with, and so I've given them a page and a half of my thoughts of it starts off with the psychology of medicines, and then it finishes with, we know where they end up. Wow. And they end up in our water courses.

STC: Like all good stories, you've gotta start a middle and an end.

Jamie: So I'm just you know, lobbying them at the moment to see if I can get a positive out them for TEDEx Cardiff. Let's see if I can if I can make that happen, it would be good to do.. We'll see. Okay.

Our micro discussion next. Look. We'll, it's the recent article on the Sunday Times “The NHS is flat lining-Here's how to save it right now”. And we've had contributions from our two previous guests from series five. Graham kicked us off. And Deborah,

STC: Would you like me to remind people what they said?

Jamie: Oh, go on.

STC: So this is the NHS 2023 Aural Apothecary ingredients for the NHS tonic, So Graham actually has got two, he's got support, then trust patients as project managers for their own health and  secondly ,analyse health data more to work out what works and what doesn't. And Deborah Duval gave us: treat the person, not the condition.

Jamie: So, Alf, did you have a chance to have a look at it and any thoughts?

Alf: I did and rather boringly, I'm gonna say “All decisions should be shared”. And you know, what we know is that broadly speaking, both patients and clinicians overestimate the benefits of medical stuff and in particular, surgical stuff.

So it's both patients and clinicians overestimate benefits, and both patients and clinicians underestimate harms. So we're trapped in a bit of a lie about just how great healthcare is. Of course, healthcare does some great stuff, but it's probably not as good as any of us would like it to be. And if we all shared decisions, understood the benefits and harms of the courses of action available to us, including simple lifestyle stuff, and it feels to me the world would be a much better place and it would cost less. Healthcare would cost less. So predictable perhaps, but pretty true as well. Actually, if we did share decision making much more, healthcare would cost less.

Gimmo: And that could go to my TED talk. Cause that's a cognitive bias, isn't it? That tendency to, to overestimate risk and underestimate benefit?

Or was it the way around?

I can't remember

Alf:

 The other way around. Yeah.

Jamie : Yeah. So Alf, I've been lucky enough to sit in on lots of GP consultations over the years as part of the, you know, education and the research agenda. And I've watched GPs embark on shared decision making, and it's become clear that the patient didn't want it. How do you know, if you were running your training sessions, what type of conversation would you have for the clinicians when they're faced with that scenario?

Alf: So, you know, there are some simple little .. you need a scenario about, I don't know, medicine or not let's say medicine, surgery, or lifestyle shift. And if the patient says what would you do, doctor? A reasonable response is, “well, I'm not, I'm not you. And you know what I really wanna do is to support you to come to the right decision for you.”

So let's look through the benefits and harms together. We'll do this together, So I'm not you is , I think a reasonable response. I'm gonna be honest if you've got a stock of half a dozen little neat little responses, you can start to engage people into a conversation.

What ideas have you got? What thoughts do you have? As we think through these options, tell me what comes to mind. Tell me what's going through your head  as we're thinking through this together. You can just. Gently tease people into the conversation, and I think it's ethically the right, it's the right thing to do.

You know, I think especially with people with low levels of activation health literacy, they tend not to have a high confidence in sharing decisions. So having these little phrases, Tell me what you're thinking. Tell me what's going through your mind. Let's think about this together. Just gently coaxing them, I think can be really, really helpful.

Jamie: Very good. Thank you. So Alf, what about, one other thing that I wanted to ask you about is digital consent. Where, what's your appreciation of that at the moment?

Alf: It's a, it's a great question, isn't it? There's a difference between shared decision making and consent. Shared decision making is the process that may end up in someone signing a consent form.

But it is a process. I think some people are starting to conflate shared decision making and consent. They're not the same thing. Consent is the end of a shared decision-making process. You know, I think it can be done digitally. It can be done digitally very well, but it's the process beforehand that we need to be really, really clear about.

And I am yet to see a digital platform that does the work for us. I still think it's really important that clinicians need to have the skills to have these conversations. Cause there's not very many decision support tools that do an awful lot of the work for us, actually. You do have to have the conversation skills as well.

We've got digital consent. I think it's a good thing, but it's the process leading up to it that we need to take care of.

Gimmo: So what do we mean by digital consent? Sorry, I'm not sure I fully understand that phrase.

Alf: So there are a number of digital platforms which you can go along to a patient with a, with an iPad or do it via the net.

And they have got the benefits and harms of the procedure under consideration listed really nicely there. And sometimes they've got options as well alongside it. But the assumption is that the patient is there to sign the consent form.

Gimmo: So it's like when I went to Welsh blood service, when I gave blood and you fill in an iPad and it asks you all the questions and so it, it cuts out the need for them to have that conversation with you, but actually you're just ticking the boxes as quick as possible and signing it without really looking at it, I think.

Is that what you mean?

Alf: It should be there to inform the conversation. It should. It shouldn't just be just something that we send to somebody and. Sign on the dotted line, please.

STC: I was just gonna go back to my zoo analogy cuz I know Jamie loved it so much. I think what you're saying is if you're sat in the bed and somebody comes and wants you to do that, consent comes up with the iPad, and actually, like I said before, they are  your keeper and you want them to do the operation.

So I, I think what we're saying is that a bit me going back to proactive and reactive, is that where possible, cuz sometimes it's not possible, but where possible you're providing this information in advance of so that the quality time spent with the health professional is just discussing values and preferences of that person ,and what you know and how you can help them.

In other words, going back to your point about all decisions should be shared.

Alf: Yeah, absolutely. Absolutely. It's a beautiful analogy, actually.

Gimmo: Don't tell him that Alf, we'll have this zookeeper analogy all the time now, and I didn't wanna point out the time see, but were you doing an impression of David Bellamy?

STC: You got it. Well done! In their own habitat. …..

Jamie: Stop. Okay. A big thank you to Alf for joining us on the Aural Apothecary 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 Sean Jennings, a patient from Cornwall who has had first-hand experience of the dangers of being over-prescribed opioids for chronic pain.

Join us next time on the Aural Apothecary. You can contact us via Twitter, @auralapothecary. We're on LinkedIn and you can email us at auralapothecarypod@gmail.com, Gimmo now for the final ingredient.

Gimmo: Okay, thanks and thanks Alf. That was fantastic. And I'm just leading into my final ingredient wondering how you do share decision making with a, with an app or with a robot.

And so, do you remember Jamie, when we had a play with chatGPT and we actually asked it about shared decision making and so sorry, chatGPT, if you've been living in a cave for the last couple of months, is this sort of artificial intelligence that answers all your questions. And so we asked about shared decision making and it was a little bit frightening cause it gave a textbook answer, didn't it?

It could have been, it could have been a paper. I know, Steve, you've had less than ideal experience when chatting to it about drug interactions but there's no doubt that AI will play a major role in the future of healthcare. And so The Times last week reported on an app used by carers that's claimed to half admissions to hospital.

It's a technology developed by 'Cera' an AI company, and it's been used by care workers, carrying out home visits to log key observations on every visit. So they log patients’ blood pressure, temperature, age, heart rate, and diet. And so the AI interprets that information taken into account their medical history.

And the research has shown that it can predict who is at risk of having to be admitted to hospital 2.6 times more accurately than a doctor looking at the same information. So this gives the care as an early warning system, alerting them to take such steps as arranging an emergency GP visit or a prescription for antibiotics.

It was interesting to me as well cuzit, it resonates with some of the work on trigger tools that was done in the NHS in the past, but it seems that the artificial intelligence can do it much better than we were. . So Dr. Ben Maruthappu, hope I've pronounced that right, who was working as an A&E doctor on the trial said “it's game changing for the patients we look after who are old and vulnerable. Typically, some would've gone into hospital. Some of these would've gone into hospital 10 times a year. And we are saving the government a million pound a day by keeping patients safe at home”

So it's just one trial amongst many, but I think it signals what's about to come.

It does start to feel like the machines are finally starting to arrive…..