Derek Hockaday, interview agent, interviewing Howard Jones in Iraq in the John Radcliffe on the 20th of May 19, 2004.
When did you come to the Alfred Hospital? I came here as a senior registrar in the early 1980s.
I think it must've been about 83 or 84. Quite sure.
And what made you come to Oxford? I, I had, um, this was at the time all I had was a medical registrar.
That's Mary's Hospital in Paddington and was becoming increasingly drawn towards geriatric medicine,
particularly seeing lots of frail elderly patients in the wards in Paddington
that we almost walk past in those days because we didn't have a medical problem.
And I started to become more interested in what the geriatricians were doing.
Having made that decision that I wanted to be a geriatrician, I was looking for a job, um,
as a senior registrar trainee geriatric medicine, having done a little bit as a medical researcher.
And you already got your membership.
I got my membership, but I almost I had written up and submitted my doctorate and I was waiting for that to come through.
But I decided that geriatric medicine was where I was going.
And at that time, there were there was a there was a very nice rotation which spent time in High Wycombe and Ambition and in Oxford.
So it was a year in Oxford in the year and how we can win.
And I felt that my training had been almost exclusively in teaching hospitals.
Statistically,
I thought that I was much more likely to get a job in the TGA than I would be in a teaching hospital and experience of what life was like.
And it was an important part of training and they were actually very few jobs in those days that seemed to have that balance.
So I was attracted to that aspect of that job.
And that's that's the job I applied for. And I was lucky enough to get in.
And was that they were actually cousins long ago.
No one knew was there. And Griffiths is just about retiring.
I started off I did my first year and I'm assuming Hardwick, I think he retired that year.
And so when it came to when I came to Oxford for my first year, which had to be my second year on the rotation, I think he'd already left.
Sean McCarthy was still there and Gordon Wilcox was just leaving as I arrived.
So that was the part. And then. Shortly after that, Greenly Evans was appointed as the first professor of geriatric medicine,
gerontology as mental illness and when its west in San Sebastian followed shortly after that.
So that must have been in a sense, I think criminy was appointed as I started.
And I think that Sebastian probably followed about a year later.
Like as a reader. As a reader. Yeah. And where was the war then when you came to the idea of the wards were down the old Radcliffe Infirmary?
Um, we had quite a lot of. I was looking at the numbers the other day.
We had over 100 beds, Daniel Radcliffe Infirmary, and there were beds.
There was Adams and Bedford with cousins and there was a Nuffield one and two.
So there are quite a lot of beds at both ends of the long corridor of the infirmary,
together with the day hospital, which seemed to have a, um, a much more mobile existence in it.
It started off at the front of the hospital, um, next to the main entrance in the fountain.
And while I was there, it seamlessly moved to the other end of the corridor into what had been a different ward at the time.
So how did you enjoy and it your year at work and that being of enquiry?
Um, I think it was, uh.
Uh. The smaller environment, which one had not been used to and, uh.
This was interesting, the the number of junior staff was less the.
As the senior registrar, you were seen much more as a font of knowledge and expertise when you had been in the teaching hospital environment,
which was both flattering but but actually, um,
was difficult because there were less people to discuss clinical cases where the money had been used to.
But having to take decisions more singularly, uh,
take on the responsibility to deal with problems without that support was quite a good learning experience.
But, uh, I think it also opened my eyes to the dangers of being single handed.
How often did the consultants come in there due to rounds?
Yeah, probably, yeah. I mean, don't get me wrong. I think I think I think they supported us.
Well, they did a very good job. Um, but the contrast was in, as you well know, in these kind of environments, you've got lots of colleagues,
most of whom are very valuable all around you all the time and actually very able junior staff who are perfectly able to question and challenge you.
Yes,
it was it was noticeably different to the degree that that depth of expertise and the readiness of people to question your decisions was was left.
And I think I've always I think I think it's very healthy to be challenged.
And, um, and if you can't defend your own decisions, then maybe you should question them yourself.
And whether in the Oxford students at the, um, from time to time and not not a lot in those days,
uh, most of the what were in those days, the preregistration hensman were Oxford graduates.
There were some who came from London. And so it's a nice boundary line.
We but most of them seem to be from Oxford that I worked with and many of them I kind of knew go over time.
Got to know from from Oxford as well. Um, the the middle grades at registrar grade often were local graduates.
And once you come back to Oxford for three months,
what was your feeling about the standard of medical care as compared to marriage compared to high income.
I mean, I thought the I, well I and I still do wouldn't like but I do.
I think the standard of medical care is generally very good, very high.
Um, I think that, uh, when I first came to Oxford, I was slightly overawed.
I thought the quality of care given by the physicians was exceptional in the contrast, you know,
with compared with what I experienced in London with the presence of the consultant
physicians with whom I work in Oxford was much more evident than it was in London.
They tended to turn up for a round in London and not be around,
whereas here it was a clear commitment, particularly by the Ontake physicians in medicine,
to be around, to be involved in the type doing the post, take more drugs in a way that I hadn't quite said before.
And I thought the nursing standards were pretty good. But of course, in those days, the John Radcliffe was a relatively new building.
Yeah. And it's interesting to see how the new building has grown old as I have it.
Did you feel that you were sort of downgraded by being at the IRA instead of the generic not good.
No, not so. Um, uh, I mean, I spent half my life in medicine and half my life in geriatrics director for family.
And that was a career that I chose from because actually it was that breadth of clinical management from the front door patients.
In those days. We had long stay patients, uh, the Churchill Hospital.
And actually there was a certain satisfaction in being able to while having the privilege of looking after patients from around the world.
No, who I did this from their presentation as medical emergencies right through to Long-stay and even to their end of life,
um, which I think was invaluable and gave.
Want a perspective about what one was doing in terms of management of patients and what people are really about?
You can see that, uh, I got in marked contrast to what we do now when medicine is much more jumped into almost shifts and the continuity is gone.
So I think that's quite a change.
But I didn't in any way feel that the different activities in which I did that, I feel to evaluate whether other people do value.
I don't know. Did you come up to the John Radcliffe once a week for grand rounds?
Yeah, well, it would depend and depended on it, depending on how the, um, the the the duties of the senior registrar undoubtedly would change.
There were times, certain times when you were fixed wholly at the John Radcliffe.
Other times you were wholly at the Radcliffe Infirmary. I mean,
there were other times when you had responsibilities in both places and various
combinations of those were trialled throughout my senior registrar period.
So, uh, one would require quite a lot of the time when I was here for grand rounds anyway and didn't have to make a special effort.
And if one was down at the Radcliffe Infirmary, they say timetabling had other commitments permitted,
but there certainly never any problem in coming up to the child. Go, go, go into the range of the regular family.
Did you get by bicycle or a car and then and went up to the Churchill.
You would continue with your patients from the Radcliffe Infirmary when they went to get your.
You looked the same chap. Yeah. Yeah. What about social services?
Because that's always important in geriatrics. How did they compare with Mary's much, much better.
Uh, much better. And that might surprise to anybody who's working in Oxford today.
And the the most striking thing that was so different was down at the Radcliffe Infirmary,
the Oxfordshire Social Services Department was on the same corridor as the geriatricians offices.
And this was an old converted ward, kind of the Radcliffe Infirmary called Abernathy, which was on the first floor.
The front end was where all the consultants and the senior registrars had offices and secretary and the foreign social services.
So and so all of the social workers were down the corridor and the social workers were allocated to individual wards,
which were individual consultants. So there was also the social work was clearly a part of the team, met regularly,
but because they were just down the corridor, there was free communication.
And Mary,
you have to fill in a form in triplicate and email it electronically to something you just used to go knock on the door and discuss the problem.
And and I think that that worked as it's very easy.
It's very difficult to be angry with somebody that you've got to face face to face, whereas it's much easier over the phone when you can't see.
So I think the working relationships were better. The immediacy of the contact was much better.
And if they had a problem, they would come and knock on my door.
And so so that unique embedding of the social services and the social workers within the clerical
department was something that I had not seen before and something that I was particularly impressed with,
because this is all or way before, Terry, the community and all of those things that happened in the early 90s.
Um, but it worked very well. We did a lot of things very differently.
The amount of care that was available at home was considerably less.
Uh, the length of time patients stayed in hospital before they went home was considerably longer.
And, uh, and I suspect the patients finally got some data just to confirm it were less dependent
when they went home than we are now sending people here because of the other constraints.
So I think that was quite remarkable. And sadly,
something that's gradually being eroded over the last thirty years is that the that the distance between the
social worker and the geriatrician has got further and further because they're all saying this has to be reunited?
Yeah, everybody says absolutely. But they didn't think that that.
Right. It doesn't happen. Um, and of course, the whole the whole system has become much more regulated.
Much more bureaucratic so that there has to be a form for almost everything,
and it's no longer me just saying that the patient is is fit for discharge.
I have to fill in a form or Section five to say they're medically fit for this job.
Well, yeah. And so the whole the whole process. Yeah, everything.
I mean, and it's largely stems out of regulation. Yeah. You have to have the documentation to show it.
So. So it comes at I think, I think some people are much more enthusiastic adopters are fulfilling than others.
And um, the social service workers when they come in the and they used to when we first started acting like they don't they don't so much now,
but they will come to the ward meetings. So they'll they'll come to uh.
I have another one of the things that slightly irks me is that the the multidisciplinary team was something that was largely invented by,
uh, British geriatrics. So the MDT without physios, nurses, social workers to plan and manage some of these care issues that, of course,
now the surgeons, the cancer doctors and everybody else have taken over the empty table as if it was their own invention.
Yeah. And so, yeah. So I MDT, which is the original,
is not fully appreciated for its complexity because it is really about a lot of different people with different views on things,
whereas the cancer MDT is about the radiology, the pathology and the surgery and the chemotherapy.
So it's kind of a disease specific, whereas our MDD are really about trying to manage complex problems with that little cousin,
which is a little cousin, I think.
Well, he he was certainly the day hospital man was me.
Um, I to my embarrassment,
I'm not sure where the origin of the MD 80s it would come from certainly comes
out of geriatric medicine and and the families of British geriatric medicine,
whether there was any one person who kind of said I think it was always the involvement of nurses,
physios actively in the management of patients and who at the time was talking to the relatives in those days?
Well, I think it was the docs spent a lot of time doing it and undoubtedly nurses did otes have always been very good at having
conversations mainly about the mechanics of AIDS and discharges as a private as the primary motivator for that conversation.
And some of them are fantastic at doing it.
And I can glean an awful lot of information about the real world and what's going on at home in a way that we can.
So that's and and I think, again, that that's always been the case, but as time moves on,
the issue is that the amount of time that family members and relatives expect has increased.
And so and not and not unreasonably, I mean, it's entirely reasonable that, you know,
I should sit down for 20 minutes or 30 minutes to discuss with family members, their wife, husband, father, mother.
The problem is, is that if you haven't got enough time in a week to do that 30 times.
So it's one of those examples of entirely reasonable behaviour. But when you scale it up, becomes unworkable.
And that's beginning to happen from time to time in the year and suddenly find that there is just not
enough time to meet all the relatives and have the conversations that they and their family deserve.
And to relatives argue that toss much these days.
Yeah. And. I think it is undoubtedly true that the, um.
That the the nonmedical relatives. Have got more ways of expressing that discontent than they used to have.
And and I think this a kind of an interesting power things.
And I think in the past, dogs could kind of get away with things because of the power relationship.
And that's been eroded for good or ill. I mean, I think for good and ill.
I mean, I think the pros and cons and all of that. So you certainly I think I can see, uh,
some groups of relatives behaving in a way that is almost unacceptable in terms of their aggression and the seriousness.
But we don't have the power to do to deal with it.
Um, and it's a different world. But, uh, I, I mean.
It's kind of interesting, I've had to respond twice to a letter of complaint from a lady who not only I,
but several other people think she's got functional disease.
And her complaint is that I didn't order an MRI scan, which I didn't think was indicated, told us so.
And she's not accepted that. So she's written another letter of complaint and the process allows that to carry on.
And actually, it's a manifestation of her other problems.
And whether that's a better way of dealing with her problem may also be her complaint that is caving in and giving her an MRI scan.
So I think that that's undoubtedly true.
Um, but equally, I think that that the most striking thing is the people now are more ready to express an opinion on the medical care.
So you have this kind of interesting, educated,
computer literate class of people who will now come along with their view of what's going on and have people occasionally quoting nice guidelines,
sometimes out of context. Um, and that's that's the challenge that people will in the same way that it used to be.
You know, my aunt is a nurse and she says you now have the Internet access.
And so they come with that. And that that's an interesting they're more prepared to disagree with you or to force you to explain your position,
which, again, isn't a bad place to be. And again, my own view would be that if I provided that reasonable you know,
if I can't persuade people who haven't had my education and training in medicine that I'm making the right decision,
then perhaps I've got it wrong because I should I should be able to do that.
You know, the time. I mean, it's the time element to debate. And that's an interesting world, actually.
And of course, it does allow some people, you know, if they're able to to do their online searches, read up their own condition,
it's quite possible for them to know stuff that you can't remember or never heard of in this one small disease area.
So you have to be careful.
And and and I think the real changes with a certain amount of humility, um, and I think you have to as always, there's always been the case.
You have to gain the confidence of your patient.
Your patient has to be confident in you. And so does that that support network need to become.
And there are lots of different ways of doing it. And one of the ways we have to do these days is to deal with this kind of information flow.
And if you can't do that successfully, then they're going to have confidence in you and things aren't going to work.
So that's as much of the same challenge in a different code that we had before it happened.
And I think that physicians have had time immemorial.
It's back the confidence of your patients. And getting him names when you first came to get your social services, which he was up here for.
Yeah, I can remember. And now Mulgrave was around.
Yes. What is he doing? I'm not sure. So I'm not sure what I was doing.
I think he was I think he might have been public health.
The for one of them would be what we were in those days, whether we whether we were an area health authority or not.
That was the days when it seemed to change. There was, uh, think I think certainly public health for the Oxford Area Health or district or region.
I can't remember. And he was. Much the same as he is now, I think, and I remember him as an extreme, is very good at finding a place for somebody.
Yeah, and if a patient really. You were blocked. Yeah, it was very good.
And so and I mean, he always expressed an interest in the care of older people and whatever.
Um, I think he moved on to greater things fairly quickly after I'd been around, but that he was certainly here then.
Um, now one of the great things was that geriatricians should do younger general medicine as well as geriatrics.
How much of that did you get involved with? Well, well, in those days, you know what?
The situation was different. But I, I was trained to do general acute general medicine is I think also was.
Yeah, I'm here in Oxford. I've done it all the way.
I mean, I, I'd always done I think the hyper specialisation that we see today haven't really fully embedded it.
And even even the specialist such as yourself was still doing general medicine.
I think I think what's been seen over the last 20 years, certainly since I mean, is is an increasing rush to hyper specialisation with, uh,
the specialists I'm pulling out of the acute medical service,
which I think has been probably a bad thing for the service of general medicine, I think to be a bad thing for patients.
And personally, my view is I think it's been a bad thing for the specialists,
because I think that that and I think we're now in an interesting situation where the Royal College is
kind of talking about the return of the generalist and hype and the need for what they are talking about,
hospitalists type people, which is fundamentally the general physician.
Um, I, I think I think we do need that.
Um, I mean, I think I think it is a bizarre situation that obviously has got itself into the game that we know that,
that the high proportion of patients coming in to hospital, both acutely and electively have diabetes.
And yet we until the last year haven't had anybody from the diabetes service involved in the acute medical service.
That's changing. Maggie, Maggie, Hammersley. Yeah, she was she was disconnected from diabetes.
So, yeah, there's been a recent appointment. Who's doing both?
Good. And that's good. But for most of the last 20 years, we haven't had it.
And then we when we also know that the huge number of acute emergency admissions are
chest related and respiratory physicians don't have a big presence in the acute service.
And I don't think that's good. I think it's good for the vet services and I don't think it's good for patients.
And I don't think it's good for for for the whole thing. So so that's kind of where it was.
I was perfectly happy doing medicine in in younger age groups and still am.
But of course, the the real change that that's been happening for a long time, but certainly over the last 25, 30 years,
is that most of the patients who are more than half of the patients who are coming in as acute emergencies are actually frail and elderly.
And I always say to the students and everybody else, I'm delighted.
I mean, I really wouldn't want to be walking around the medical wards seeing lots of twenty five year olds dying of TB and rheumatic fever,
which is how it used to be. And and I think that the fact that most of the patients who are coming in are elderly is is kind of great.
It means that young people aren't being being sick. And my own view is that, you know, getting the medicine right for that group is important.
And it doesn't always mean doing high tech medical interventions and make a proper assessment and
making the right judgement on what the appropriate thing to do is and giving them a fair crack.
The whip in the modern world is as important. So actually, having trained to be able to do all ages,
the number of younger people that will now actually see coming through the door, um, is very it is very, very different.
And and lots of things have disappeared from the acute medical take.
Um, keep my college and infarctions. You just don't see that go directly to to the to the lab and have mediated coronary interventions.
And, um, and one that you'll know more about, I, I can barely remember the last time I saw a diabetic ketoacidosis.
Let's go through the front door on table, whereas I think when I was a junior doctor,
it was one to every other take you would have a lot to three months after it was a lot more common.
And the bizarre thing now is that people are not very familiar with managing it when they see it.
You know, they think they don't quite get how serious it is and how dry these patients can get.
But I think, you know, so that's just two examples of gastrointestinal the damage.
Yeah, they closed down. That's that's that's less common.
And it's still a bit of an issue in older people when it came to endoscopy service, kind of deals with a lot of them and they certainly.
I mean, the endoscopically interventions for GI bleeding are really quite, quite dramatic so that people can get diathermy and laser and everything.
And of course, that the whole endovascular, um, thing with a lot of what was major surgery is not done with stents and various things.
So big bleeding, you know, the interventionists will just call the artery and stop the bleeding.
And it's quite stunning. I mean, the patients go from being shocked to not shocked almost immediately and by having spent three hours in theatre.
And so I think they're huge, huge changes.
But I'm much over the years, have you had to deal with the cottage hospital, say, with me, uh, wanted give you gone?
Um. Yeah, well, I, I ever since I've been appointed, I have been doing a clinic, uh,
out of Whitney once a month and and I did want to increase it to at least fortnightly when I was first appointed,
and that was blocked in all sorts of ways and never happened. Um, I thought about it.
Well it was the community unit in those days, um, I think and and I did spend a lot of time.
I did some work going around various of the community hospitals. I used to go see patients on the wards with me whenever whenever requested.
I and I think that's the the the big issue for Oxford, I think was and perhaps still is the community hospital.
Um, I think I think whoever labelled them a community hospital understood p are extremely well raised me really.
I think that well the issue is I would contest, I would suggest that if you have a community hospital,
it should be available to the to the patients in the community and it shouldn't have any restrictions where the only hospital in Oxford
that has a completely open door with no limits on age or disability or acuity is the John Radcliffe is the only community hospital.
Most of the other community hospitals are so restrictive in what they do that actually you can live next door to it, but may not qualify to get in.
It seems to me to be a bizarre way of running a health care service, but there are large numbers of beds and they were traditionally run by the GP.
And I think that may very well come back.
I think as demands have got greater demands on GP's have got greater the acuity and dependency of patients has got greater in their complexity,
that became increasingly difficult in various places. The GP's no longer wanted to run the hospitals.
So then it's been all sorts of various arrangements for contracting out.
And I'm not sure that efficient. Interesting. Interestingly, I think over the last five years,
geriatric department is again becoming more and more involved with the community hospitals in Oxford Health,
which runs them now and putting in acute care and acute assessment.
And the as the emergency medical unit,
which has been running and having to for a number of years and is now kind of celebrated as an example of how things can be done.
And I think what it shows is that there is a place for a certain degree of expertise in assessing the elderly patients,
and that's worked very well, although it's quite well resourced.
Well, where that will go in the future, I think will be very interesting.
Um, I think we've got the increasing numbers that demography means that there will be more older people.
I think that if I think care at home, which is what everybody says that everybody wants.
If that is able to keep this situation stable,
I'd be surprised because we just kind of have the in indicators going to be more and more people with
dementia if we can just keep the situation stable and not grow in terms of what's required in hospital.
I think we will have achieved a huge amount, um, put that in the affording of that care and the expertise to manage it.
I think that. The I think it's interesting to speculate on what the role of the doctor will be in the future in that I think
it may be that we need to have much more of the routine work being done by less expensive medical workers.
You know, and the danger there, of course, is how do you train people every generation?
Because in order to deal with a difficult case, you need to see a lot of the routine cases.
And if you devolve all of the routine work to a non medical workforce,
you then have to think very seriously about how you train people to take on the role in the next generation.
And I think there is a is a real issue that's being discussed.
The various pourer around the introduction of specialist nurses into various areas of work in the battle to actually do a fantastic job.
But one of the effects is that the skilled junior trainees in the management of those cases and the knock on effects may not be seen for some time,
but there will be some. And for some reason, I associate you with David with or you work with.
Oh, yes, I did. When I heard that you were the detached geriatrician, right?
Yeah. Yeah, I am. Well, the the the the senior registrar training programme involved, uh,
in doing and in fact I think I did most of my medical training on the SDM for me, as it was in those days with David Wetherall and John Ledingham.
Um, and so I spent quite a lot of time as their senior registrar.
And that was in the days when David Wetherall had his office up on level seven.
Um, and that was kind of exciting.
And it was it was good medicine.
Um, uh, it was, uh.
Interesting to work with people who have and.
And they were great people to work for, you looked a lot and I think that was sometimes quite pleased to have a geriatrician, David,
who is very keen on wondering whether an investigation was necessary and just routine around wondering whether it was truly necessary.
And that was one of his great skills. And I don't think.
Yeah, I mean, it's it's I think it's becoming increasingly pertinent and and I think the the cost of investigations is.
Gary.
You know, I think some of the some of the some some tests are coming down because of volume, but but I mean, the real the real change is around image.
Um, and, uh, it is undoubtedly the case that you do need to ask yourself the question, why am I doing it and what am I going to do with the answer?
Because the problem with modern imaging is a number of kind of incidental findings that
then force you into some kind of surveillance programme or further investigation.
So it's certainly a question of do I need this test needs to be asked more and more.
But everything's changed. Everything. Yeah. How often do you get the imaging?
And that's the real surprise. Well, I hope not too often that I'm a real illumination.
Yeah, well, I think I think that's right.
I mean, I think that that from time to time, um, you are glad you've done it because you've picked up something that you might easily have missed.
I mean, I think that kind of surprised, uh, is particularly true around I mean, colon cancers.
I think perhaps the best example, because this.
Particularly in older patients, it's a curable disease and but also the investigations are not entirely pleasant,
but the incidence is more common in older people. Uh, surgery is more risky.
So there's a whole multidimensional jigsaw that you have to kind of, uh, put together to make that to make the axes work.
Um, and it's quite nice when you get somebody and you think, well, actually,
I have cured this person and they may go on for another 10 or 15 years with good luck.
So so that's not the incidental findings are more tricky.
And the makes this is the kind of the difficulty where occasionally you're kind of pleased that you were right in your diagnostic skill.
But the implications for the patient are not good. You probably saved them a lot of unnecessary tests, but, uh, that's kind of it.
Split emotion, isn't it? Do you think it's good to get the diagnosis right?
But the implications for the patient are not the best. That's not a good.
That's what we live with. And how do you think the administrators got the upper hand that as a judge when you already know I'm the grass?
Yeah, I think I think, uh, I miss lots of things.
I mean, I think the whole process is gone. I think we've gone from, you know, the single handed doctor and, you know,
Dr. Finley as a kind of a one man cottage industry to really industrialised medicine.
And we're much more, um, even even as individual physicians dealing with individual patients,
there's always this idea of the service and the and the wider public health issue that your kind of thing.
So I think I think that over time the whole business has got much more complex.
And and I think that that as it got more complex, doctors tended to kind of say that's an administrative task.
It's not for me. And doctors are quite good at that.
But, you know, they're quite good at saying, you know, that's not an appropriate job for newly qualified doctor.
Well, actually, it probably is. But but so we're very good at saying it's not our job.
And I think that we we we moved to we ran away from too many of the complexities of the problem,
citing pressure of clinical work, which is kind of what we wanted to do and didn't take it on.
And I think that allowed a much more administrative type people to get in without the benefit of some of the medical input to kind of get.
So actually, I think that the group, the complexity, increasing work loads, clinical priorities and probably medical preference,
that we tended to move away from a lot of the management issues that were coming along and then the whole management structure built up.
I think it is now becoming increasingly recognised that the physicians and doctors should be much more involved.
And we've got this so-called clinically led organisation.
But actually the key management posts below the executives in the trust are all practising physicians, practising docs.
Sometimes some of them are surgeons. And and I think that's good.
But what is clear is that, uh, the complexity is such that you actually you can't do it on your own.
And I do it, but I can't do it on my own. I need a pretty good team around me with managerial expertise and financial expertise because
they can do the missions that you and I can understand how to run my household accounts.
And it doesn't quite work. And when you when you're dealing with.
So I think I think that that I think the medical profession is responsible by not being has evolved over the years, as it should have been.
I think it would be difficult for us to be involved. I think emotionally we try to do something else.
We're much happier looking after patients than we are looking after a cancer, sitting in in what appear to be futile, non-productive meetings.
Um, we. And so I think that that's how we moved out of that sphere.
So I think for all very understandable and reasonable reasons and and often because we'd
rather be sitting with our patients than sitting in a board meeting and trying to do that.
It's what you're good at. It's what you want to do. I think you know us.
I think other people took advantage of the fact that we prefer to be somewhere else.
Um, but it ended up I think that's why we are where we are.
I hope that the thing is not so complex that, um,
maybe it is important that doctors are more involved in what's going on and some clinical perspective is brought into into decision.
The danger with it is that I think that the kids, the clinical commissioning groups.
Have one type of doctor heavily involved, and that's the GP,
and the idea is that they really understand what the health needs of the population are because they are embedded in it.
But I think it is a bad idea to have doctors running the health service on their own.
And I think it's an even worse idea to have just one type of doctor. Do I think that we need to kind of get more?
And of course. The financial situation we find ourselves in is such that resources are going
to be limited unless there is a real difficulty in under resourcing talented,
ambitious, driven achievers like most docs, if you underresourced them and then make them compete, you're going to have a difficult time.
Yeah, and I think that's kind of where we are at the moment,
because I don't think there's any way that I've never yet seen anybody say, you know, you need to have that piece of equipment.
And guess what? I don't think I'll have this piece that I need until you've got yours.
That's not happening in that kind of collaborative work, both within the hospital and outside into general practise, unless that starts to happen.
Think will always be in detention. Yes, I mean, basically, it's very simple, you know, and it's very complicated.
It's also very simple and that medicine gets more neuborne, more complex.
So the cost goes up and gets the 15 percent of GDP or whatever.
It is an impossible. Yeah. And how do the doctors and the politicians persuade the people of this to face up to it?
Absolutely. No, you're absolutely right. I mean, at the moment,
we've got we've got the politicians kind of almost saying that you can have everything that you want in the health service and you can you know,
you can do the four hour waiting a day. You don't have to wait very long for operations.
So to some extent, some of the old controls that we had were running out of money where we could just kind of push things into next year don't exist.
I think the expectation of the population is growing and the resources and until the politicians start to be honest,
that we have a fantastic health system which by and large works very well,
occasionally there are things that go wrong and it's an absolute tragedy if you happen to be the individual where that happens.
But it's such a high risk, large, complex business that if you want to find the right, you will always find what we make to that.
And I don't think we can have a Rolls Royce treatment on cooperative funding, you know,
but I think that's going to be a real challenge going forward because there's no sign that the population won't last.
And as the technology gets better, I think that one of the issues is that paradoxically,
um, you know, technological advances, better imaging, better surgery,
laparoscopic surgery actually mean that you can do things on patients who are frailer and higher risk that you couldn't have done 10 years ago.
So this is a bit like seatbelts, although all that happens is people drive faster when they wear and what the surgeons and lots of the interventions
that we're not doing interventions on people that 10 years ago we might have said we can't do anything,
let's go on. And the costs we are talking about endovascular work.
You know, there is a kind of a legitimate question which you can't have about the individual patient.
But if you're going to do things that cost thousands of pounds to people in their 90s with life expectancies of a year or less, there is a question.
It's a difficult question. It's not a question that can be answered in real time by real people with real grandmothers and mothers there.
But it is a question that society is going to have to face up to because I can't make the decision one on one that easily.
Do you feel you can catch the biological age of a patient, as is the chronological age?
And if so, how do you how do you think surgeons are actually quite good at it?
Believe it or not, I know I think surgeons are good at it.
Yeah. And they don't know how they do it.
Um, I think, uh, I've got all sorts of things, um, that have been tried over the years to put this on a on a real basis.
I think I think you, um, something about performance status, um, and what people can actually do I think is very important.
So simple functional things give you quite a clue as to where people are more than talking to people.
Well you get it. Yeah, yeah, yeah, yeah, yeah, yeah.
But what they can and cannot of the conversation with them about their functional ability you need to compare.
I think, I think the things that, that, um, you need to be careful of are, uh,
makeup that can make people look a lot better than I can unhidden vascular disease.
And I think that often there are people who seem to be okay.
But when you go and examine them, you find that a pulse is missing and you've got to ski because.
So so I think that the functional assessment,
together with some kind of assessment of vascular risk or evidence of actually that I've seen I've seen that go wrong,
um, um, where everything looks all right.
And then the postoperatively they go to crash. Heart failure.
And when you look at it, it's quite obvious they got quite a significant coronary disease risk isn't quite right and that's all kind of being missed.
So I think their functional assessment, vascular risk factors are an important part.
And and then the other thing that you must always keep an eye on is that kidneys,
because people can have pretty bad kidneys and still look pretty good.
And I think if you do all of that, you can then I don't think the conversation, as you say, is there.
And at its simplest level, I've always thought that if you can make an estimate of somebody's life expectancy.
Then you have actually judged that biological age.
Yes, in that, you know, if if you've only got a year to live for whatever it is, matter how old you are.
You're well into your 90s in terms of biological terms.
But it's an interesting area, one I don't think we've it's a bit like the concept of frailty as well.
And it's it's something that, you know, when you see it, but it's kind of hard to measure and describe.
And I think that the that but I think the real impact is less is actually the trauma that we put people through for what used to be quite major.
You know, laparoscopic cholecystectomy isn't quite what I know you can cholecystectomy was.
So, you know, if you get your cold cystitis in your reasonably fit, there's no reason why you couldn't do it.
Whereas I think when I was a student, you didn't see many people in their 80s having that gallbladders removed and anaesthetic.
So they change in the damage they do to a degree. Yeah, I think yeah.
I think all of that I think needs to do everything much better. I think there is a there is still there is still a problem of post-operative delirium.
And because we're doing more and more and in older and older people, we're probably seeing more of it.
And certainly as a geriatrician and certainly the author,
geriatricians who have worked closely with your feet to see quite a lot of post-operative delirium,
whether it's that the surgery, the anaesthetic, you know what particular component it is, just start very keen on the anaesthetic.
But I think that, you know, when they tell me how the anaesthetic works, I'll take more notice along that as well.
Yeah, it's difficult. I think the other thing I think that that's changed is that I think when we were younger,
delirium was a kind of an acute short lived thing that had a bit of an infection.
You could be delirious. Trachea, infection, delirium goes away.
And that's undoubtedly true and that happens.
But I think what we've become increasingly recognised is that delirium can persist, particularly in older people,
and it may go on for six weeks or more or may become permanent or even permanent delirium.
And of course, the problem is that, uh, the biggest risk factor for delirium is dementia.
So so you have, um, the problem is it delirium or dementia?
The delirium is often likely to result in a further downward step in terms of dementia.
So I think we recognise that better. I think we're getting better at managing it in that it doesn't require it doesn't always require treatment.
You may have treated the precipitating cause and it may not be just supportive therapy until they get better.
And recognising that's quite a good thing. Not it's not overly sedating and using dangerous drugs.
Yeah. Um, which which a lot in the evidence for the use of drugs and delirium is patchy.
Uh, I think we understand it better. Um.
And I think it's becoming increasingly it's an increasingly important component of the reasons for admission to hospital,
the development of a delirium.
So the emergency surgery may or may not precipitated the fall, of course, the broken hip or the infection that caused the fall.
There are so many factors in this that it's quite obvious, but it's there.
Where do you think the demented in Virginia is going to end up?
Are they going to end up into one function, uh, mini hospitals, or are they going to be mixed in with others?
Well, I think I think it's going to. Yeah. Are we were talking about that.
I suggested the most specialities needed to have a year of geriatric medicine built into their training programmes.
Yeah, because unless you're going to do obstetrics and paediatrics, the future of medicine is going to be about looking after older people.
And as I said earlier, I think that's that's great for but represents presents its own challenges.
So I think everybody will need to do. I think I think we need to improve.
I think we do need to improve the community services and the support that you can get in the community.
And I think that quite a lot of patients will be able to be looked after at home rather than in hospital.
I think there is a there is a view that if you ask people, that's what they would say they want.
I don't think we can always deliver it.
I think that provided people, particularly elderly, get an adequate assessment and the advantages of modern technology are not denied to them.
So I think, for example, Skåne, you know, what's wrong with this person?
I need to find out.
The amongst technologies is that we can do in a few hours what used to take us a week to give me some modern blood tests and imaging.
So. So I think that, for example, a lot of these frail elderly people who have a delirium and a dementia and often the
cause is not that obvious and often the cause may not be found who may have gone away.
So I think rapid assessment of those people and looking after them at home while their delirium settles is the way forward
because we've got far too many people coming to hospital because we can't support them at home and don't require any.
They require quite expert medical attention to say there is no problem that needs intervention, but now they need to be looked after and supervised.
Many of these people would probably settle quicker in their own home familiar environment than they do in the distorting,
disturbing environment, the hospital. So.
So one of the things I think that will happen is I think that the and we've talked about this for 10, 20 years.
And I think the boundary between the community and the hospital has to merge.
And I think that there may be a lot more virtual wards in that we will be as hospital
dogs looking after more patients in their own homes and either with remote monitoring,
uh, teams of nursing who have the expertise to do it or even visiting other relatives can be involved.
I mean, they're very important, but then they have more fun is OK?
Yeah, I think I think my aphorism would be if the family don't support the discharge,
the discharge may not may not be successful, particularly for frail older people.
And and that works in both directions.
You see some families who are supporting people at home and you wonder how on earth can they possibly be doing that?
And then on the other hand, you see people who are because of the lack of support for the family.
People have to end up in some form of institutional care where you wonder whether that's really the right outcome.
But but but the social services support of it wouldn't be that if the family don't support it, um, it's that.
So so, yes, the whole.
But it is getting interesting, as we get older and older population, we know that we're married routinely admitting people over 100.
And that kind of puts their children into their 70s.
And and just from time to time, the children are afraid of it.
And the parents and and, you know, so.
I mean, whatever you think, it's never going to be as that happens,
it's going to be unless the cohort of 70 year old becomes considerably fitter, they're not going to be the solution to looking after you.
I'm sorry. Is it going to really skip a generation? Well, it's hard to say with social mobility that's needed in the modern economy.
The grandchildren will be able to look at. So some interesting times ahead.
Have you seen any signs of the decrease in mass market share in dividends?
I'm. I think I talked to I don't know.
I don't know. I mean, I'm trying to think what what would I have noticed?
I mean, we certainly see, as we said earlier, my having fortune to see less of that going in different direction, which I think they see less of it.
I mean, I think that I think the one that probably has much to do with the treatment of hypertension and hyperlipidaemia is it is to do with smoking.
But it's the whole package is to show the.
Maybe you don't see quite as many severe COPD as we used to,
but it came with such a heavy move to manage those people in the community that I don't know whether that's being successful.
Um, uh, what we do see it directly is every time there's a AM an advocate on the charity side, you've got a cough,
get a chest x ray that our referrals from our friends together and our detections of lung cancers don't seem to change.
So it's a bit like the breast that you can see more and more people for the absolute numbers that you detect doesn't change very much.
So that's kind of an interesting area where all we.
Yes. Um, let's see what communities outside Oxford will be on the committees with this.
I'm done a lot of what I did for a while do something with the National Association of Clinical Tutors and when I was doing education.
But I have committed myself pretty well to most of my activities being within the ring road for good or ill.
That's it. And you went to take him to live near to him as soon as you came when you were trying to make of it?
Yeah, well, I came I was the most surprised person to get the consulting job.
Well, so so when I when I came,
I guess I have already alluded to I was interested in the job postings that time was geographically that the right place to be.
And, um, to my great surprise, I ended up getting a consulting job and hadn't expected to stay here for 30 years.
But, um, we just never moved that serendipity.
Really. Yeah, there's no need to it was fairly comfortable in those days.
It was only a 20 minute drive to the John reclose. It's, uh, what is it now?
I would say at the moment it's 45, happening a little bit on the time of day.
Um, but in the rush hour, if you if you if you're aiming to get to the John Radcliffe by nine o'clock, it's at least 55.
It's an hour's drive. So if you want to get here by age, then it's a lot shorter than seven thirty is perfect.
So for the traffic, the traffic has changed in the last thirty years, then what committee is administrative committees, etc.?
Have you been on the inside. Oh you name.
Yeah, I'm currently on the trust management executive, which is you know,
I go to the Clinical Governance Committee, um, uh I was on the Education Committee but I can't just give that up.
Um, I have to chair a lot of the divisional work.
So we have divisional governors here at Reagan Medical Medical.
Yes. The whole division. Yeah. So I mean, has medicine, um, gerontology, neurology, the whole of cardiac services, cardiac surgery, cardiology.
And, uh, and then I've got quite a lot of the medical services from the church.
And so diabetes and the current respiratory, clinical genetics, dermatology, infectious diseases.
So it's quite a large area. It's about 180 million pounds is how often does that come at you?
Well, we we we, uh, fortnightly to run the division.
The CME makes fortnightly to to deal with trust wide issues around jobs, job planning.
Replacement posts, strategic views, finance, finance is the dominant issue.
Um, and then various other committees within the trust mortality reduction, how many outpatient clinics you kill?
We, uh, I used to do two. I married to one.
I'm thinking of going back to it and I think even.
Would you say you're busier now than when you were young? Go the other way around?
I think that's. Yeah, I see an interesting question, I think I think that I saw more patients.
In the past, the one does not in any given time, and and I'm not altogether sure that I fully understand why that is,
because having already said that, we can do things much more effectively in terms of investigations and diagnoses.
You'd think it would be easier to see more because one of. I suspect that.
The complexity of the patients in geriatric medicine has gone up.
I think that with the with the increasing specialisation of things,
if the GPS know what the problem is, the patient goes to the right organ specialist.
And so if it's cardiac, they will go to the cardiac clinic.
And if it's, um, respiratory, they'll go to the respiratory clinic.
And if they know. So if it's a TIA to check.
So I still run a kind of a general gerontology clinic, which many of my colleagues don't.
So I get the ones where they're not sure what the problem is.
And it's often multiple problems. And, uh, and so I think that the complexity of the patients I've seen, I used to see people with funny turns.
Well, the funny turns don't come to me anymore.
They I think they now go to the Falls Clinic and all the TIAA clinic and they back kind of taking them all out.
So that group where it's postural hypotension arrhythmias or Tieh vascular, they're all dealt with.
So anyone's I get the ones where people aren't quite sure what it is.
And maybe it's a testament to how difficult I find it, but are a lot more complex, I think.
Uh, but I do remind me a bit of, um, being in John Ledingham, you know, quite a lot of it was quite difficult.
But every now and again there was a Jamie I has this level of development help.
Fantastic. Good. In what sense?
Well, it's a it's a it's a nice ward. It's the paediatric ward which kind of tells you about where.
But every every everybody there is a single room.
Yeah. And they're quite big and some of them are big. You know, some of those.
Yeah. I think they're all adequate. Uh, some of them are really quite large.
Uh they all, they've all got an old suite toilets.
Most of them have got on suite bathing facilities, although the smaller rooms are ready to go to washbasin.
Um, and it is interesting that most patients quite like it.
There was some anxiety. People didn't like being on their own, but actually that's very rarely the case.
We have had the old, uh, complaint that, um, people are frightened and felt left alone, um, usually by relatives complaining.
Um, and I guess that's probably true. I mean, I think some people could be lonely, frightened to get in a room on their own.
And I thought there'd be much more of that when we first moved to it.
But the reality is that most people prefer it. And I think we can understand why.
I think I'd rather be in that environment. So that that's nice.
It creates problems that are easy to understand in terms of nursing and that if you go one, that's eight bed.
Well, in the old open Nightingale ward, one nurse can see a bedroom, one guy and I can see one nurse.
Uh, perhaps more importantly, when they're all in single rooms, you see the nurses in that maybe she can't see what's going on.
Nobody can see where she is. And, um, and that creates tension.
And of course, if you're the visitor and you come to the ward,
you may walk on and not see any nursing staff because they're in a room with other patients.
Yeah. And and the conclusions that people draw tonight aren't necessarily the correct answer, but, you know, emotionally charged.
Well, yeah, that that's true. And and of course, if two patients needing attention at the same time, then that becomes quite a problem.
Yeah. So there is there are some nursing issues around the single rooms.
I think we're probably in an ideal world, we'd need more nurses.
But whether we can afford to do that, were you surprised that the job market didn't get to the region?
But it was on the CBC. Yeah, I know. No, I think I think the CBC writing was pretty good, actually.
And yeah, I'd done something. Yeah.
Yeah, well, out of four points. Yeah, there was some there were some areas um where we didn't do as well as we could have done requiring improvement.
And I think largely across the whole trust and certainly Microvision where the main issues were around the accident and emergency department,
there was nothing there that we weren't already aware of and got plans in place to try and improve.
I, I have to say, I think the department was slightly hard to come by in the report, um, in that, uh.
There are some issues around overflow areas in terms of privacy,
but they are overflow areas and there's a good deal more private than we used to have and we have got to be able not to have to use them.
But there are times when the department overflows and sure,
it would be better for the physical design of the building means that that's the best that we can do.
So I think it's a bit hard to be critical of that because it's trying to do the best in a circumstance that you're trying to avoid,
but you've planned for the contingency that you find.
And and so I think that that was slightly unfair.
But it is a department under pressure. And they alluded to that, that we we don't make the 95 percent for our target all the time.
Um, but that actually, although there are always internal things that can be addressed, is also a function of the rest of the hospital.
And, you know,
if there are no beds to move people into from the department and you'll remember we used to have that long corridor where we had patients on trolleys.
And I think one of the areas was that nobody's fault in particular.
But when the whole department was redesigned, I don't think that corridor, the capacity of that corridor was fully taken into account.
And so it's always been slightly pressurised upon.
And then as demand goes up, we go.
But I think overall, overall, it is a consideration.
And I have to say, I, I think that I think you see itself has been the subject of some criticism and it's reorganised.
And I think in the world of targets and inspections, there are a lot of difficulties in how you get this right.
And I think, you know, and of course, the problem would be that even in something as complex and as high risk as a large hospital like this,
something could go disastrously wrong tomorrow. And I think in the current political climate,
if the secrecy with the writers is excellent and something were to go wrong, yes, that wouldn't be seen as that.
So I think I think there are constraints on what we can do in the political environment, which really was a helpful exercise to do.
Yeah, I think I think I think it probably was.
It's I mean, there's a lot of people, a lot a huge amount of um.
Yeah. Huge amount of. Well, that's exactly right. I think the I think the issue, of course,
is that given the nature of where we are and how real this is an inevitable consequence of the political climate in which we operate,
I think that what I found was reassuring about it because I don't think there was anything in there that was a huge surprise.
So I think it suggests that we are internally monitoring what's going on.
So outsiders are not coming in and saying, look at that.
So so we were so I think in that sense, in which it was useful and reassuring that they didn't find anything that we had internally.
And I think that the criticisms, such as they are, um, are more hurtful to the staff in the departments than perhaps people appreciate.
Can never be the same in schools. Yeah. And I think that that's an issue.
And yes, some good people, uh, feel quite upset.
And I don't know whether there's a better way around that objectively.
It's it's it's you know, you need to know what's going on in your department.
And I'm not telling you the truth is a bad thing.
On the other hand, the kind of official document that is not always seen as being wholly objective, that is critical, can have damaging effects.
So I think supporting those areas that were criticised and emphasising to them that it's not a personal criticism,
but that this is a systemic it is what we have to do.
Yeah, but it can be difficult because because the very nature of what we've got is people who feel responsible.
The system wouldn't work if they didn't feel responsible. So criticism is is hard for them to take.
And I think that job is what senior people used to try and support people who are not well equipped to be.
Criticised in that kind of harsh, harsh way, I don't think that yeah, I don't think so.
Say they're not they're open to criticism, but I think this isn't always the best way of doing it.
But a lot of people take that criticism personally.
Systemically. Yeah. As you say. Yeah. And I think that's the very nature of what we are.
Yeah. Actually, I mean, you know, we will take things personally because that's how the system works.
But I'm not sure that the that our political leaders and people fully they may understand it,
but they don't act as though they understand you as what happened last year that the I should have that.
I think you've been pretty thorough and you've you've covered most things, I think, as medicine got better in the last 30 years.
Yes. Probably that we're all living in everything's better.
Uh, I think that, um, huge progress.
I think that the progress that's been made is not, you know, another breakthrough on the six o'clock news.
And I'm kind of disturbed how often medical stories seem to be released in The Observer or The Telegraph before they're in the journals.
Um, but, uh, but I think the real progress has been in the little.