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Hello and welcome to the Oral Apothecary Podcast, authentic chat
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about medicines, pharmacy and healthcare in the UK.
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Pharmacist Jamie Gimmo and STC take on topical and controversial
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stories but keep it edgy yet lighthearted.
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Podcasts share their career defining drug song and book and
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also share their joyful patient stories.
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Welcome to the Aoropothecary Podcast. My name is Jamie Hayes.
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For this episode, we're joined by Professor Nick Barber. Nick
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is emeritus Professor of Pharmacy at University College London and
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Head of Clinical Outcomes at AID Health. We will welcome
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Nick in a moment as he shares a drug for
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our formerly his career anthem and recommends a book for
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the Oral Apothecary Library. Nick has a new book out,
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How to Take Drugs, was published on the twenty eighth
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of May, so yesterday for many of you, and proposes
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a new approach to medication for better results and fewer
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side effects. How do you know if the medicine you're
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taking is right for you? Should you worry about side effects?
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And if so, how much? And how can you advocate
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for a loved one when it comes to being prescribed medication.
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Before all that, let me welcome my two fellow apothcarys
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stc Is in Bournemouth and Gimmo's in Cardiff.
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Welcome both evening, Good evening, loud Jamie. Just to break tradition,
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I want to hear all about your trip to Montreal
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before we hear about anything else.
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Okay, Well, International Conference on de Prescribing in Montreal. Been
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back a few days. Interesting conference. Loved it, loved it.
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Made lots of new connections, international connections. We missed you stc.
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You were meant to be on the trip but couldn't
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couldn't quite make it. In the end, Apothecary's four and
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five were there. I ran a workshop with Apothecary five
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and doctor Joe Hayes. My wife ran a workshop with
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Apothecary number four. Oral apocary alumni were in the room.
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Emily Reeve from Melbourne and Lauren walk Up from.
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Liverpool, Orshey chelminical pharmacologists.
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Indeed, so it was lovely to catch up with with
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all of those. Yeah, it was a great, great few days.
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Claire Howard Pothcreeen number four gave her a brilliant closing keynote,
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which went down really well. The conferences a lot you
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know is very folk, hyper focused on deep prescribing. And
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I think when Claire came in with some implementation stories
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as well, that just wow would people. So it was
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good and then might look at one thing I do
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want to talk about, look which is and I get
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pinged for this and rightly so. But it's people's biography photos.
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I've always I've always said that.
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Now that came up, there were several people which I mean,
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I think my biography photo is at least six years old.
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Oh released, it was six years old when we started
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the podcast, Jamie, five years ago.
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But yeah, there was a few sort of giants in
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the academic world who were well.
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Photo from twenty years ago at least, say.
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At least so theyby are Yeah, great conference.
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And like any good pharmacist, Jamie, you did what all
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pharmacists do on holiday, which the only photo you sent
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back to us was a photo of a pharmacy in Montreal,
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wasn't it all? Well, it was the Apothocream Museum.
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It was the Apothecary Museum in Niagara on the Lake.
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Oh yes, that's right, just up the road from Niagara Falls,
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and it was Yeah, it was very impressive.
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You're not a pharmacist if you don't send back pictures
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of pharmacies when you're abroad.
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Well, I hope you found us some new guests. I
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was so crushed to not go. But if you think
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about all the presentations you've ever done in your life,
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let me tell you this, if you've never done a
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eulogy before, that's the hardest three minute presentation I've ever
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given about my cousin. So I had good reason not
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to go, and so, yeah, that was tough a couple
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of things for me. Then listen, I don't want to
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worry you guys, but I've been having a lot of
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emails from Transport for London, the legal department. No, it's okay.
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It turned out that I sold my car to some
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sub crook in London and I forgot that I had
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it on auto pay and so ragged up this big
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bill of congestion charge and so I've been having multiple messages. Thankfully,
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I have electronic evidence of the day I sold it
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and told the DVLA electronically, so I'm hoping I'm in
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the clear. But yeah, I was having a lot of
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messages from Transport for London did worry me when I
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saw it. And the second thing, very quickly is two things.
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You know, we like a name or an acronym. So
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one of my colleagues, pharmacy technician Fiona, was telling me
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about this great melotonin liquid that she'd come across called
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kid Naps, which I thought was great. And also the
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same day I came across an organization called OUCH, which
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is the organization for the Understanding of cluster Headache, which
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I also thought was brilliant.
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So Kidnaps reminds me of Kidstoned Chewable Valuum, which is
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a parody video from a long time ago. Give So
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talking to Canada.
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Some of you who listened, I think I've mentioned that
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my son went to live my dream and work at
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a ski resort in Canada. Will he there's a knock
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on the door at eleven o'clock the night before last.
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It was him.
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He sort of surprised us and came home after six months,
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so that was nice. What wasn't so nice for him
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was that we'd thrown his bed out and so he
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had no way to sleep. So yeah, welcome home, Jack.
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Just to check you all voted today. I know this
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is we're in the future for people who are listening,
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but for us it's polling day. And talking of the
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fourth Apothecary. I saw Claire today, she didn't see me.
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She was running a webinar for the I'm guessing for
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the Polypharmacy Network and stuff had. It was on anti
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coolin ergic burden and it was very good. And they
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talked about the medi check app, which is the app
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that they've developed, isn't it. I think it started off
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as drugs across the blood brain barrier, but it's a
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bit more general now about drugs that you want to
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avoid in in frail to. So I'll put the link
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into that because I thought it looked great. Obviously, not
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being a clinician like Steve, I'd never use it, but
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it looked great.
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It is a great app. You're right, and it's quite
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complicated when you first look at it, but actually, yeah,
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once you understood it, it's really really good, very good.
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Let's move on our great pleasure to welcome Professor Nick
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Barber to the Oralopothcrey Emeritus. Professor Nick is one of
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the world's foremost experts in the field and recipient of
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the Lifetime Achievement Award from the Royal Pharmaceutical Society. What
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happened to the RPS? He developed a National Service of
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Patients Starting New Medicines, which is currently being used by
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around seven million people a year in the UK alone
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and which has been copied in six countries. It saved
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the NHS over six billion pounds so far. He's also
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developed a national framework of good prescribing against which all
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GPS were measured, and his work on medication errors in
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k homes led to a ministerial summit and significant changes
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to national policy. He's published over two hundred research papers
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and has been souded thousands and thousands of times. And
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I mean mentioned the Victorian Faracy will come on too that.
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I'm sure. Welcome to the or pot green.
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Nick, Thank you very much. It's a pleasure and the
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privilege to be here.
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The honor is ours, Nick, the honor is ours. So
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you've got a book out, Nick, Okay, we'll come on
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to that in a bit. I'll just bring you back
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to I think you were catching up with the boys
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in the green room. I take you back to this.
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Look can you see what I'm holding out?
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Oh?
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Yes? With Alan Wilson.
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Yeah, I'm holding up a copy, a second edition copy
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of Clinic Churchill's pocketbooks Clinical Pharmacy, which I had the
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honor of writing a chapter for Nick back in two
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thousand and two thousand, I think or two thousand and one.
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That was our first introduction. I wrote the chapter with
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Nikola John at the time. Nick, so you've always been
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doing books then, Nick.
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Well, it was easier to ask for other people to
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write the chapters. Have they finally written one myself? I
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highly recommend asking other people to write them.
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Very good, very good. And so how to take drugs?
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Tell us the background.
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So when you were a researcher, and I've been one
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for a loss of years, I often say it's a
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bit like being a bricklayer. You know, you spend five
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years on a project and at the end of it
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is two facts you can stick on top of the
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other facts which are out there, and you don't really
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get a chance to be an architect and say what
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the big picture is, what the big story is, where
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we're going? And so I wanted to do that. I eventually,
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in retirement, drafted. I went on some creative writing courses,
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and then you have to write a pitch to get
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an agent, first of all, and so I wrote one
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where the you know, this grand scheme of things about
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all the things about medicines, from you know, animals using
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them all the way through to you know, current technologies.
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I sent it off to four different agents. Three ignored it,
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and one said this is not in any way a
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commercial proposition, but there might be something in here. Come
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and see me. So I went to see her, and
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she said, this isn't what the market's interested in. They
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want things like ultra high process food and that sort
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of thing. And so she said, you want to say
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there's a problem and here's a solution, here's a way forward.
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And I thought, well, that probably is actually much more useful.
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So I rewrote a pitch around that sent it to
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a different and ended up with a different agent in fact,
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and then she pitched it to to publishers, and eventually
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I got a contract. So once together an overview, so
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we could look at medicines in the round and try
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and find a way forward to live with them and
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get the best out of them.
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And I think you've done that. I think I think
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I think it's it's a really ambitious book. Isn't it.
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And in some ways it's you know, you cover a
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lot I'm sure, well, I'm sure we'll come on to this,
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but you cover a lot of ground that we've covered
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in the in the podcast. But it's really it's really
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good as a as a tale of the whole tale
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of medicines, but but focused on how the people use them.
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And I think that's what I liked about it was
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was you've tried to look at this from a person
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taking drugs point of view, as opposed from the clinical
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point of view. And that's what we've always tried to do,
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you know, sometimes well and sometimes not, but it's trying
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to think of it from a lay person's perspective.
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Yeah, I think that's what I have been very consciously
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trying to write it for normal people who are taking medicines.
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And you know, there's other people who have been ahead
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of me on these sorts of things. But I think
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we want people to be able to be empowered and enabled,
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and one of the key ideas, which you may well
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come on to, is just having the person's relationship with
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their medicine as something which is to be valued and
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thought about.
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Yeah, I think it's a great job, and it was
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lovely to see that right at the very beginning. And
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you give a lot of personal stories. I was saying
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before we came on air that I've always known you
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to be a great storyteller, even in the presentations that
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you give. And I was just very briefly saying that
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I remember in Florida a massive conference in twenty ten.
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I was there and I was very excited to know
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that you were doing the plenary. I cannot tell you
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to this day what you were actually talking about, other
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than the beginning of the presentation was about how Panzer
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German Panzer tanks out out did the rubbish Russian tanks,
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and so that kind of idea of taking a story
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and then using analogies and the boys and if you've
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ever listened to any of these episodes, I love an
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analogy as well. And it don't always work, do they,
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And you have to test them out. So I think
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you've done a great job at trying to aim it
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at the public because and what I was going to
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say was that it was lovely to see that at
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the beginning the grayham Press, which analogy which you know
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we've had Graham on here, and it really runs all
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the way through, doesn't it, which is if you trust
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and support people to do their own thing with medicines,
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we'll probably get a better outcome. And I think that
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runs all the way through the book, and I think
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it's a real success and I think people will will
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really like it because you explain in nice analogies as
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well about you know, how medicines get absorbed and broken
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down and eliminated, which is difficult to find, you know,
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in language. But the one tough question I'll give you,
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because we don't want this to be a complete love in,
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is why was it how to take drugs as opposed
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to how to take medicines?
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Because we live in a world of marketing, because we've
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had our.
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Own problems with the BBC where they were worried about drugs.
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So we did talk about it, and we just felt
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it was you want something which pings off the shelf,
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you know, which in a in a bookstore, and which
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gets attention and people talk about it. And then and
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when we tried it, people, you know, broke into a
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smile or laughed, and so that's the sort of reaction
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we wanted. So it's obviously slightly tongue in cheek as
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I think you're alluding to it. You know, right at
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the start, I say, you know, the difference between a
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drug and medicine. You know, if you're hoping to read
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this to finding snorting the cocaine, you're going to be disappointed.
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And I like that the difference between a drug and
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a medicine because I think it's just not something people
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think about, is it. But it was a really nice
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way to set up the book. And I think it
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was in the chapter with Graeme. I think that you
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talked about the three questions that you recommend people ask,
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does it work somewhere, does it work generally? And will
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it work for me? And again, I think a theme
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in the book is encouraging that curiosity and that knowledge seeking,
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but also if it achieves anything, it'll be helping people
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to realize they've got a choice about whether they take
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a drug or medicine.
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I hope, So, I hope that gives clarity. So I
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actually that comes from the philosophy of science, and I
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got it from a book called medical Nihilism from Jacob
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Siganga was at the time of philosopher in Cambridge. And
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when it's laid out like that, It's so clear, isn't it.
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You know, why is it that once something's been done
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in a large clinical trial and got its license, it's
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still shown it works in an experiment and nothing further.
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And then the question about whether it will work generally
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is something which can only emerge with further experience in
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different populations and people with different conditions and all those
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sorts of things. Just because something works generally doesn't mean
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it's going to work for you. And you know, a
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pivotal point of the book is the engagement with with
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nmts numbers needed to treat and basically saying, you know,
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as Jamie said in his Ted talk and so on,
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if it's you know, most drugs don't work for most people.
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And I think that feels like a breach of trust
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for the public. And I think that's the springboard for
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saying we need to reassess what they are and how
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we use them.
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Yeah, there is that, you know, we overestimate the benefits
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and we underestimate the harms, don't we consistently as healthcare
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professionals and as patients. And there's been the public I
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like the it's the lead up to the grainpress, which
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but the problem was medicines, and I love the way
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you do it. Are our drugs working for you, probably not?
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Are you having side effects? Probably not? Are you taking
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them properly? Probably not? Are you getting value for money?
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Probably not? And I thought, well that, Yeah, really enjoyed it.
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I read it in two sit ins. Nick, okay, So
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when it arrived I picked it up.
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He often does books in one sitting. Does be too impressive.
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I read half of it and I thought, yeah, absolutely,
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and I couldn't wait to come back and read the
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second half. So yeah, really really enjoyed it. And we
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do talk on the pot a lot about people's relationship
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with medicines, and so it was you know, you've articulated
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in great form what we've sort of managed to get
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around to say in in a roundabout way once every
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three or four episodes.
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I think, Yeah, and your personal stories within it as well,
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you know, where you've talked about, whether it be about
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placebo response for example, I think your description of of
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love and whether or not you know the side effects
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of love. I thought that was beautiful the way that
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you described that, and so, yeah, there's so much good
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stuff in there. Will come to the nuts and bolts
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of the eupharmic relationship, perhaps in a minute, but overall,
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And I also remember you. So I qualified in ninety
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one and so again used to do a lot of presentations,
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used to do a lot of teaching to junior doctors. And
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I think the first time I came across you without
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actually meeting you, was when I used to teach around prescribing,
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so before I was a prescriber myself, and I've been
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a prescriber for twenty years, and you talk about it,
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and I know that this is I've heard you talk
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about this before and that this is a very important
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part for you, isn't it. Perhaps you can describe it
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better than me, and perhaps you can explain to the
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listener about you ended up being having an editorial in
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the British Medical Journal about what is good prescribing and
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the case that you talk about, and then you using
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the book. Perhaps you could explain that to the listener.
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Yeah, I'd be delighted to because that is one of
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those things where you know, reflective practice, where you do
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something and your work and you think this feels wrong,
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but I don't know why. So there was a as
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chief pharmacist of a general hospital in Romford. At the time,
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we had a patient who had been brought into to die.
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He had terminal cancer, he had no relatives, he probably
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had a week to live, and he had he was
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on broum azipam, which is at that time was the
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NHS wasn't paying for. So a load of the azipams
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came out very rapidly and at high prices, and the
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NHS so, enough's enough, We're going to not use most
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of them because they don't have any benefit. So he'd
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run out of his personal supply and which he did
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get from a private doctor, and the doctors asked me
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to get it on so they could prescribe it. And
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I said, you know, I was responsible for the purchasing
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of drugs and the drug budget, so I said, well,
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you know I can't purchase it. It's not allowed in
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the NHS. And I said, we've got to mazipam, and
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why don't you you know he can just add to mazipam.
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And my shame. I never went down to the ward
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to see him or speak to him. And he'd said
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he'd had t mazipam in the past and it didn't work.
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That really niggled me. I really felt I'd done the
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wrong thing, but I couldn't rationalize it because the guidance
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for the NHS at the time HC. Eighty eight fifty four,
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which those of you in the Hill Service will remember,
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was that prescribing he should be safe, effective and economic.
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And what we'd suggested, I'd argue was that it could
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have been you know, tim Azipan been shown to be effected.
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And I used to wake up at four in the
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morning really worrying over this and what I'd done wrong.
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And it wasn't until I left the hospital service in
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the NHS and became an academic I met Alan Kribber,
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philosopher of a moral philosophy who's who's hidden influence runs
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throughout this book. I've leance so much from him, and
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he was explaining about values and that they can and
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that quite often values can conflict and the decisions about
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the trading off of values. So I just said, well,
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why don't we have an extra value to safe, effective,
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and economic, which is there's patient choice. And then I
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did it as a sort of a cross with opposing
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you know, economy versus choice and effectiveness versus safety, but
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just said you could sort of map on those four
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terms where you were very crudely and that your job
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was to make a value judgment with these trade offs.
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It wasn't a simple factor of what the pharmacological records said.
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And that became and when the National Prescribing Center was
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founded in ninety six, I think it was as you said,
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it was published in ninety five, asked whether they could
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use that as their template, their framework to discuss prescribing
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with them with GPS when they were going round, and
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it was and was used until the NPC was inmalgamated
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into Nice.
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So we used to use them in workshops all the time, Nick,
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And so you know, Professor Neil Maascri would all of
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a sudden just go to a flip chart and draw
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some barber boxes and that would be a way of
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explaining whether we got stuck on something or whether we
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were just going you know. And so yeah, absolutely, yeah, yeah,
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So it.
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Was right up there. It used to be on my
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slide with all the different possible definitions of prescribing. You
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were there, including the American Ambrose Ambrose Bias who said
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it simply said that prescribing was a death warrant.
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So it occurs, doesn't it With what we chatted with
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last episode where we talked about evidence based prescribed and
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we've talked about this before, but where it went wrong,
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and pharmacy probably complicit in this in terms of, you know,
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it's easier to follow the guidelines rather than to think
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about it in a in a in a bigger sense,
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isn't it so? So I think echoes of what happened
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with evidence space prescribing sort of encapsulated in that example
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as well.
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Yeah, when I read that example, Nick, I scribbled I've
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got my notes scribbled by the side of it, and
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it's Joe, my wife is a palliative care consultant. So
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it comes home, you know, when we do the debrief
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most days, he says.
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You tell her about all the WhatsApp messages. The STEC
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has said, WhatsApp.
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We do that, we do the debrief. But and you know,
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fairly often examples of pharmacy centered prescribing come come to
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the foe. And that was the example that I scribbled down.
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Then I won't go into any more detail, but yeah,
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it's so.
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Maybe then this is a book for healthcare professionals, I'd say, so.
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I think it is. I think it's the other side
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of the equation, aren't they. So it's tooling up the patients.
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But it's also particularly in the last chapter, where I
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sort of look to the future, very somewhat vaguely at times,
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but sort of thinking for the next ten years, what's
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the direction of travel. I think it should be something
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we're all engaged in, and I know that lots of
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doctors and farmsists are already there ahead of me.
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In this you talk about there are two sides. Who
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made me think about an analogy? Let me try this
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on Nick. The guys don't like this, but if you've
435
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ever heard me talk about my analogy, you've heard of bitcoin.
436
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What about med cooin? So there are two sides. You
437
00:22:30.640 --> 00:22:33.279
haven't got heads and tails on this. You've got harms
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on one side, and you've got triumphs on the other.
439
00:22:39.279 --> 00:22:42.720
Arms and triumphs anyway, I've used it sometimes, but lots
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of people keep that silence in that it doesn't really work.
441
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But anyway, I used a bit of AI just to
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create a nice bitcoin med coin, so I use it
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sometimes anyway. Yeah, it's not binary. I accept that. That
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would be Jonathan's point is that benefits and triumphs that
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you know triumphs and harms are not It's not binary.
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One or the other could have both.
447
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Yeah, a ven diagram with an oval.
448
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App aren't they? Yeah? Exactly.
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00:23:08.519 --> 00:23:10.519
Look some reviews of the book I've got in front
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of me oral Apothecara alumni doctor Lucy Pollack, author of
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the book about getting Older a lively, empowering read full
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of definitely explained science, good humor and humanity. So we
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can't argue with that. And then the other one I
454
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liked as well, Look was from a former Welsh government minister,
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Andrew Davis and chair of Swansea Bay Health Board. An important,
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timely and above all very enjoyable book I hear it is. Look,
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Nick does what a few writers can manage in making
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complex and technical issues easily understood by the lay person
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with a very easy style and a wry sense of humor.
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And so I think that captures it nicely.
461
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So I got a quick question on that, because you
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did quite a lot on numbers needed to treat and
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number needs to harm. I just wondered that have you
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ran that past any late people, because because it's something
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we all struggle with, isn't it. How do you explain
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things like that? And probability and has that been field tested?
467
00:24:05.319 --> 00:24:08.319
It has with it. I had a couple of lay readers.
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One was a patient, you know it had cancer himself
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and was a sort of a patient advocate. But the
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other was a journalist who got no interest, you know,
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wasn't interested in reading nonfiction books and so on, and
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they got it. I think it lands with some but
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not with others. But when I was sort of analyzing
474
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what's the what's the promptu action, it is that what
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hits people most when you talk to them. It is
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this that most drugs don't work for most conditions. And
477
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then I debated the lengths to go to that, and
478
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in the end I decided to sort of put the
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detail in. I had the publishers gave me an editor
480
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who was absolutely brilliant, and she did a chapter to
481
00:24:55.319 --> 00:24:58.119
time as I did them, and she was very good
482
00:24:58.119 --> 00:25:02.319
at keeping me grounded as well, including taking out a
483
00:25:02.359 --> 00:25:05.279
whole chapter which I'd written on the history of medicine
484
00:25:05.480 --> 00:25:07.839
and pharmacy and prescribing.
485
00:25:08.119 --> 00:25:10.599
So you did sneak something though, I'll come on to
486
00:25:10.680 --> 00:25:11.079
that later.
487
00:25:12.160 --> 00:25:14.960
Well, we're all pharmacists. We tend to be, you know,
488
00:25:15.200 --> 00:25:19.680
quite careful at reading and picking up on things, so
489
00:25:20.240 --> 00:25:22.880
I didn't see any typos. There's one thing I will,
490
00:25:23.200 --> 00:25:26.240
I will, I will pick up the esteemed Professor Nick
491
00:25:26.279 --> 00:25:31.160
Barbaron on page one hundred and eighty one, where it's
492
00:25:31.279 --> 00:25:34.880
you talk about a regime rather than a regimen. Shame
493
00:25:34.920 --> 00:25:38.039
on you. Oh my god, I'm going to have to
494
00:25:38.119 --> 00:25:43.720
have it pulped now. It's a favorite. It's a favorite
495
00:25:43.720 --> 00:25:46.319
of mine on the Auralopothecary. So you know, I know
496
00:25:46.640 --> 00:25:48.960
I'm only pulling your leg, but yeah, maybe the other
497
00:25:48.960 --> 00:25:50.680
thing I think it's really important to get you to
498
00:25:50.720 --> 00:25:56.240
explain is this idea of eupharmic relationship. So do you
499
00:25:56.240 --> 00:25:59.960
want to just explain that? And then the four parts
500
00:26:00.480 --> 00:26:02.599
that are very important, which I'll let you explain.
501
00:26:03.119 --> 00:26:06.720
Well, thank you, because I do think this is intellectually
502
00:26:06.759 --> 00:26:08.720
it's one of the most important parts of the book,
503
00:26:08.720 --> 00:26:13.039
although I'm not sure it lands with a lot of
504
00:26:13.079 --> 00:26:17.079
the public. So I've spent years trying to explain what
505
00:26:17.200 --> 00:26:22.119
I do in having patients and medicines, and you end
506
00:26:22.240 --> 00:26:25.519
up when I was doing the pilot work. So the
507
00:26:25.599 --> 00:26:28.799
new medicine service is based on fifteen years of my research.
508
00:26:29.119 --> 00:26:32.000
And we used to say people, how are you getting
509
00:26:32.000 --> 00:26:34.559
on with your medicine. And everyone understood that and understood
510
00:26:34.559 --> 00:26:36.119
what it meant. And now I thought, well, it is
511
00:26:36.119 --> 00:26:40.400
about a relationship. It's like a person. And so I51200:26:40.440 --> 00:26:45.279
was trying to think, what's a very patient centered concept,51300:26:45.839 --> 00:26:49.279
not necessarily a measure of patient centered concept which doesn't51400:26:49.279 --> 00:26:53.680
involve a questionnaire and have theoretical feels behind it. And51500:26:53.720 --> 00:26:56.640
I just thought, do you get on with your medicine.51600:26:57.119 --> 00:27:00.559
It's a relationship. If there is a relationship, it there,51700:27:00.960 --> 00:27:03.480
it's it's worth giving it a name because then we51800:27:03.519 --> 00:27:06.920
can sort of focus on it and say, at least51900:27:06.920 --> 00:27:09.279
if we're talking as professional as you know are, how52000:27:09.319 --> 00:27:12.400
you fharming is the patientur or whatever? So I came52100:27:12.480 --> 00:27:15.920
up with this word eupharmia. So the eu is a52200:27:15.960 --> 00:27:19.720
Greek prefix for harmonious or good. You think the you know,52300:27:19.880 --> 00:27:24.440
the eurrhythmics and others, and then see what you did there,52400:27:24.599 --> 00:27:29.799
very good Farmia comes from from the Greek farmer Carna's52500:27:30.200 --> 00:27:32.480
you know which we know is that grace is basis52600:27:32.480 --> 00:27:38.079
for pharmacist and pharmaceuticals. So I stuck them together and52700:27:38.200 --> 00:27:41.200
said this this is a concept worth considering because it's52800:27:41.440 --> 00:27:45.880
entirely patient centered. It's their lived experience with this medicine,52900:27:47.200 --> 00:27:50.839
and it means that part of the background comes from53000:27:50.920 --> 00:27:54.000
technology adoption. You know, how is somebody living with and53100:27:54.079 --> 00:27:57.960
interacting with a with a technology and is that sort53200:27:58.000 --> 00:28:00.000
of good or bad? And it just seems to me53300:28:00.200 --> 00:28:03.319
it's quite a useful concept to be able, even if53400:28:03.319 --> 00:28:05.960
you don't use the term to have in mind to say,53500:28:06.039 --> 00:28:09.480
how are what's it like taking this? You know, the53600:28:09.559 --> 00:28:13.680
sort of things you ask on prescribing review or as53700:28:13.759 --> 00:28:16.759
part of the new medicine service? How are you getting53800:28:16.759 --> 00:28:20.440
on with your medicine? And you're clocking does this mean53900:28:20.480 --> 00:28:24.880
that they do they like it? Is it? Is it54000:28:24.960 --> 00:28:31.039
something they're having difficulty with? They may like the guy54100:28:31.039 --> 00:28:33.880
who called it a wonderful poison. They may be quite54200:28:33.920 --> 00:28:39.799
ambivalent Rob the fireman. Yeah, yeah, And so so that54300:28:40.880 --> 00:28:43.759
is something where they know they don't like it, but54400:28:43.839 --> 00:28:46.559
they know it's worth it sort of thing, and it54500:28:46.640 --> 00:28:49.079
allows these complexities, I think to come out.54600:28:49.279 --> 00:28:49.400
Well.54700:28:49.440 --> 00:28:50.400
I was just going to say, I think it's a54800:28:50.440 --> 00:28:52.880
useful idea, isn't it, Because it's away from for you,54900:28:53.119 --> 00:28:55.240
taking a medicine is transactional and you go into that55000:28:55.279 --> 00:28:57.480
bit when you talk abou adherents as well. But I55100:28:57.519 --> 00:29:01.720
think I think that idea of having a relationship with medicines,55200:29:01.759 --> 00:29:05.599
I think that's the centerpiece of what you're trying to do, really,55300:29:05.640 --> 00:29:08.319
isn't it, And it's what it's what we've tried to55400:29:08.359 --> 00:29:11.480
do when we talk about Sir Chicken and things like that.55500:29:11.519 --> 00:29:14.480
I think. So I think as a concept it's it's55600:29:14.519 --> 00:29:17.359
definitely one we could all work with.55700:29:17.519 --> 00:29:19.200
And Nick, do you want to just then explain that55800:29:19.240 --> 00:29:22.000
the four parts that you use in your your analogy,55900:29:22.000 --> 00:29:24.200
because we we've talked a lot about analogies and for56000:29:24.279 --> 00:29:26.759
me it works really well, so perhaps you could just56100:29:26.799 --> 00:29:27.400
explain that.56200:29:27.640 --> 00:29:30.759
Well, thanks, So if you're going to have a relationship56300:29:30.799 --> 00:29:35.920
with this, this technology, this medicine, then I thought, well,56400:29:36.799 --> 00:29:40.000
what are you Let's base it so people can understand it.56500:29:40.119 --> 00:29:43.519
Like relationships with people. So what are your options when56600:29:43.559 --> 00:29:46.319
you meet someone or when there's a chance of having56700:29:46.359 --> 00:29:50.440
a relationship. So the first is do you avoid them?56800:29:51.279 --> 00:29:53.880
You say this is this is not for me. You know,56900:29:54.160 --> 00:29:56.160
I don't think I'm going to get on with this person,57000:29:58.559 --> 00:30:02.880
but maybe you want to try and find out whether57100:30:02.920 --> 00:30:05.279
you could get on with them. And I use the57200:30:05.319 --> 00:30:10.000
analogy of It's like asking being asked to take an57300:30:10.039 --> 00:30:13.720
ambiguous stranger into your home, you know, and will they57400:30:14.480 --> 00:30:17.119
And this is even more personal. You're taking this you know,57500:30:17.200 --> 00:30:21.359
molecule into your body. And so at first you make57600:30:21.400 --> 00:30:24.039
all these accommodations for them, you know, you put clean57700:30:24.079 --> 00:30:25.799
sheets on the bed, and you make them a meal57800:30:25.960 --> 00:30:28.680
and offer them a drink and so on. But the57900:30:28.680 --> 00:30:30.960
longer they're living there, the more you're expecting them to58000:30:31.039 --> 00:30:34.599
really contribute to the household. And so ultimately you end58100:30:34.680 --> 00:30:39.160
up with sort of three scenarios of actually the whole58200:30:39.200 --> 00:30:42.440
household gets better, or it sort of rubs along like58300:30:42.480 --> 00:30:46.599
a grumpy flat share, or you kick them out. And58400:30:46.680 --> 00:30:49.480
I think you can see the parallels there. So this58500:30:50.359 --> 00:30:56.960
is a bit about the four phases are avoid, kissed, marry, divorce.58600:30:57.359 --> 00:31:00.000
So we've looked at a void and I talk more58700:31:00.119 --> 00:31:03.799
about things within that. So kiss is this trying out?58800:31:04.119 --> 00:31:06.599
Can you get on with it or not? We can58900:31:06.599 --> 00:31:09.880
come back to that. It's originally the New Medicine Service59000:31:09.920 --> 00:31:12.759
is an illustration of that. This is thinking much more59100:31:12.759 --> 00:31:15.680
about it. And then if you think you can live59200:31:15.720 --> 00:31:18.400
with this drug, are you going to marry it? Are59300:31:18.400 --> 00:31:20.559
you going to have a long term relationship and if so,59400:31:20.759 --> 00:31:25.319
like all marriages, that's going to take work and what59500:31:25.480 --> 00:31:27.720
is that work and how do you do it? But59600:31:27.799 --> 00:31:30.839
ultimately you have to be asking whether this relationship is59700:31:30.839 --> 00:31:35.880
still working or not, and why don't we consider divorce?59800:31:35.960 --> 00:31:38.799
It may be a trial separation or it may be59900:31:39.920 --> 00:31:42.519
a divorce that goes on. So I think that gives60000:31:42.559 --> 00:31:48.880
a model for patients avoid kiss married divorce, and it60100:31:48.960 --> 00:31:51.880
allows them to feel that they're part of the process60200:31:52.119 --> 00:31:55.599
rather than just right, you're on this for life, off60300:31:55.680 --> 00:31:55.880
you go.60400:31:56.319 --> 00:31:59.920
Yeah, I think it's great And I've said before that myself,60500:32:00.079 --> 00:32:02.880
doctor Lawrence Brad came up with an analogy using cars60600:32:02.920 --> 00:32:06.640
when we did the mechanics for Problematic Polypharmacy, and it's funny.60700:32:06.680 --> 00:32:08.799
We'll not funny really because it's very similar in that60800:32:09.160 --> 00:32:12.039
your four stages we came up with and we talked60900:32:12.039 --> 00:32:14.759
about buying and owning a car in the same way,61000:32:15.240 --> 00:32:19.359
so we had consider, start, review, and stop, and so61100:32:19.559 --> 00:32:21.880
it's the same idea but with a different type of analogy.61200:32:21.960 --> 00:32:24.480
So for me, it dovetails beautifully. And the bit that61300:32:24.519 --> 00:32:27.559
I think I'm mot interested in is the kiss bit,61400:32:27.640 --> 00:32:30.759
where you talk a lot about an equals one studies.61500:32:30.799 --> 00:32:33.079
So for the listener, this is this idea, and I,61600:32:33.519 --> 00:32:35.640
as a clinician, now do this a lot. And I61700:32:36.079 --> 00:32:37.759
use this phrase a lot, and I say to them,61800:32:38.119 --> 00:32:40.440
it's okay, we're going to do we can do a61900:32:40.519 --> 00:32:43.440
controlled science experiment, you know, in a safe way. So62000:32:43.720 --> 00:32:45.759
and I will give you some latitude. So, going back62100:32:45.799 --> 00:32:48.440
to Graham press riches bit, if I think the person62200:32:48.519 --> 00:32:51.400
understands me, I will give them and say, if they,62300:32:51.599 --> 00:32:53.440
you know, try this, and if that doesn't work, you62400:32:53.440 --> 00:32:55.200
can do that and allow you to double it or62500:32:55.240 --> 00:32:58.400
even quadruple it, you know, according to this. And I62600:32:58.400 --> 00:33:01.319
think that bit is really really import And so the62700:33:01.440 --> 00:33:03.920
kissing bit, as you call it, is a good way62800:33:03.960 --> 00:33:05.559
to know whether you want to marry it, isn't.62900:33:05.359 --> 00:33:08.240
It precisely well, it struck me. And this was part63000:33:08.279 --> 00:33:11.640
of my one of my original criticisms of shared decision63100:33:11.640 --> 00:33:14.640
making when it came out, which isn't isn't valid now63200:33:14.640 --> 00:33:18.680
because the concepts developed, But it was. It was that63300:33:19.359 --> 00:33:23.559
you're asking people to make a decision. Aren't vastly uncertain data,63400:33:23.640 --> 00:33:25.480
You've got not a clue whether it's going to work63500:33:25.599 --> 00:33:28.240
or not? Answer is it probably won't and you've got63600:33:28.559 --> 00:33:30.480
not a clue whether you're going to have side effects63700:33:30.559 --> 00:33:32.559
or not, and if so, what they'll be. But also63800:33:32.680 --> 00:33:36.319
you've got no physical engagement with this technology beforehand. You63900:33:36.319 --> 00:33:38.240
don't know whether you can swallow it, or you don't64000:33:38.279 --> 00:33:40.599
like the taste of it, or you can't actuate it,64100:33:40.720 --> 00:33:43.599
or whatever it may be. So it's a you know,64200:33:43.640 --> 00:33:50.160
there's that additional technology interface and acceptability element in there.64300:33:50.279 --> 00:33:54.640
So given all those unknowns, why don't we just say, okay,64400:33:54.720 --> 00:33:56.680
let's try and reduce some of those unknowns.64500:33:57.480 --> 00:33:59.319
Because he could have got it first and first base64600:33:59.359 --> 00:34:02.359
and second base, maybe that wouldn't have been a bit appropriate.64700:34:03.359 --> 00:34:03.680
It was.64800:34:03.720 --> 00:34:06.279
It was another version of this which is not bearing.64900:34:06.400 --> 00:34:09.719
I have to say, so Nick, let me come in65000:34:09.760 --> 00:34:13.079
because I'm gonna have a different view from from from65100:34:13.119 --> 00:34:15.880
Steve and so you Fharmia, I get completely and and65200:34:16.239 --> 00:34:21.159
again the relationships with our medicines get it completely, enjoy it.65300:34:21.320 --> 00:34:23.559
So again, Lucy Pollock, when she was on she was65400:34:23.639 --> 00:34:26.440
she was using language that she uses with her patients. A.65500:34:26.440 --> 00:34:29.880
But when my medicine start fighting with each other, so65600:34:30.039 --> 00:34:32.559
you know, sometimes the medicine start fighting against each other.65700:34:32.679 --> 00:34:35.960
So another stretch to the relationship metaphor if you like.65800:34:36.119 --> 00:34:38.360
But yeah, the avoid kiss, married, divorce. To me, I'm65900:34:38.400 --> 00:34:40.559
still open minded on it. I still it doesn't it66000:34:40.599 --> 00:34:42.599
doesn't do it for me. And so I love the book,66100:34:42.639 --> 00:34:46.119
but but that bit I struggled with, and I still66200:34:46.119 --> 00:34:48.679
struggle with Steve's car analogy as well a little bit.66300:34:48.760 --> 00:34:51.920
And so they they're the two that I'm I remain66400:34:52.000 --> 00:34:56.000
open minded, and I will I'll really look with interest66500:34:56.039 --> 00:34:58.199
to see how it you know, how it lands with.66600:34:58.400 --> 00:35:02.599
And what's your analogy? Essa Hayes, what's my analogy on this?66700:35:02.840 --> 00:35:04.599
So we we've been good enough to give hours.66800:35:04.679 --> 00:35:06.119
Well I haven't got one. I haven't got one.66900:35:06.159 --> 00:35:09.079
So okay, case closed, no more questions.67000:35:09.440 --> 00:35:12.159
Well is a poor analogy better than no analogy?67100:35:12.559 --> 00:35:15.639
So Jamie, what's what's your what's your problem with it?67200:35:15.679 --> 00:35:15.840
Well?67300:35:15.880 --> 00:35:18.079
No, I've put some there's a personal element to it.67400:35:18.239 --> 00:35:22.800
So I do have antibodies to avoid kissing, to avoid kiss, marry, divorce.67500:35:22.960 --> 00:35:25.280
I think as a as a you know, if you're67600:35:25.280 --> 00:35:27.039
in a if you're in the in the pub and67700:35:27.119 --> 00:35:29.440
somebody said, I know, let's have at that, would I67800:35:29.480 --> 00:35:32.320
would pick my paint up and walk off? So that67900:35:32.480 --> 00:35:34.199
you know that does go back a long way, Nick,68000:35:34.280 --> 00:35:35.159
so a lot.68100:35:35.199 --> 00:35:37.320
It's saying a lot about Jamie. To be honest, Nick,68200:35:37.320 --> 00:35:38.079
I wouldn't worry to.68300:35:40.559 --> 00:35:43.559
But yeah, no, I will. I will remain open minded.68400:35:44.039 --> 00:35:45.519
But I think that's what you're trying to do with68500:35:45.559 --> 00:35:47.920
the book, isn't it. It's it's a tough ask to68600:35:48.000 --> 00:35:51.480
try and simplify such a complex area. So so really68700:35:51.519 --> 00:35:54.880
all the analogies aren't you know that well, as we've68800:35:54.880 --> 00:35:58.840
seen with med coin, it's it's difficult to use these analogies.68900:35:58.840 --> 00:36:01.239
But I think what I do like about it is69000:36:01.519 --> 00:36:04.159
it is something that people can understand and relate to,69100:36:04.960 --> 00:36:09.159
and you know, is in the context of a wider69200:36:09.159 --> 00:36:12.039
discussion about medicines, I can see that it would be useful.69300:36:12.119 --> 00:36:14.400
To be honest, what you're doing is making people think.69400:36:14.559 --> 00:36:16.559
At the end of the day, and analogy will will69500:36:16.599 --> 00:36:19.239
never be for everybody, will it. And I recently used69600:36:19.239 --> 00:36:22.400
the car analogy in a big non medical prescribing conference69700:36:23.000 --> 00:36:26.119
and although the vast material vast majority of people really69800:36:26.199 --> 00:36:28.800
liked it, some people absolutely hated it and slated it69900:36:28.840 --> 00:36:31.400
and gave me one out of five, So you know it.70000:36:31.800 --> 00:36:34.320
But my point is I made you think.70100:36:34.360 --> 00:36:37.880
And It's day to day language which any doctor or70200:36:37.920 --> 00:36:41.679
pharmacist talking with a patient could talk to prepare them70300:36:41.719 --> 00:36:44.639
because one of the difficulty to de prescribing is getting70400:36:44.719 --> 00:36:48.079
people to accept that you're not just trying to save70500:36:48.119 --> 00:36:50.800
the NHS money by taking them off the drugs. You know,70600:36:50.960 --> 00:36:57.159
it's managing that expectation I think is helpful and that70700:36:58.119 --> 00:37:00.519
you know it's one attempt at using language to do that.70800:37:00.599 --> 00:37:03.920
Okay, well, I'll wrap up if I may, with having70900:37:03.920 --> 00:37:06.800
a bit of fun myself. I decided that no one's71000:37:06.800 --> 00:37:08.719
ever going to ask me. But when they talk about71100:37:08.880 --> 00:37:11.400
people having book blurbs on the front cover, and I71200:37:11.400 --> 00:37:13.800
didn't know that Jamie was going to use Lucy Pollocks.71300:37:14.079 --> 00:37:15.079
But this is what I wrote.71400:37:15.159 --> 00:37:15.400
Nick.71500:37:16.320 --> 00:37:20.239
This is a blissful marriage of pharmacology, academia, personal and71600:37:20.280 --> 00:37:24.119
professional medicines, expertise, insight, and the gray and press switch71700:37:24.400 --> 00:37:28.920
patient as project manager ethos with kiss and tell type storytelling,71800:37:29.280 --> 00:37:32.280
and enough data to make you want to actively divorce71900:37:32.320 --> 00:37:35.760
yourself from some of your daily medication routines. This is72000:37:36.199 --> 00:37:39.920
for the general public, one health and lifestyle book not72100:37:40.360 --> 00:37:41.000
to avoid.72200:37:41.440 --> 00:37:44.280
Very good. Just get that transcribed and stick it on72300:37:44.320 --> 00:37:44.960
the adverts.72400:37:45.519 --> 00:37:46.920
Send it to Panic Mellin.72500:37:48.199 --> 00:37:53.000
S Okay, that's been a great chat, and it goes72600:37:53.039 --> 00:37:56.119
without saying that if you're listening to this podcast, we72700:37:56.159 --> 00:37:58.639
would highly recommend that you buy and have a reader.72800:37:58.679 --> 00:38:02.719
This book will definitely make you think. And even I've72900:38:02.719 --> 00:38:05.800
already thinking about buying it from my dad so who73000:38:05.880 --> 00:38:07.760
was a pharmacist. But I think you'll really enjoy it.73100:38:07.840 --> 00:38:10.519
Yeah, and Nick, you know I'm doing lots of public workshops,73200:38:10.559 --> 00:38:12.519
aren't there, which I've mentioned on the pod. So the73300:38:12.840 --> 00:38:16.599
Women's Women's Institute audiences and the University of Third Age73400:38:16.639 --> 00:38:20.239
audiences each canry each connect, so again I think there's73500:38:20.280 --> 00:38:21.800
a great target audience there as well.73600:38:22.480 --> 00:38:27.119
The Oral Apothcary is sponsored by Jamie Hayes Executive Coaching73700:38:27.440 --> 00:38:29.360
and one Less Pill dot Com.73800:38:29.599 --> 00:38:32.400
Okay, Nick, so I know you've been listening before, so73900:38:32.440 --> 00:38:35.719
you'll know what's coming next, So we'll dive straight into74000:38:35.760 --> 00:38:37.800
it if we may. So, what would you like to74100:38:37.800 --> 00:38:41.880
give us for the Oral Apothecary formulary as your Desert74200:38:41.920 --> 00:38:42.599
Island drug.74300:38:42.840 --> 00:38:45.079
Well, the clue to that, we've already talked about it74400:38:45.559 --> 00:38:49.000
as it because it was such a pivotal role in74500:38:49.679 --> 00:38:54.719
my development of thinking about medicines, and without that incident,74600:38:54.880 --> 00:38:55.960
this book wouldn't be there.74700:38:56.119 --> 00:38:56.480
The story.74800:38:56.480 --> 00:38:57.840
I know we didn't sort of do the story in74900:38:58.320 --> 00:39:02.920
any detail again, but that's the exact. That emotional connection75000:39:03.679 --> 00:39:06.000
you have with that medicine keeping you up at night75100:39:06.079 --> 00:39:08.880
over the decision is the type of thing that we75200:39:09.000 --> 00:39:12.239
thought when we first thought of Desert Island drugs. You know,75300:39:12.559 --> 00:39:15.320
a medicine a drug you have an emotional connection to,75400:39:15.880 --> 00:39:18.079
and so it comes in all shapes and sizes and75500:39:18.119 --> 00:39:19.599
all types of things. So thank you for that.75600:39:20.280 --> 00:39:22.719
Okay, excellent. Yes, we've already had the story and it75700:39:22.800 --> 00:39:25.880
is fundamental to the book, so that's great. The second75800:39:25.920 --> 00:39:31.400
thing is the something for the Oral Apothecary Spotify playlist.75900:39:31.440 --> 00:39:36.320
So this is a career anthem. Again, you've mentioned eurhythmics earlier,76000:39:36.400 --> 00:39:37.840
but I don't know if this is going to be76100:39:37.880 --> 00:39:39.960
the pick. But what would you like to offer us76200:39:39.960 --> 00:39:40.519
and why?76300:39:41.079 --> 00:39:44.599
So the last two pages of the book are about76400:39:45.239 --> 00:39:47.639
a story from when my mum was dying, just a76500:39:47.679 --> 00:39:50.480
few days before her death. So I want a piece76600:39:50.480 --> 00:39:52.880
which I played at her funeral. But I've known it76700:39:52.920 --> 00:39:54.599
for a long time and I think you know I'm76800:39:54.639 --> 00:39:56.800
not the only one here who's had periods of depression76900:39:57.480 --> 00:40:03.679
and sometimes there's there's something which just spiritually moves you.77000:40:04.000 --> 00:40:06.440
And so this is a short piece. It's called The77100:40:06.480 --> 00:40:10.199
Deer's Cry and it's by Arvo Part.77200:40:10.400 --> 00:40:12.239
That's one of the ones I've written down. And it's77300:40:12.719 --> 00:40:16.119
like any story is tragic and funny at the same time.77400:40:16.400 --> 00:40:18.679
I just wanted to, you know, put all this sort77500:40:18.719 --> 00:40:21.360
of work into trying to get people to think in77600:40:21.360 --> 00:40:23.360
a certain way and so on it. I just thought77700:40:23.679 --> 00:40:27.639
it's getting a bit earnest. Yet it was such a77800:40:27.639 --> 00:40:28.360
funny moment.77900:40:28.559 --> 00:40:29.960
You know, it was worth doing.78000:40:30.039 --> 00:40:32.360
We said at the start of the podcast episode one,78100:40:32.440 --> 00:40:34.119
I think where is truth is humor?78200:40:34.840 --> 00:40:39.960
Yeah, indeed, very good. The Deer's Cry by Arvo Part78300:40:40.119 --> 00:40:43.199
makes it into the Oral Apothecary Spotify playlist, and yes78400:40:43.519 --> 00:40:46.800
it really is on Spotify. And the third thing then,78500:40:46.880 --> 00:40:49.639
Nick and no, you can't have your own book or78600:40:49.679 --> 00:40:53.079
not this one anyway, So what would you like to78700:40:53.119 --> 00:40:56.320
give to the Oral Apothecary Library.78800:40:56.559 --> 00:40:58.280
I don't know if anyone else has done it, but78900:40:58.360 --> 00:41:02.119
this is a must read The Doctor Who Fooled the79000:41:02.159 --> 00:41:13.159
World by Brian Deer. It is the Venison Podcast, so79100:41:13.599 --> 00:41:17.280
Brian Dere was the investigative reporter who broke open the79200:41:17.760 --> 00:41:23.440
Andrew Wakefield story. Anybody who is involved with vaccines, anybody79300:41:23.800 --> 00:41:27.880
in promoting them, anybody who's a vaccine vaccine skeptic, should79400:41:28.039 --> 00:41:32.880
read this. It is it's like reading a thriller, The Manipulations,79500:41:32.920 --> 00:41:35.679
which went on the fact that he was at the79600:41:35.719 --> 00:41:39.119
start he was trying to use it to to get79700:41:39.159 --> 00:41:44.000
money out of drug companies. Why did it get into79800:41:44.000 --> 00:41:47.280
The Lancet, Well, he and the editor of the Lancet79900:41:47.440 --> 00:41:52.159
used to be colleagues. You know. There's a lot of80000:41:52.199 --> 00:41:56.119
really interesting stuff in there, including the fact that at80100:41:56.119 --> 00:41:58.800
the end of the book, Andrew Wakefield is living with80200:41:59.039 --> 00:42:06.039
el McPherson in the USA, and it is Wakefield has80300:42:06.079 --> 00:42:10.199
tried to prosecute Brian Deer, and Brian Dere's no apologist80400:42:10.239 --> 00:42:14.039
for the drug industry. He's done stuff breaking open bad80500:42:14.119 --> 00:42:18.079
practice in the drug industry in the past. But it's80600:42:18.400 --> 00:42:23.159
a fascinating read, absolutely gripping, and it's essential that everybody80700:42:23.239 --> 00:42:27.280
who comes across people who mainly persuading about vaccines or80800:42:27.320 --> 00:42:31.440
rejecting them should read to be able to explain the80900:42:31.480 --> 00:42:36.880
origin of the modern trend of vaccine denial excellent.81000:42:37.000 --> 00:42:40.559
No, nobody's picked that. We have had some. I think Brian,81100:42:40.679 --> 00:42:44.760
one of our patient representatives who's on the rural collegy81200:42:44.800 --> 00:42:49.800
GP's Overdiagnosis group, has some very strong views about COVID vaccination.81300:42:49.920 --> 00:42:52.360
So Brian, if you're listening, you might want to read81400:42:52.400 --> 00:42:55.599
this one. Clearly, this was before that. So The Doctor81500:42:55.599 --> 00:42:58.199
Who Fooled the World by Brian Deer makes it into81600:42:58.239 --> 00:42:59.719
the Oral Apothecary Library.81700:43:00.159 --> 00:43:02.679
Nick, So, Brian Dere was the BMJ journalist.81800:43:02.760 --> 00:43:03.000
Wasn't he?81900:43:03.000 --> 00:43:04.840
I think wasn't he broke the story for the BMJ?82000:43:04.960 --> 00:43:06.079
Didn't he? Or something like that?82100:43:06.639 --> 00:43:07.920
Now is Sunday Times.82200:43:07.960 --> 00:43:11.599
Okay, I'm just listening to Deborah Cohen's book Bad Influence,82300:43:12.440 --> 00:43:15.920
and at the start of that it she majors on82400:43:15.920 --> 00:43:21.400
on on the Brian Dere and the the story. Okay,82500:43:21.440 --> 00:43:23.519
we've got a micro discussion. But what we thought we'd do, Nick,82600:43:23.599 --> 00:43:27.280
is just focus on the future bit of the book82700:43:27.320 --> 00:43:29.840
really and just you know, have a wrap up discussion82800:43:29.880 --> 00:43:32.039
around you know, it's looking a lot of the book82900:43:32.079 --> 00:43:35.199
is looking back over your your career and the impact83000:43:35.280 --> 00:43:38.840
you've had. Just take us to your thoughts on the83100:43:38.880 --> 00:43:41.480
future and what can you share with us.83200:43:42.760 --> 00:43:47.199
There's quite a bit of theory underpinning the book, which83300:43:47.199 --> 00:43:50.360
I don't talk about after discussions with the editor.83400:43:53.440 --> 00:43:55.400
Much to your discuss we can tell.83500:43:55.320 --> 00:43:58.360
Yeah, I know. So one of them is systems theory,83600:43:58.400 --> 00:44:05.039
which I love. And if we have this, we see83700:44:05.159 --> 00:44:08.840
prescribing as a simple ordered system. You know, you have83800:44:08.920 --> 00:44:11.559
condition A, therefore you're given drug b off you go.83900:44:12.239 --> 00:44:15.280
And it's a complex emergent system which means you don't84000:44:15.320 --> 00:44:17.239
know what's going to happen at the end, and it's84100:44:17.280 --> 00:44:21.280
open to influence and different things may influence it and84200:44:21.800 --> 00:44:25.679
obviously experience the medicine and things like that. So if84300:44:25.679 --> 00:44:31.760
that's the case, what we're doing is moving in systems84400:44:31.760 --> 00:44:34.880
theory turned from a complex emergence system into a simpler84500:44:35.199 --> 00:44:40.480
ordered system, something which is stable and sustainable. And that's84600:44:40.519 --> 00:44:42.920
what the Kiss phase is in a way, and that84700:44:42.920 --> 00:44:45.440
that's what the new medicine service has been in a84800:44:45.480 --> 00:44:49.719
simplistic form. So you say, well, who's going to who's84900:44:49.760 --> 00:44:53.639
the best person to work with patients to say here's85000:44:53.719 --> 00:44:56.559
how you know, what's your experience? Can we do any85100:44:56.559 --> 00:44:58.840
of one? So as Steve was saying, you know, can85200:44:58.880 --> 00:45:01.280
you can you get people to try things out and85300:45:01.880 --> 00:45:06.199
study them themselves, all sorts of options. We need somebody85400:45:06.199 --> 00:45:11.079
who really understands about medicines in that and also recognizing85500:45:11.159 --> 00:45:14.760
the shortage of GPS, certainly in the UK. Although the85600:45:14.760 --> 00:45:19.079
book's written for an international audience, it's obviously fair UK focused.85700:45:21.719 --> 00:45:24.679
You say, well, you know, we need people to do85800:45:24.719 --> 00:45:28.360
that who know about drugs, and that's pharmacists and they85900:45:28.400 --> 00:45:31.719
have between five and eight years experience, depending where in86000:45:31.719 --> 00:45:35.920
the world you are, and it seems daft that we86100:45:36.000 --> 00:45:42.079
have experts there who aren't being used appropriately. So and86200:45:42.159 --> 00:45:45.599
if and when well as they have, as Steve has illustrated,86300:45:45.639 --> 00:45:51.239
prescribing rights, then there's the ability to tailor that. It's86400:45:51.239 --> 00:45:53.320
going from off the peg to bespoke if you want86500:45:53.360 --> 00:45:56.719
another analogy, so you can tailor it to that person's86600:45:56.960 --> 00:46:01.079
personal needs. So the first thing is I argue for86700:46:01.840 --> 00:46:04.800
the use of pharmacists for that tailoring process, and I86800:46:04.840 --> 00:46:07.360
think that's something which will continue to grow over the86900:46:07.400 --> 00:46:10.639
next ten years. It's good for the health system as87000:46:10.679 --> 00:46:13.000
well because this is a better use of medicines. We87100:46:13.039 --> 00:46:18.159
haven't talked about environmental impact and so on, but when87200:46:18.199 --> 00:46:21.239
you think of the costs and the environment and all87300:46:21.280 --> 00:46:23.880
sorts of other things. We need to get the best87400:46:23.920 --> 00:46:26.599
out of medicines if we're going to use them. The87500:46:26.639 --> 00:46:30.920
second thing is, then if people are in the marriage phase,87600:46:31.000 --> 00:46:32.840
how do we support them in the marriage phase? And87700:46:32.840 --> 00:46:36.639
I suggest that you know I've lost there's various software87800:46:36.679 --> 00:46:41.239
options out there, and I suspect it will be some87900:46:42.079 --> 00:46:47.519
form of software support which will different people might want88000:46:47.639 --> 00:46:53.039
different things, and that the company I work with AID88100:46:53.239 --> 00:46:57.480
is one of those options. But so many people really88200:46:57.519 --> 00:47:01.760
don't understand the software deers they often develop for one88300:47:01.840 --> 00:47:05.480
drug aided as several. But the point is they don't88400:47:05.519 --> 00:47:08.239
understand why non adherance happens, and they mainly think it's88500:47:08.280 --> 00:47:12.079
a reminder thing. It's the old blame the patient. So88600:47:12.159 --> 00:47:16.400
I think you need well constructed software which which you88700:47:16.400 --> 00:47:18.960
can work well with, is it's easy to use, and88800:47:19.519 --> 00:47:23.199
if the software developer gets brought out by somebody who88900:47:23.280 --> 00:47:25.440
changes it or whatever, you can take your data with89000:47:25.559 --> 00:47:29.519
you and go somewhere else. And the third element we're89100:47:29.559 --> 00:47:33.280
thinking about, which I think is perhaps a theoretical option89200:47:33.440 --> 00:47:38.159
more than the pragmatic one, is just make better medicines. Frankly,89300:47:38.800 --> 00:47:42.039
you know the problem with the way most technologies improve89400:47:42.239 --> 00:47:45.039
is that there's a feedback between the user experience and89500:47:45.079 --> 00:47:49.599
the developer, and that doesn't really exists with medicines. They're89600:47:49.639 --> 00:47:55.800
being sold in effect to the medical and pharmacy profession89700:47:56.519 --> 00:47:59.480
and the user feedback is not really part of it.89800:48:00.199 --> 00:48:03.719
And there's some brilliant formulation ideas out there. I was89900:48:03.760 --> 00:48:07.079
talking to a specialist and pediatric formulations. You know, you90000:48:07.119 --> 00:48:09.800
can develop a drug, sets of film which dissolves on90100:48:09.840 --> 00:48:15.239
the child's tongue and all sorts of other things kidnaps, yea, yes, yes,90200:48:16.440 --> 00:48:21.519
and so you can. The problem is whether there's enough90300:48:21.519 --> 00:48:24.320
money in it for anyone to do. And a specialist90400:48:24.320 --> 00:48:27.320
in formulation told me of a product that they developed90500:48:27.320 --> 00:48:29.960
which sounded fantastic, and they talked to one of the90600:48:30.000 --> 00:48:32.519
big companies and they said it's not worth doing. We90700:48:32.559 --> 00:48:35.159
don't make a few million quid out of it. So90800:48:36.039 --> 00:48:38.400
you know there's a gap in the market there somewhere,90900:48:40.039 --> 00:48:42.480
but it's the market, as we know, is not a91000:48:42.559 --> 00:48:46.320
perfect market in pharmaceuticals. So those are the broadly the91100:48:46.320 --> 00:48:48.320
three things which I suggest.91200:48:48.920 --> 00:48:52.360
Of course I would speak highly of pharmacists as Midson's expertise,91300:48:52.400 --> 00:48:57.440
and prescribers and I wrote an abstraction under the blog91400:48:57.480 --> 00:48:59.880
of the Oral Podigree website a couple of years ago91500:49:00.079 --> 00:49:02.679
now called do I need to see a doctor? Who91600:49:02.719 --> 00:49:05.719
else could help me? And it was really the same idea,91700:49:05.760 --> 00:49:07.559
which is, you need to break down what it is91800:49:07.599 --> 00:49:10.639
that you're after, you know, do I want a diagnostician91900:49:10.719 --> 00:49:14.480
or an interventionist, or a prescriber or a researcher, and92000:49:14.559 --> 00:49:18.360
so then you Although I'm very, very happy with the92100:49:18.400 --> 00:49:23.480
idea of competent prescribers as in any profession, but your92200:49:23.519 --> 00:49:27.760
book beautifully highlights what I always call the subtlety and92300:49:27.800 --> 00:49:32.239
complexities of medicines or drugs as you describe it, as92400:49:32.280 --> 00:49:35.039
to why you if you get the right one, you'd92500:49:35.119 --> 00:49:38.599
probably be better off with a medicine's expert prescriber than92600:49:38.639 --> 00:49:41.079
another prescriber, although a lot of prescribers could do it.92700:49:41.559 --> 00:49:43.920
And I think, really that's your point, isn't it.92800:49:44.000 --> 00:49:47.800
And that's right, And a lot of prescribers or prescribers92900:49:47.840 --> 00:49:49.719
can tend to be, you know, it's an asthma nurse93000:49:49.840 --> 00:49:53.119
or something like that. We need someone who the patient's93100:49:53.199 --> 00:49:55.960
experiencing a range of drugs, and we need someone who93200:49:56.000 --> 00:49:59.360
can understand the range of drugs and how they interact.93300:50:00.079 --> 00:50:02.679
Going to add something to number three on that list93400:50:02.719 --> 00:50:06.440
then and it's you know, let's get better medicines. So, Nick,93500:50:06.480 --> 00:50:11.199
I took one of your papers from two thousand and nine, Okay,93600:50:11.519 --> 00:50:16.920
say Sarah Garfield, Nick Barber, Paul Wahleanna Wilson, Lena Ellison,93700:50:17.880 --> 00:50:20.639
can you remember quality of medication use in primary care?93800:50:21.440 --> 00:50:23.599
And it was so I took that paper when it93900:50:23.639 --> 00:50:26.719
came out, and there's a graph in it, and the94000:50:26.760 --> 00:50:29.119
graph in it talks about the error rates at each94100:50:29.159 --> 00:50:33.039
stage of the prescribing process in primeria. Yeah, so you know,94200:50:33.079 --> 00:50:35.599
we start off with, you know, one hundred percent intention94300:50:35.760 --> 00:50:38.079
to do well, We've had a good day, decisions have94400:50:38.119 --> 00:50:41.440
gone well, we arrive in practice and you know we94500:50:41.480 --> 00:50:44.119
make some prescribing decisions. Well, we make some errors, don't94600:50:44.119 --> 00:50:47.519
we in our prescribing decisions. And then we we hand94700:50:47.559 --> 00:50:51.199
the prescription to the to the patient, and some era94800:50:51.440 --> 00:50:53.760
in that transaction and when whether they take it to94900:50:53.800 --> 00:50:55.679
the pharmacy or what you know. And then this era95000:50:55.800 --> 00:50:57.800
is in dispensing, isn't it. This is all your work.95100:50:58.679 --> 00:51:01.880
And then this era is in take the medicines. And95200:51:01.920 --> 00:51:05.199
then there's there's clinical clinical outcomes. And so I used95300:51:05.239 --> 00:51:09.480
that graph in workshops hundreds of times, Nick okay. And95400:51:10.000 --> 00:51:13.000
the bit is there's all that error in the system.95500:51:13.199 --> 00:51:15.280
And then on the graph and this is what I95600:51:15.280 --> 00:51:18.639
would introduce as the last thing. Then I introduced numbers95700:51:18.679 --> 00:51:22.719
needed to treat with the Look, here's the errors inherent95800:51:22.760 --> 00:51:26.079
in the system. If the medicine worked was effective one95900:51:26.159 --> 00:51:29.239
hundred percent of the time, these errors are in the system.96000:51:29.320 --> 00:51:32.440
But let me show you this. This is how effective96100:51:32.440 --> 00:51:35.280
our medicines actually are. And so that's what you did.96200:51:35.320 --> 00:51:37.880
So honestly, it was just a love your opportunity to96300:51:38.039 --> 00:51:40.159
share with you a piece of your piece of your96400:51:40.199 --> 00:51:43.639
back catalog, which I turned into a practical and I96500:51:43.679 --> 00:51:46.239
honestly I delivered it hundreds and hundreds of times to96600:51:46.320 --> 00:51:50.480
audiences to non medical prescribers in training right across the board.96700:51:50.519 --> 00:51:54.280
Always went down really well. So thank you, oh thank you.96800:51:54.599 --> 00:51:58.039
Delighted that it was there. We'd been working. We're one96900:51:58.079 --> 00:52:00.639
of the leaders working in medication era the world at97000:52:00.679 --> 00:52:04.679
the time. And Alan Wilson, of course, the genius of97100:52:05.079 --> 00:52:07.840
who was also running Thousand Lives in Wales at the time.97200:52:07.679 --> 00:52:11.119
A genius indeed, Dick What a thinker. What a thinker,97300:52:11.239 --> 00:52:11.880
What a thinker.97400:52:12.280 --> 00:52:15.039
He's been very influential on my thinking is as well.97500:52:17.039 --> 00:52:18.960
Of course you could just say I just neck fload97600:52:18.960 --> 00:52:21.400
of his ideas, but I prefer to say influential in97700:52:21.480 --> 00:52:22.000
my thinking.97800:52:22.159 --> 00:52:25.239
He's a truth So Alan is a truth teller, isn't he.97900:52:26.639 --> 00:52:29.159
Everybody loves a truth teller, but not many will employ them.98000:52:29.159 --> 00:52:30.840
I think it's that's what they're saying, goes, isn't it98100:52:30.880 --> 00:52:31.840
or something like that.98200:52:32.519 --> 00:52:35.000
There's a lot of truth in that. So he did98300:52:35.039 --> 00:52:38.320
it as he did it as a presentation, saying, you98400:52:38.360 --> 00:52:42.960
imagine you're doing the equivalent of Amazon, you know, and98500:52:43.039 --> 00:52:46.039
here's a delivery system, and here's your company, and here's98600:52:46.079 --> 00:52:48.440
how often things go wrong in all the way from98700:52:48.480 --> 00:52:50.840
the ordering through to delivery. You know, would you invest98800:52:50.880 --> 00:52:54.760
in that company? Which is another very good way of98900:52:54.840 --> 00:52:58.440
storytelling about it. Oh, I'm so pleased that that was useful.99000:52:58.599 --> 00:53:00.559
Okay, A big thank you to Nick for joining us99100:53:00.599 --> 00:53:02.639
on the Ural Apothecary and for sharing his stories, his99200:53:02.639 --> 00:53:05.239
Desert Island drug, his career anthem, and his book for99300:53:05.320 --> 00:53:09.360
the Oral Apothecary Library. Coming up next time, we're joined99400:53:09.440 --> 00:53:14.400
by doctor Ellie Cannon Ellie is NHSGP with a specialist99500:53:14.480 --> 00:53:18.440
interest in women's health. She's the resident health columnist for99600:53:18.480 --> 00:53:22.280
The Mail on Sunday and Mail Online, and frequently appears99700:53:22.360 --> 00:53:26.719
as the medical expert for ITVS This Morning, BBC's Women's99800:53:26.719 --> 00:53:31.239
Hour and LBC. Join us next time on the oral Apothecree.99900:53:31.280 --> 00:53:34.199
You can contact us via x You can follow us100000:53:34.239 --> 00:53:37.079
on LinkedIn gimo. Now with a final ingredient.100100:53:37.360 --> 00:53:39.880
Okay, so thank you and thank you Nick. Thank you100200:53:39.880 --> 00:53:41.599
for that, and thank you for a great book which100300:53:41.599 --> 00:53:45.400
I know we'll all found useful in terms of recommended100400:53:45.440 --> 00:53:48.760
to people. But I think probably did down the three100500:53:48.800 --> 00:53:50.840
of us, probably wishing that we wrote it.100600:53:53.760 --> 00:53:55.079
I wish you'd written it as well.100700:53:57.840 --> 00:53:59.400
I doubt we could have done us. Got a job100800:53:59.440 --> 00:54:02.280
so well, and so.100900:54:04.000 --> 00:54:06.239
The Yeah.101000:54:06.280 --> 00:54:11.199
So the final ingredient, what connects heart failure and broad beans? Well,101100:54:11.960 --> 00:54:15.960
surprisingly the answer is maybe bees, but perhaps more accurately,101200:54:16.000 --> 00:54:20.079
foxgloves and so, as you may know, have recently acquired101300:54:20.079 --> 00:54:23.519
an allotment, and being a pharmacist, I couldn't resist giving101400:54:23.519 --> 00:54:26.039
it slightly medically themed twists. So one of the first101500:54:26.079 --> 00:54:29.440
things I planted was foxgloves, which helped me on the101600:54:29.519 --> 00:54:31.760
Latin here did you tail this per purea?101700:54:32.920 --> 00:54:35.480
Yeah, that's the English one.101800:54:35.880 --> 00:54:36.119
Yeah.101900:54:36.159 --> 00:54:39.760
And so foxgloves are actually very useful on allotments because102000:54:39.760 --> 00:54:43.239
they attract bees, and bees are super pollinators, which means102100:54:43.239 --> 00:54:47.159
they help other plants thrive, including my broad beans. But102200:54:47.199 --> 00:54:50.519
of course foxglove has another claim to frame. It's the102300:54:50.559 --> 00:54:53.039
source of the drug de joxin, which is one of102400:54:53.079 --> 00:54:56.400
the most famous medicines ever to treat heart failure. And102500:54:56.480 --> 00:54:58.280
so the story of this is in your buck, nick,102600:54:58.440 --> 00:55:00.440
isn't it. So if you don't mind, I'm going to102700:55:00.480 --> 00:55:04.320
read from your story and so so so paraphrase from102800:55:04.320 --> 00:55:07.440
How to Take Drugs. In nineteen seventy five, the physician102900:55:07.480 --> 00:55:10.440
and botanist William Witherin he heard about a local herbal103000:55:10.480 --> 00:55:13.760
remedy that appeared to cure dropsy, which he now recognized103100:55:13.800 --> 00:55:17.079
as congestive heart failure. The remedy contained a mixture of103200:55:17.119 --> 00:55:20.960
herbs and withering did something that feels surprisingly modern, he103300:55:21.039 --> 00:55:25.000
systematically investigated it, so one by one he worked through103400:55:25.000 --> 00:55:28.199
the ingredients until he identified the active plants Fox Club103500:55:29.079 --> 00:55:31.559
and at the time it was known by the rather103600:55:31.599 --> 00:55:35.960
ominous name of dead Man's Bells because it was considered poisonous,103700:55:36.519 --> 00:55:38.920
but within realized with the right dose, SI could strengthen103800:55:38.920 --> 00:55:42.239
a failing heart. So he studied the plant, harvested the103900:55:42.320 --> 00:55:45.199
leaves just before flowering as he woke up. That was104000:55:45.199 --> 00:55:47.599
the most effective way, drying them and grinding them into104100:55:47.639 --> 00:55:50.119
what he called a beautiful green powder. And then he104200:55:50.159 --> 00:55:53.119
did what was remarkable for the time, documented the outcomes104300:55:53.480 --> 00:55:57.320
in what was effectively one of the first early clinical trials,104400:55:57.880 --> 00:56:02.119
involving one hundred and fifty eight patients. And so over time, obviously,104500:56:02.159 --> 00:56:05.440
scientists discovered that foxglove contained compounds that act directly on104600:56:05.480 --> 00:56:09.400
the heart cardiac glycosides, and eventually, in nineteen thirty the104700:56:09.440 --> 00:56:13.679
most important of them was named de jockson. So what's104800:56:13.679 --> 00:56:17.199
extraordinary is that even now Dejoxon is still derived from104900:56:17.239 --> 00:56:21.119
plants using a process that's not totally you know, it's105000:56:21.159 --> 00:56:24.800
not entirely unlike Withtherin's original method nearly two hundred and105100:56:24.840 --> 00:56:29.199
fifty years ago, and it's still an essential is still105200:56:29.360 --> 00:56:33.480
listed in the World Health Organization's model list of essential medicines.105300:56:33.960 --> 00:56:37.000
So they have it. Excellent story Nick in the book,105400:56:38.559 --> 00:56:40.760
you know, and there's and you know, lots of stories105500:56:40.840 --> 00:56:43.840
like that in there but a story of broadbeans, bees,105600:56:43.920 --> 00:56:46.599
heart failure, and a poisonous flower once known as dead105700:56:46.639 --> 00:56:49.320
Man's Bells. Who said drugs are boring?105800:56:49.760 --> 00:56:52.719
You have been listening to a three Epothcreeze production sound105900:56:52.760 --> 00:56:57.280
engineer Jimbo Slough, original music Jamie Brewster, artwork by David106000:56:57.320 --> 00:56:58.880
Baker and Jacob Howard.106100:56:59.159 --> 00:57:02.599
Thanks for listening to The Oral Apothecary podcast. Do not106200:57:02.840 --> 00:57:06.639
listen more than eight times in twenty four hours.106300:57:07.239 --> 00:57:10.840
This episode of The Aural Apothecary is sponsored by One106400:57:10.920 --> 00:57:27.920
Less Pill dot Com, a medicine's optimization consultancy,
