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Your name now. So could you start by giving your name and your position?

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So Richard helps out of academic primary care at the University of Oxford and was until fairly recently a part time GP.

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Thank you. So first of all, can you tell me a little about yourself.

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Without going into your entire life story? Because we haven't got time for that.

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Can you just give me the sort of headlines of how you got to be where you are now?

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Well, I initially trained for cardiology, but decided to actually qualify for general practice.

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It was at a time when it was easier to qualify for it and then thought it would be in my back pocket if at some point in my career I wanted to go in.

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But having actually trained for it, I was surprised to discover that you could do a lot of general medicine out of hospital.

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Is it is it featured very little on my undergraduate teaching programme and enjoyed the general physician role and thought,

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Oh well, I'll just do a few more years having trained for it before going back to cardiology and I sort of got stuck,

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ended up in an inner city practice in Birmingham and in fact I practised there for 38 years as an inner city GP,

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initially full time, and then as I took on some academic roles, became really quite part time as a, as a GP.

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In my sphere, most academics actually do carry on doing some clinical work as well.

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And I became a senior lecturer in about 1985 and then in 91 was appointed as as a professor and had in

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Birmingham and then built up a very large department there before moving here in 2011 and doing the same here.

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It was quite a small unit in 2011, very high quality unit.

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But since then we've sort of grown five or six fold actually in that decade and are now very large department for primary care internationally.

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So what would you say if I had to ask you what the overarching big question was that got you have to bed in the morning.

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What would it be?

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Well, I've always been a little bit passionate about my chosen area of medicine, primary care, because it's a bit of a Cinderella topic, to be honest.

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It's perceived often by colleagues either in hospitals or indeed in medical schools as a bit of a.

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Dropping off the ladder, discipline and although patience,

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I think by and large in the UK really value their relationship with GPS and and

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often score it amongst the highest of all the NHS services that they write.

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They nonetheless probably think that they're lucky with their GP and the average GP is not very good really.

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And going to see a nurse hospital consultant is probably much better.

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So I think it's it's added grit I suppose to my career in having decided not to do what would have been a very

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highly ranked discipline of cardiology and choosing a relatively low ranked discipline that's of general practice.

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So I suppose that's got me out of bed.

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I won't methods for the main sort of methods that used to explore questions in terms of general practice,

31
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I mean rather similar actually to what you do in clinical practice.

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I there's a lot of both questions that are relevant to individuals to that sort of advocacy role for the individual,

33
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but also to the sort of population level and that dynamic.

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How you balance benefit for the majority against benefit for the individual I think is

35
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a is a dynamic that both presents problems for clinical practice but also for research.

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So my main methodological interests have been largely epidemiological,

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the sorts of things that highlight risk of major disorders, perhaps not surprisingly,

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because my background, most of my research interests have been in cardiovascular disease, but across the populations at Sandwich Hospital.

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So how do we diagnose diseases more reliably and earlier?

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And then what are more appropriate treatments? So both using epidemiological studies but also clinical trials where we're testing one

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intervention against another and trying to determine what what's the best option.

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So the epidemiology is that largely based on medical records,

43
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some of it is so big data has become a much more important tool, partly in the UK quite early on actually,

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because general practice is the most computerised area of the NHS and the NHS until

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comparatively recently was amongst the most digitised health system in the world.

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So we actually have very rich and the fact that we have the single registered list

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is that everybody's registered on the system is actually pretty powerful really.

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And until, as I say, a few years ago we were definitely ahead internationally in the ability to use routine

49
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clinical records for research and we do a lot of that in risk identification.

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Can you determine what phenotype, what clinical characteristics are more predictive of worse outcomes?

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But some of it is also screening studies where you go out and actually try and identify particular disorders within the general population.

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That's quite important when there aren't the data that well, I a lot of patients are diagnosed when they get to hospital,

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but of course, that is often at the end of a disease trajectory.

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So you're not necessarily picking up early stages. And for many diseases, the most important factor for prognosis is the point it's diagnosed.

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So what you really want to do is if you are unfortunate enough to be developing,

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a major problem is to get it diagnosed early and if there are preventative treatments,

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then initiate those early and that can only occur in the community.

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So hence the importance of data relevant to community populations, which is complementary to data presence in hospital populations.

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All kinds of political questions. I want to ask you a bit about the next question I'd written down and you've half answered it,

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mostly answered it, really wise research in primary care important.

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Yeah. Well, I think as we've said, I think it's it's if you look at a health system like the National Health Service,

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about 90 plus percent of all contacts occur in the community.

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The hospital care is very much the visible part of the iceberg, but there's a huge floating amount of ice below it.

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And really that's where we're operating, is to try and bring a bit more sunlight onto that submerged iceberg.

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So how is the funding balance between those two things?

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Well, what do you think? That's my question.

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Well, if you look again at the NHS as a percentage of NHS GDP, the total expenditure on healthcare, then it's fairly constant at around 60%.

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Possibly 65% is spent in hospital care.

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There's quite a large amount spent on community care.

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Believe it or not, although we obviously worry about community and social care, currently general practice in terms of its clinical provision.

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That's all the stuff practice staff, practice nurses, GP's, etc. is around six and a half percent.

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And then there's the drug bill, which is about 15%.

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So I mean, most drugs are prescribed in general practice, although obviously many of them are initiated in hospital.

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But it's been fairly constant as well. So one of the problems you run into during my I mean,

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it's been interesting during a career as long as mine is that the one thing that you can guarantee

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is that unfortunately politicians will not learn lessons from history and will repeat things.

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So, I mean, I've seen all sorts of impending crises in the NHS and specifically general practice which, you know, just repeat crises basically.

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So the current one of course is that the. There just aren't enough people in the community.

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And so a lot of health care professionals in the community.

80
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Sorry, I'm just clarifying for future. Yeah. Yes. Yes.

81
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Which is going to be a big problem because there's a lack of time to creating the workforce you need.

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And I mean, in my political career industry enough, the number of hospital doctors is tripled.

83
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But the number of jeeps is the same as it was when I went in to practice.

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And there was a big attempt actually over the last about five or six years, but three secretaries of state.

85
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I wanted to increase numbers of Jeeps by 10,000.

86
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But we're actually now minus three. Sorry, plus 6000.

87
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Sorry, but we're minus three. So we're by 3000. We're -3000 since they wanted to add six.

88
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So that's on government owned estimates of what they need.

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So we're -10,000 jeeps and there are only 28,000 of them.

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So you've lost you basically down a third of the workforce.

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And then you wonder there are problems with. Access and provision and stuff like that.

92
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Mm hmm. So let's move on to Clovis.

93
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So. Oh, no, sorry. I've got another question. Important question. And that's nothing to do with my academic group.

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These are the observations, but it's the world within which you operate.

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I think it's very much.

96
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Well, it does create tensions for us because, of course, we want to spend some of that time teaching and undergraduate students and researching.

97
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And of course, they're rammed with everything else. You know, it's more difficult for them.

98
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Mm hmm. So can you just run over what your main area of research interest was before I became.

99
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Yeah. So before COVID, my principal area was.

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Was cardiovascular disease, particularly heart failure and stroke in relation to atrial fibrillation and hypertension.

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So. So what can you unpack that a little bit?

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So this is the question, the sorts of thing I spent about 15 years or so doing quite a lot of work around

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identifying that heart failure is much more common than we thought it was.

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The its impact and quality of life was much more dramatic.

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What is heart failure as opposed to heart attack? I mean, pe lots of people.

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So heart failure is where the heart pump is, works less efficiently and it's syndrome.

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Also, there are many different causes of it.

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And basically by not working as efficiently as a pump, then you get a variety of consequences,

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including shortness of breath and lethargy, and you can start getting volume overload.

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Things like fluid retention, but often in early stages, it mainly manifests with feeling tired and more short of breath.

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And since it's obviously or as we get older, it's often ascribed to getting older.

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So patients will often tolerate symptoms because they think it's just them getting less fit and less active.

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There are a number of predisposing factors. Heart attack is actually a very significant cause of one type of heart failure,

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where the left ventricle, the left side of the heart pump works less effectively.

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That's more associated with fluid retention. But the other big cause is arrhythmias, things like atrial fibrillation,

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because that makes the heartbeat less effectively and stiffening of the heart as it ages.

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So you can imagine if it's stiffer, it contracts less effectively.

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It's a bit unfortunate because it's the term itself, I think is rather dramatic.

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So many patients who do actually have impaired cardiac function, which is a heart failure, is effectively.

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It's not necessarily discussed as openly as it perhaps should be, because it sounds pretty dramatic.

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If somebody said to you you've got heart failure, you'd probably think that that was a pretty terminal diagnosis.

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So that's been a feature of it is that is is perhaps talked about.

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Less than it should with patients.

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But it's an important diagnosis because it does mean that things if you don't do things that reduce its advancement,

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then it will show up in your life and it will cause gradually increasing symptoms and poor quality of life.

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But there are things that you can do that can slow down that progression.

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And that's really what I spend most of my time doing, is researching interventions that help and in particular new ways of diagnosing it.

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So we now have a blood test that can help determine whether somebody has got elements of pump failure.

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And because it's syndrome, well, it's not necessarily easy to diagnose.

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You need a number of different factors. But then putting those together,

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you can be more certain that somebody does or doesn't have heart failure to explain their symptoms and then you can initiate treatments.

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So there's been a big change in my time.

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I mean, when I was in hospital treating heart failure patients in the distant past, we had no treatments for failure at all.

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And in advanced states, patients, you know, would really be incredibly symptomatic.

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And we'd do things like drain fluid off by sticking needles into the it damages lower limbs and just draining off the fluid and things.

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And you can't imagine I mean,

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that was like 19th century medicine compared to now where we have quite a number of effective treatments that will slow things down.

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Mm hmm. So I was doing that, and I also did quite a lot of work around.

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Atrial fibrillation, particularly some early trials about the effectiveness of anticoagulants like warfarin.

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Blood thinners, which had been shown to be effective in younger people.

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But we didn't use them in older people because we thought that the risk of the blood thinner bleeding was greater than the benefit stopping stroke.

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So we did a pivotal trial about 15 years ago called BAFTA, which actually demonstrated that it was as effective in older people as younger people.

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And that changed quite rapidly, change world guidelines.

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In fact, it would have been even more impactful as a trial had there not been a whole new class of drugs come along at the same time,

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which stole all the glory, really. But. But that's still, I think, my.

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Third or fourth most cited. Piper.

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So it's still. He cited a lot, even though.

148
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Hmm. So right now, we will get on to Kobe.

149
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So can you remember when you first heard that there was something happening in China and that it looked like it might turn into a pandemic?

150
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Well, I remember reading the reports about the Chinese whistleblower doctor terribly.

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I can't remember his name, but that was back in December.

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Yes, 2019, I think. And.

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It was clearly there were some concerns then that it effectively re-emerged in East Asia.

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And so I think. The first time.

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I probably encodes a bit.

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Difficult to remember the distant past now, but certainly would have been early January.

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Of that, I think the Lancet paper came out towards the end of January.

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Yeah, I think I think we were aware of it before then because I think there was a sort of impending crisis apparent within the medical school.

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And I can't remember exactly when we had a first meeting, but there was a sort of meeting.

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A weekly meeting established in late January.

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Of a variety of different people that might contribute to thinking about what we should be doing across the whole medical school.

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Across the medical school, it was there were about but it started off with being with 25 or 30.

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Parties were convened and then it grew.

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And this involved basic scientists, epidemiologists and.

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And Triallists and both hospital and community peers.

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About what it was likely to mean, and I think certainly by February.

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I think I've taken on board that this was going to be a global pandemic and.

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We should be starting to think about our response to it, perhaps mid-February.

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So. And then by.

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Late February, certainly beyond the first week in March, I.

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Took the decision with the senior department staff that we needed to hibernate our main research programs,

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and so we were actively doing that as quickly as we could.

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This was before they told us to start doing it. So was that so that you could work on COVID or just because people wouldn't be able to come into work?

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Because initially we were thinking about people not coming to work.

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But infection is one of our themes in the department.

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We've got cardiovascular disease, cancer, health behaviours and infection are all big interest themes.

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And so in parallel to that, we were working up a number of clinical trial proposals around COVID.

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So that was in early March when they then announced that they were going to be these rapid funding schemes.

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And we basically set up the repurposed medicines in the community platform alongside the hospital,

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one which is recovery, which is that the repurposed mat.

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Is that the same thing as principle? Yeah. Right. Okay.

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So principle was that if you like the community urgent public health trial platform recovery was the hospital one.

183
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Yeah. And, and where did that rapid funding come from.

184
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That came from UK Ukraine. Yeah. So I to remember exactly.

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I should have looked at the dates really. But that, that might have been it was either mid March or end of March, early April.

186
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It all started incredibly quickly then though because the closed dates for all those

187
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early programs were like two weeks and there was a degree of negotiation about them.

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And then we started doing that.

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We recruited the first patients, I think, in about ten days after the decision was taken to fund the trial.

190
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But you just explain a little bit more about the trials. So what was the thinking behind?

191
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So the thinking on that was that the were likely to be drugs.

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There already were reports from particularly in China whether we're using mass cocktails or treatments in and to try and obviate things quite a lot.

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So observational data suggesting that this drug might work.

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Hydroxychloroquine was the first time we put into principle and lots of theoretical reasons why some

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drugs might be better because they've been used in other viral illnesses and things like dengue fever,

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plague, etc. So there were quite a number of candidates of drugs that might work.

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And then you obviously are thinking Masami work in a more ill patients or might something need to be given early?

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And if it's given early, you'd need to be given before somebody was ill enough to be admitted to hospital.

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That was thinking behind that in parallel to that that we also just by chance

200
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run the national screening programme for then it was Public Health England,

201
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but it's now the National Protection Agency on flu surveillance.

202
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So we've been running that for 55 years. And how does that work?

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That basically works on what was then about 300 practices who who basically take the blood samples of

204
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patients with syndromic flu and come up with the incidence and prevalence rate into that population.

205
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So that had been running for quite a long number of years and obviously in early 2020,

206
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we test that onto COVID as well and agreed with Public Health England,

207
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we'd supplement that and also doing serology in the general population,

208
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just looking at antibodies to see if people have been infected who hadn't realised they had been.

209
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And is this the Royal College of General Practitioners study. So that's, it's that's jointly with the Royal College GP's.

210
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It moved to Oxford about three years ago and which was probably lucky because it was creaking at

211
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the seams then and we made a strategic decision to increase the size of it to 500 practices.

212
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In 2019. And and I did that very quickly in 2020 because of the impending pandemic and then continued to expand it.

213
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So it's just every patient to who comes in with symptoms of a sample taken or.

214
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No, not all. So now we've expanded the sort of observational elements to around 1500 practices,

215
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but the blood taking aggregate is supplemented, blood taking is done in 500 sentinel practices.

216
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So as I say, we scaled up in early 2020.

217
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So that's been quite important as well. In fact, the first UK case within the network was 29th of January of 2020.

218
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As it turned out, it wasn't being tested full then,

219
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but there was still a Roman public that then went back and tested some of the earlier ones that it was a case in end of January.

220
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And in fact, the first clusters in the U.K., I think we're on the SAP GP in the south coast, which is around then as well.

221
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So so we were doing that. And also the Centre for Evidence based Medicine here started doing a lot of systematic reviews around the emerging,

222
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rapidly emerging evidence base and published a lot of rapid reviews on.

223
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Weather. Things that people worried about early on, though, with there were views that, for example,

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certain types of drugs used for common diseases like hypertension might be harmful because theoretical grounds.

225
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So doing systematic reviews around that also happened quite a lot.

226
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And then the whole digital science bit of the department.

227
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Sort of refocused entirely around COVID.

228
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So there were a lot of rapid papers around the associated risk factors to worse outcomes.

229
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And this is working from patient health records.

230
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These are from the routine record. So early on, there were quite a lot of papers reporting what the associated risk factors were and those were.

231
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Gradually coalesced into what eventually was commissioned.

232
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From the CMO. To produce a COVID risk score, which was operationalised in just a few months in mid 2022.

233
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What was the well that that was then used to to produce a better a better more

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discriminating score for who should shield rather than just using age and also produced.

235
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I mean to be honest at that point it was probably less relevant but also could be used to determine who should get an vaccine.

236
00:27:42,780 --> 00:27:47,280
In what order? Mm hmm. And what were the main factors that came into that?

237
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Well, age is obvious. Yes, the single most important factor. But things like obesity came out that hadn't been thought about ethnicity,

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having significant degrees of renal dysfunction or cardiovascular dysfunction, which is what you'd expect.

239
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Really a lot of the fatal outcomes associated with COVID are cardiovascular.

240
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You might clot who it might precipitate.

241
00:28:23,640 --> 00:28:27,480
A heart attack and things because you get big. Well,

242
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some individuals for some reason get this massive inflammatory response and that has all sorts of detrimental secondary effects on health systems.

243
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So if you've got a predisposing chronic problem, then you're more susceptible to worse outcomes.

244
00:28:43,230 --> 00:28:47,970
But we still don't really know why some individuals are much worse than others because obviously.

245
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There are a lot of people out there have got vascular disease, but not everybody has vascular disease, has a bad.

246
00:28:55,640 --> 00:29:03,920
Mikovits And there's still some genetic makeup that we haven't identified that causes that.

247
00:29:04,220 --> 00:29:07,100
But at least if you're going on the phenotype,

248
00:29:07,100 --> 00:29:14,570
which is what you can measure without looking at somebody's DNA, then you can become a bit more predictive.

249
00:29:16,100 --> 00:29:21,560
And so that was another platform was also engineered very quickly and safely.

250
00:29:22,370 --> 00:29:28,510
And the advantage of that is that that by within about three,

251
00:29:28,520 --> 00:29:35,450
four months was effectively looking at the health records of everybody in the United Kingdom.

252
00:29:35,570 --> 00:29:39,200
So I'm hoping to talk to Ben Goldacre as well.

253
00:29:39,200 --> 00:29:44,780
So, yeah, you needn't expand the safety. Yeah, I think there's a huge amount to say about this.

254
00:29:44,930 --> 00:29:49,520
I think I'll probably get Ben to do that if I. If he hadn't read to me.

255
00:29:50,660 --> 00:29:55,280
Let's just go back to the drug trials. So what were the the candidates?

256
00:29:55,790 --> 00:30:01,790
So what were the outcomes? The first one we looked at was hydroxychloroquine,

257
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which was stopped by the MHRA after a fraudulent big data paper was published that suggested it was harmful.

258
00:30:10,940 --> 00:30:16,490
And although that was exposed as a fraudulent paper within about ten days, they didn't reverse that decision.

259
00:30:16,970 --> 00:30:20,330
But we did also look at antibiotics at that point.

260
00:30:20,330 --> 00:30:24,830
It was thought that through muscle nucleus, myosin, which are long acting macrolides.

261
00:30:25,770 --> 00:30:29,040
Would be beneficial and we showed it to be of no benefit at all.

262
00:30:29,070 --> 00:30:33,300
That was really quite important because a lot of patients were getting antibiotics.

263
00:30:34,440 --> 00:30:43,680
Even though it is of our condition? Well, because I mean, the assumption at that point was that even if it didn't affect the viral infection,

264
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that the actually secondary bacterial infection opportunistic could be quite a big factor in deterioration.

265
00:30:50,520 --> 00:30:59,170
So it is a reasonable hypothesis. I mean, there is some observational animal data to suggest they have antiviral effects as well.

266
00:30:59,190 --> 00:31:05,600
But, you know, as you'd think, just having some basic observational science isn't enough.

267
00:31:05,610 --> 00:31:10,110
You need to test it empirically and it doesn't matter how convincing.

268
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The evidence from Trump is that these things are affected.

269
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It's better to have randomised controlled trial evidence in in a larger proportion of the population.

270
00:31:24,570 --> 00:31:33,510
So those were shown not to be effective. We did show that inhaled budesonide, which is just an inhaled steroid was effective.

271
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That's an asthma treatment normally, I guess. And we showed that high dose use of that for two weeks did significantly improve duration of illness.

272
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It shortened illness both three days, but also within the the contemporary control population actually reduce hospital admissions as well.

273
00:31:57,060 --> 00:32:02,790
We're very disappointed that nice though have not recommended.

274
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It's why the use is a cheap, very safe drug and they feel for a variety of rather we think aesthetic reasons that the

275
00:32:13,080 --> 00:32:20,100
evidence is not yet strong enough for them to recommend that everybody's given it which.

276
00:32:21,430 --> 00:32:26,310
Well, it is interesting, but we are exploring whether we reopen.

277
00:32:29,350 --> 00:32:32,709
But it's it hasn't been announced yet,

278
00:32:32,710 --> 00:32:43,570
but it will be announced shortly that we actually are going to be running the new community viral, new antiviral platform.

279
00:32:44,290 --> 00:32:50,800
So all our efforts at the moment are operationalising that course, hoping that that which is called panoramic,

280
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which in a week or two should be fun to report because it will be public then and this will take much longer before it gets to that stage.

281
00:33:01,240 --> 00:33:04,810
And then that will be testing all the new antivirals that might appear.

282
00:33:06,160 --> 00:33:07,840
So at the moment we're operationalising that,

283
00:33:07,840 --> 00:33:17,820
but if we get a space where we might react in inhaled budesonide because we think actually it is effective, it's cheap and cheerful.

284
00:33:17,890 --> 00:33:28,690
And obviously if it does, which we think it does, reduce the risk of being admitted, then that's an important intervention,

285
00:33:29,290 --> 00:33:35,700
given that there's nothing currently other than dexamethasone or monoclonal antibodies.

286
00:33:35,710 --> 00:33:43,290
And the point about the monoclonal is they're very effective, but they're sort of three, four,

287
00:33:43,300 --> 00:33:53,500
5000 quid a pop and there's no way you be giving them to the total population that they're being trialled as part of hospital treatment at the moment.

288
00:33:53,530 --> 00:34:03,999
Right. Know that they are. Although in fact we also as part of a list which really was one of the most difficult trials I've ever operationalised,

289
00:34:04,000 --> 00:34:10,240
I actually was the PII on the AstraZeneca monoclonal antibody trial tackle,

290
00:34:11,290 --> 00:34:20,770
which which is just reported very positive findings, but you have to treat.

291
00:34:20,980 --> 00:34:26,200
So we've done the trial in the community looking at very early use.

292
00:34:26,710 --> 00:34:39,220
It was a really complicated trial because it it required monitoring the patient for 4 hours in a practice who was hot, who'd got COVID.

293
00:34:39,460 --> 00:34:49,420
So you can imagine complicated that was organised and in fact it was really problematic for us to get that trial approved operating across.

294
00:34:49,420 --> 00:34:58,479
I think there were about ten countries in the end, but we managed to get started in the UK two months ahead of anybody else and and actually

295
00:34:58,480 --> 00:35:04,299
just managed to recruit virtually all the patients they needed for the very start,

296
00:35:04,300 --> 00:35:13,900
which is when you add them on to them for, for as the first 20 patients in the world who were in the in the pivotal trial were actually in the UK.

297
00:35:14,740 --> 00:35:22,960
And then but after that it became virtually impossible to recruit to because the immunisation programme was at full steam ahead and,

298
00:35:23,440 --> 00:35:30,850
and you weren't going to give it to people who were vaccinated or rather if you were in the tackle trial then,

299
00:35:31,350 --> 00:35:37,690
then it was you had to wait a month before you could have your vaccine and obviously people didn't want to do that.

300
00:35:37,690 --> 00:35:44,350
So, so then became impossible to run it. But that was another thing that we did on top of everything else.

301
00:35:45,010 --> 00:35:54,430
So I suppose for from really March of last year to now and probably around 50% of the

302
00:35:54,430 --> 00:36:02,710
department was was just completely devoted to urgent COVID research of one sort or other,

303
00:36:06,310 --> 00:36:13,990
although we've continued doing most of the other studies that we do, continued at a reduced rate,

304
00:36:14,560 --> 00:36:20,920
although we've been trying to bring most of those back on stream in the last few months as well.

305
00:36:22,360 --> 00:36:25,809
I've got another one. That was an ivermectin.

306
00:36:25,810 --> 00:36:29,630
Did you. Yeah, we've got that in language. Yes, of course.

307
00:36:29,780 --> 00:36:33,370
I couldn't find a report on that. Well, that's because we haven't been able to do on that.

308
00:36:33,370 --> 00:36:36,730
So we've got favipiravir, which is an antiviral. Yeah.

309
00:36:36,970 --> 00:36:40,000
And Ivermectin are still in.

310
00:36:40,240 --> 00:36:46,900
Yeah. Which is that creates a little bit of a response.

311
00:36:47,650 --> 00:36:52,330
So there are two arms of principle that are ongoing.

312
00:36:53,590 --> 00:37:01,330
We're slightly surprised that we haven't had any report because the other ones have stopped reasonably quickly.

313
00:37:02,320 --> 00:37:08,240
I mean, now approaching 7000 people in. In principle.

314
00:37:09,870 --> 00:37:13,129
So. Quite what it means. Who knows?

315
00:37:13,130 --> 00:37:20,150
But but we have quite sophisticated futility or benefit algorithms that are operating in the trial.

316
00:37:20,160 --> 00:37:23,240
So. So the kind of flag that comes up.

317
00:37:23,270 --> 00:37:31,640
Yeah. I mean, if, if they really affect. Exactly. If there's a flag that is really a waste of time, then we get an early in reader on that.

318
00:37:32,270 --> 00:37:38,719
Or if there's a flag that is beneficial, we get an early reader on it and then can make a decision about whether we stop the study or not.

319
00:37:38,720 --> 00:37:43,580
But we haven't had anything yet, so I'm not quite sure what that means.

320
00:37:45,410 --> 00:37:53,180
But obviously we will be particularly concerned about the ivermectin because of the sort of huge controversies that have been associated with that.

321
00:37:56,740 --> 00:38:02,800
Um. I probably ought to just get you to say what that controversy was, because we can't assume that people will know.

322
00:38:03,370 --> 00:38:13,510
Oh, it's the one remarkable thing about COVID has been quite how it's exposed divisions in societies.

323
00:38:13,780 --> 00:38:17,860
I mean, if I was if that's me as a sort of more.

324
00:38:19,700 --> 00:38:22,280
A human level commentator, but.

325
00:38:24,100 --> 00:38:34,990
I think I started off feeling really quite optimistic that it would be to the betterment of society because we've got this sort of battle of Britain.

326
00:38:36,360 --> 00:38:38,040
So it's a corporate approach.

327
00:38:38,040 --> 00:38:47,280
Certainly within Oxford, I think there was a feeling that we all had to pull together and really commit whatever was necessary to try and help.

328
00:38:49,050 --> 00:38:51,600
The world and our selves get after this.

329
00:38:52,260 --> 00:39:01,140
So there was that sort of common sense of purpose, and even groups that never talk to each other might have competed for all I know.

330
00:39:02,070 --> 00:39:11,700
Resource pushed aside. Really. We were all on the common agenda and you sort of felt that that might permeate society.

331
00:39:11,700 --> 00:39:16,019
And certainly early on I think you did because I think people seemed to adopt mask

332
00:39:16,020 --> 00:39:25,260
wearing fairly early on and and and people were pretty compliant with the first lockdown.

333
00:39:26,160 --> 00:39:29,880
I mean, if I had to come into the department, that didn't really affect me.

334
00:39:30,270 --> 00:39:33,540
Work was, I think coming in right from the start,

335
00:39:33,540 --> 00:39:39,480
largely because we had a clinical trial team not in this building but in our of the building we were in all the time they were in.

336
00:39:40,570 --> 00:39:47,290
24/7 for one period and it felt inappropriate for staff to be in without the seniors in.

337
00:39:48,130 --> 00:39:52,180
But I felt for example, I'd throw up at a gun, get permission from the police,

338
00:39:52,660 --> 00:39:59,350
didn't really want to get the embarrassment stops on the motorway and stuff because it was legal then going about your way normally.

339
00:40:02,920 --> 00:40:09,159
But fairly soon it you know, things started to deteriorate.

340
00:40:09,160 --> 00:40:15,320
You know the aggro in house, in shops about people who wouldn't wear masks who.

341
00:40:17,260 --> 00:40:23,749
The. I don't have to wear a mask sort of response to things.

342
00:40:23,750 --> 00:40:33,710
And then it's just got worse on trains where 70% of people wouldn't wear a mask and we're never going to wear a mask.

343
00:40:34,410 --> 00:40:38,060
And you think this is just crazy? This is such a minor.

344
00:40:39,000 --> 00:40:43,720
Bit of your infringement of your personal.

345
00:40:43,740 --> 00:40:50,910
And I think it's just got worse since then. I mean, I think there have been tensions there were tensions in the department as well,

346
00:40:50,910 --> 00:40:57,180
because inevitably there are scientists who don't necessarily agree with other scientists, and that's a good thing.

347
00:40:57,270 --> 00:41:08,490
That's always been one of the exciting things about being somewhere like Oxford, which actually has an incredibly profound sense of academic freedom.

348
00:41:09,810 --> 00:41:17,670
So in our employment contracts, there are several pages of the contract that talk about academic freedom.

349
00:41:17,970 --> 00:41:20,730
Really bizarre. Frankly, I was shocked when I first came.

350
00:41:24,650 --> 00:41:34,160
But I think that that that public debate has been difficult because I think it's been used a lot by anti.

351
00:41:35,380 --> 00:41:41,230
Think groups. Lot of pressure groups for one reason or another, even if goodness knows what.

352
00:41:41,230 --> 00:41:50,950
But presumably there's a commercial gain somewhere along the way or a political gain or something that results in people.

353
00:41:53,100 --> 00:42:04,020
And people forming civil pressure groups around these questions that have attempted to undermine the science consensus.

354
00:42:05,400 --> 00:42:11,200
So how did this apply specifically to ivermectin? Well, in ivermectin, I think there's a few.

355
00:42:12,540 --> 00:42:18,239
I was written to soon as we announced within the trial that we were we were committing manslaughter,

356
00:42:18,240 --> 00:42:28,620
that we should be pressuring governments to provide act and not undermining the existing science that says it's the best thing since sliced bread.

357
00:42:29,580 --> 00:42:36,450
That the very existence of the trial undermines the unequivocal evidence base that says it's effective.

358
00:42:37,780 --> 00:42:44,800
Which is interesting because obviously we'd reviewed the literature and come to an alternative conclusion.

359
00:42:44,980 --> 00:42:49,750
We felt that we potentially could be effective, otherwise, obviously it would have been an effort to do the job.

360
00:42:49,960 --> 00:43:00,040
It's a it's an anti-parasitic drug which is not licensed actually in the UK except in veterinary use.

361
00:43:00,340 --> 00:43:07,750
It is used though for some. Rare skin disorders and you can use it of licence in those conditions.

362
00:43:09,010 --> 00:43:12,370
But like any drug, you know it, it isn't without risk.

363
00:43:14,450 --> 00:43:28,190
The vaccines and unbelievably tiny risk has resulted in mass hysteria about the likelihood that an individual may suffer an alternative response.

364
00:43:28,340 --> 00:43:32,270
I think this balance between risk and benefit is really quite a difficult one.

365
00:43:33,560 --> 00:43:42,080
I think in retrospect. I think there was mistakes made in how the.

366
00:43:43,600 --> 00:43:50,139
Evidence bases being used during the pandemic to make decisions that in retrospect, I think,

367
00:43:50,140 --> 00:43:57,340
have contributed to some of the some of the sorts of consequences that we've seen within society.

368
00:43:57,430 --> 00:44:05,880
Can you give an example? Well, I think just I think the science debate has has been won because I think.

369
00:44:09,220 --> 00:44:22,300
I probably would have included more. Disagree is on the scientific panels that have been out to try to try to get that science debate.

370
00:44:22,690 --> 00:44:23,710
I mean, you could argue.

371
00:44:24,000 --> 00:44:31,270
I don't think so, actually, but I don't think it is I think I would have wanted that debate, at least initially behind closed doors.

372
00:44:31,390 --> 00:44:35,950
Right. I wanted to get scientists to see whether they could come up with a balanced view.

373
00:44:37,760 --> 00:44:43,999
With people who disagree with what was happening and those who agree, at least initially.

374
00:44:44,000 --> 00:44:48,379
And I think so on the whole, this is disagreeing that there should be any kind of.

375
00:44:48,380 --> 00:44:54,590
Yes. Response that restricts public freedom of economic activity.

376
00:44:54,620 --> 00:45:03,529
Yes. Yeah. Of which, I mean, that's a perfectly legitimate starting point that the long term consequences of things,

377
00:45:03,530 --> 00:45:08,080
the decisions you make may be worse than the disease itself.

378
00:45:08,090 --> 00:45:17,270
That is entirely fallible. Sweden took that position, but they had a really big death right in the first wave.

379
00:45:18,210 --> 00:45:26,070
I'd rather got away with it in subsequent ways, but that was because, frankly, it killed off the at risk sections of their population.

380
00:45:26,970 --> 00:45:34,770
But they were almost unique in not doing very much initially, but they were touted as an example of how you could get away with it.

381
00:45:38,360 --> 00:45:43,490
I think it would have been very difficult not to have done an initial lockdown.

382
00:45:45,300 --> 00:45:51,330
Although I think that was partly because of what China did, because, frankly, I don't think anybody would have thought about it.

383
00:45:51,990 --> 00:45:57,240
Otherwise, I think if the Chinese hadn't done that and completely well,

384
00:45:57,330 --> 00:46:05,490
virtually completely succeeded in Wuhan, nobody would have thought that would have done it, I don't think.

385
00:46:05,880 --> 00:46:08,880
It wasn't in any of the sort of pandemic planning documents.

386
00:46:08,880 --> 00:46:21,050
Not that I've read them, but I understand that. Mass lockdowns wasn't a feature in the last iteration of the National Pandemic Response document.

387
00:46:22,220 --> 00:46:30,230
Because I think people want to think about it. But the Chinese did bring a massive epidemic under control.

388
00:46:30,540 --> 00:46:34,120
And but the Chinese have a completely different social structure to us.

389
00:46:35,810 --> 00:46:40,520
They were able to completely impose lockdown on the community.

390
00:46:41,000 --> 00:46:48,490
And by and large, the population wanted as well because they didn't want to be infected.

391
00:46:48,500 --> 00:46:52,200
And so the scenes in Wuhan and didn't want it to happen to them.

392
00:46:52,220 --> 00:46:57,590
So because they live in these very large communities which have effectively

393
00:46:58,280 --> 00:47:03,680
community services that also enable you to effectively secure the communities.

394
00:47:04,010 --> 00:47:07,340
They could do it and it worked.

395
00:47:08,570 --> 00:47:17,690
But and it obviously worked here as well. So the idea that what they were trying to do was to bridge what would have otherwise swamped the NHS,

396
00:47:18,650 --> 00:47:24,229
I think was the right decision personally because I think the scenes in Italy shocked everybody

397
00:47:24,230 --> 00:47:31,520
here and I think we would have had those scenes in the UK had we not gone into lockdown.

398
00:47:34,400 --> 00:47:38,510
And I think that the only time during the crisis where I thought the NHS is going to get

399
00:47:38,510 --> 00:47:45,920
overwhelmed was just in the new year to 2021 where actually we thought things were looking up.

400
00:47:47,090 --> 00:47:58,219
But then Delta arrived and I was part of a couple of group meetings, second or 3rd of January or something,

401
00:47:58,220 --> 00:48:08,240
and that was the first time I thought that I heard fear amongst hospital leaders that they were going to get swamped,

402
00:48:09,530 --> 00:48:12,570
which is when we went back into that hard lockdown again at the beginning of the year.

403
00:48:14,820 --> 00:48:18,440
And they were exaggerating. You could tell that they were a bit fearful.

404
00:48:18,590 --> 00:48:24,020
And I've got some friends as well who were in, I think very early on in the first wave.

405
00:48:24,200 --> 00:48:36,950
There were some parts of the UK where they were full in ICU and things and and they thought that they, they might be,

406
00:48:37,490 --> 00:48:46,280
you know, effectively having to just palliative care for people who were basically going to die in a hospital bed.

407
00:48:48,020 --> 00:48:52,160
But I think that that sort of ease the pressure as soon as we went into lockdown, did ease the pressure there.

408
00:48:52,700 --> 00:48:56,810
But I think there was a rising panic at the beginning of this year that it was going to get swamped again.

409
00:48:57,080 --> 00:49:00,370
And all the hospital the extra hospital bed provision was all.

410
00:49:02,050 --> 00:49:06,380
It just, you know, it was never going to work because there aren't enough staff.

411
00:49:06,410 --> 00:49:13,940
Yes. Yes. Yeah. So, yeah, you could have admitted somebody from home, stuck them in bed and given them some water and much more for them.

412
00:49:13,940 --> 00:49:19,970
So. So that I think was. So things.

413
00:49:19,990 --> 00:49:25,479
But having said that, if I was in government, I think you can have to make these sorts of decisions.

414
00:49:25,480 --> 00:49:28,690
And yeah, they wasted unbelievable amounts of money,

415
00:49:28,690 --> 00:49:39,459
but they wasted them in retrospect and they probably had to do what they did, like build, build capacity,

416
00:49:39,460 --> 00:49:41,560
because I think the population expected it really,

417
00:49:42,610 --> 00:49:47,170
and it probably frightened the populations about which they needed to do, otherwise it wouldn't have gone into lockdown.

418
00:49:47,180 --> 00:49:51,070
But you can only get away with that once. It doesn't it's not working anymore.

419
00:49:51,670 --> 00:49:57,250
People just don't believe that it's that bad now. All sections of the community don't think it's that bad.

420
00:49:57,550 --> 00:50:01,600
So that was always the danger of, you know,

421
00:50:01,600 --> 00:50:08,499
potentially exaggerating the risk first time around is that is the it's then quite difficult to get people back to normal again,

422
00:50:08,500 --> 00:50:12,490
which I think we've got you know, there are a lot fearful people about it,

423
00:50:13,450 --> 00:50:20,170
but as well as having a lot of fearful people who probably don't want to go to work ever again, who go on public transport,

424
00:50:20,290 --> 00:50:29,860
you've got another group who are completely unfair and think that it's conspiracy theory, I mean, where it all comes from.

425
00:50:30,960 --> 00:50:36,000
But so we've got really we're not in a good place at the moment, I don't think.

426
00:50:36,450 --> 00:50:43,590
And and early on I thought we this could be good for the planet in a weird way.

427
00:50:43,900 --> 00:50:45,320
Mm. Oh, I understand.

428
00:50:46,570 --> 00:50:55,420
Um, so just going back to the research that you've done, a lot of the studies that you work on involve big national collaborations.

429
00:50:55,450 --> 00:50:58,690
Yeah. How, how do they work and how well do they work?

430
00:51:01,270 --> 00:51:06,819
Well, things like the trials and surveillance platforms are partnerships.

431
00:51:06,820 --> 00:51:15,580
I mean, we provide the infrastructure and the design of how you answer a question efficiently but reliably.

432
00:51:16,510 --> 00:51:23,829
And then we'll obviously need to have partnerships with quite a number of groups.

433
00:51:23,830 --> 00:51:34,870
So for something that's a big platform trial where we need to recruit people all over the UK, then we need to be able to access the people.

434
00:51:34,870 --> 00:51:40,479
So we started off principle, for example, thinking that we'd run it through practices.

435
00:51:40,480 --> 00:51:48,879
But of course practices weren't seeing patients with COVID because they were trying to keep match surgery, so they went to assessment centres.

436
00:51:48,880 --> 00:51:57,010
So we engaged the assessment centres and then they were slow to get going and so we developed much more direct to patient

437
00:51:57,970 --> 00:52:05,020
relationships and we recruited a lot of patients for the principle who effectively have recruited themselves into the trial.

438
00:52:05,290 --> 00:52:11,650
So we still had to check that they didn't have any reasons why they couldn't take part,

439
00:52:11,710 --> 00:52:14,470
which meant we still had to have relationships so that practices.

440
00:52:15,560 --> 00:52:21,500
But we've had a much more direct relationship with patients, both for recruitment and follow up,

441
00:52:22,400 --> 00:52:26,690
which has been very interesting because that's very different than what we'd normally do.

442
00:52:30,350 --> 00:52:37,780
And you know, it's as and that we've had to develop a bigger clinical team and to be able to manage those interactions.

443
00:52:37,790 --> 00:52:41,360
And that would be the same for the viral antiviral study.

444
00:52:42,110 --> 00:52:48,390
But it's been really big partnerships with the, with the research networks which are run by.

445
00:52:49,970 --> 00:52:54,590
National Institute for Health Research and a regionalised. They liaison practices locally.

446
00:52:55,220 --> 00:52:58,670
Direct relationships it practices threat relationships with.

447
00:52:59,600 --> 00:53:02,800
Different bits of the NHS structure.

448
00:53:06,220 --> 00:53:11,890
But it's been very hard work, to be honest. It's been very hard work because.

449
00:53:15,560 --> 00:53:23,600
We've had to overcome all sorts of difficulties that were created by the pandemic.

450
00:53:23,900 --> 00:53:27,799
There was much less testing initially in the community,

451
00:53:27,800 --> 00:53:33,920
so it was often difficult to discover with somebody was COVID was actually stopped at one point, wasn't it?

452
00:53:34,010 --> 00:53:37,760
But it was, yeah. And you know, early on in the trial, for example.

453
00:53:40,560 --> 00:53:46,750
The Post Office refused to handle samples that were being sent in case they infected all the workers.

454
00:53:46,750 --> 00:53:51,790
So we had loads of problems early on that we had to overcome.

455
00:53:51,900 --> 00:53:56,550
We seemed to spend the whole 18 months just trying to engineer.

456
00:53:57,750 --> 00:54:03,270
Out of crises, constant crises. We also didn't get the sort of.

457
00:54:04,800 --> 00:54:10,320
National endorsement of the same. The recovery has a mean recovery.

458
00:54:10,710 --> 00:54:15,600
The recovery is another. The whole story explained. Yeah, which which?

459
00:54:15,600 --> 00:54:20,400
I mean, you probably interviewed yourself in the Hobby Lobby.

460
00:54:20,410 --> 00:54:24,120
Sorry, I've been postponed once. I'm supposed to be seeing him next Monday.

461
00:54:24,150 --> 00:54:32,610
Yeah, well, he talk about recovery, which, I mean, what happened to the recovery was that it was viewed as a sort of national priority

462
00:54:32,610 --> 00:54:38,400
trial and all the hospital trusts were pretty much mandated to recruit into it.

463
00:54:38,550 --> 00:54:46,590
And of course, you know, it's pretty simple to identify. A patient with COVID in hospital because they come in with COVID and they're diagnosed.

464
00:54:47,790 --> 00:54:51,449
But it achieved unbelievable numbers,

465
00:54:51,450 --> 00:54:58,409
patient numbers very quickly because of the way it was sort of regimented in it in one

466
00:54:58,410 --> 00:55:04,290
bit of the NHS hospital care and they were able to get all the ascertainment as well.

467
00:55:04,300 --> 00:55:09,900
So I mean obviously the data on dexamethasone, which was very important early on,

468
00:55:12,060 --> 00:55:16,170
but for all sorts of reasons probably back to the sort of cultural reasons we started off with.

469
00:55:17,160 --> 00:55:24,510
It's it's although it is up to trial, principle has always struggled to get that sort of central C needed.

470
00:55:25,590 --> 00:55:34,250
You need to support this trial blah blah. So it's all been a bit of an uphill struggle, to be honest with.

471
00:55:34,260 --> 00:55:40,740
I think that the new antiviral platform will have more central support.

472
00:55:40,770 --> 00:55:45,150
Expectation of the service that people do support it.

473
00:55:45,570 --> 00:55:48,780
But we'll see. But. So you're talking about from the Department of Health.

474
00:55:49,350 --> 00:55:58,200
From the Department of Health, from the government, from the NHS, England, from the CCGs,

475
00:55:58,290 --> 00:56:06,000
from from the sorts of political structures saying that this should be supported and indeed,

476
00:56:06,540 --> 00:56:13,649
you know, the general public where the public are aware and think about whether they take part in the study before they get infected and if so,

477
00:56:13,650 --> 00:56:20,820
how they can rapidly engage. It's important because for antivirals, definitely, you know, you've got a relatively narrow window.

478
00:56:20,870 --> 00:56:23,370
Are you going to use them early on? They probably won't be effective.

479
00:56:24,390 --> 00:56:31,680
So one of your interests before COVID came along was the interaction between respiratory infection and cardiovascular disease.

480
00:56:32,190 --> 00:56:35,630
Has the work you've done on COVID advance that understanding all?

481
00:56:36,990 --> 00:56:38,330
No, not really.

482
00:56:38,340 --> 00:56:49,500
We've got a dphil at the moment, actually, where he's interested in whether infections per say, a trigger for subsequent vascular events.

483
00:56:50,940 --> 00:57:01,010
But that pre-dates COVID, really. So no, I don't think it would have really helped our thinking around disease.

484
00:57:02,150 --> 00:57:06,680
So what long term problems do you think the pandemic poses for general practice?

485
00:57:10,460 --> 00:57:22,770
I think for general practice, I think. The difficulty is trying to get back to a more normal service provision.

486
00:57:22,770 --> 00:57:28,909
That's still I mean, the one thing the pandemic did, which I never thought I'd see in my lifetime,

487
00:57:28,910 --> 00:57:35,360
was introduced the concept of digital consulting in a completely unparalleled way.

488
00:57:35,390 --> 00:57:45,020
So if you look at UK general practice, it switched from being 9090 4% face to face.

489
00:57:46,180 --> 00:57:50,980
To to around 50% face to face in a month.

490
00:57:51,250 --> 00:57:54,640
And I think that the online provision.

491
00:57:56,080 --> 00:58:00,459
Warts and all, has been amazing, to be honest. And that's persisted.

492
00:58:00,460 --> 00:58:06,460
So still, around 40% of consultations are digital.

493
00:58:06,670 --> 00:58:12,790
Most of them are because that's what the patients want is convenient. It's it's more rapid.

494
00:58:13,420 --> 00:58:15,160
Doesn't involve you having to go anywhere.

495
00:58:16,060 --> 00:58:22,570
I mean, it isn't appropriate for some types of consultations, but for some consultations is clearly better than a telephone call.

496
00:58:22,570 --> 00:58:27,520
Which call which was the, you know, the alternative way of not doing face to face.

497
00:58:28,480 --> 00:58:35,889
But that's been a bit of a problem because obviously there's been a backlash from some patients that that that's being used inappropriately.

498
00:58:35,890 --> 00:58:47,440
And of course, some MPs, ministers, ministers are quite happy to undermine the employees by saying how outrageous it is.

499
00:58:47,440 --> 00:58:52,810
But I think for most GP it is based on clinical need and patient preference not.

500
00:58:53,140 --> 00:58:58,680
So there's always going to be some room providing the services should, but I think for most.

501
00:58:59,140 --> 00:59:02,650
So that's been an interesting dimension. But I think it's.

502
00:59:05,580 --> 00:59:12,840
I think there's still a massive backlog. That that's the biggest tragedy is that if you look at the data currently more than 50% of excess

503
00:59:12,840 --> 00:59:18,360
deaths in the UK now on Non-covid related and it's what you would have predicted a year ago,

504
00:59:18,360 --> 00:59:22,260
which is that it's cancers and vascular disease. So it's people.

505
00:59:22,530 --> 00:59:27,329
We did some work in the autumn to look at how general practice recovered.

506
00:59:27,330 --> 00:59:30,930
And it was remarkable actually that by September of last year.

507
00:59:32,010 --> 00:59:39,630
British jeeps had recovered about 75% of the sorts of simple prevention stuff that they normally do.

508
00:59:39,900 --> 00:59:43,440
Blood pressure checks, glucose checks, cancelled checks.

509
00:59:45,060 --> 00:59:48,209
Which we thought was pretty remarkable because if you looked at the figures in April,

510
00:59:48,210 --> 00:59:56,010
it went to virtually zero and then by September it was 70%, but it's still obviously a big backlog.

511
00:59:56,460 --> 01:00:02,160
And we were also a bit worried that there might be difficulties getting GP that was affecting two week weights because you know,

512
01:00:02,160 --> 01:00:07,920
if you've got potential cancer, you're supposed to refer them in within two weeks and that was dramatic reductions there.

513
01:00:08,550 --> 01:00:15,510
But actually looking at the data that we were able to report it, it looked as if it was patients.

514
01:00:15,510 --> 01:00:20,630
Patients were not presenting when they presented. They were getting the two week wait.

515
01:00:21,510 --> 01:00:28,829
But so there's a big gap there in trying to get people to think again about presenting when, you know,

516
01:00:28,830 --> 01:00:36,540
they've got their rectal or vaginal bleeding that they shouldn't be having or if they're losing weight for no obvious reasons.

517
01:00:36,540 --> 01:00:43,169
I mean, those sorts of things. I think we've got to restore that if the NHS is capable of responding to course.

518
01:00:43,170 --> 01:00:53,790
But but I think we've got to start to get patients presenting themselves early again because otherwise I think the consequences will be even more.

519
01:00:53,790 --> 01:01:02,669
People will end up dying indirectly because of COVID directly, and of course they'll be younger people as well, which would be a bit tragic.

520
01:01:02,670 --> 01:01:07,049
So I think that's going to be a big problem and that's going to be a big issue for general

521
01:01:07,050 --> 01:01:12,660
practice because a lot of these preventive or early triaging activity happens in the community.

522
01:01:14,460 --> 01:01:23,970
So tell me about your role in national and global policymaking around public health in the community?

523
01:01:24,840 --> 01:01:33,630
I don't really I mean, I liaise quite a lot with external parties when it's appropriate.

524
01:01:35,700 --> 01:01:41,879
We do quite a lot of work with the College of GPS and trying to support their interests.

525
01:01:41,880 --> 01:01:51,480
But but actually, I, I have largely withdrawn from my sort of more political roles over the last few years.

526
01:01:53,340 --> 01:02:00,360
I do some international work in relation to the advancement of primary care and digital health.

527
01:02:00,360 --> 01:02:05,129
So I think most health systems actually, interestingly enough,

528
01:02:05,130 --> 01:02:14,070
over the last ten years have realised that if they don't invest in primary care, they will bankrupt the, the health GDP.

529
01:02:14,610 --> 01:02:21,690
So and I think the model, the UK model, it's interesting that for a third of my clinical lifetime,

530
01:02:22,650 --> 01:02:28,440
I think the NHS was looking overseas for better models of clinical provision,

531
01:02:29,460 --> 01:02:36,000
but in fact actually quite accidentally we ended up with probably the most controlled

532
01:02:36,000 --> 01:02:43,440
global health system model and one where most general physician general medical

533
01:02:43,440 --> 01:02:48,809
care occurs in the community and a lot of the sort of prevention and disease follow

534
01:02:48,810 --> 01:02:52,590
that occurs in the community and it enables super specialisation hospitals.

535
01:02:52,590 --> 01:02:57,240
So the other thing especially is to become more specialised and that model,

536
01:02:57,780 --> 01:03:02,700
I think most health systems and I recognise that that model in the registered list.

537
01:03:04,710 --> 01:03:10,560
Rather than the source of private provision is the most equitable and cost effective.

538
01:03:10,710 --> 01:03:15,970
So there's lots of health systems are trying to orientate more to the way we do things here.

539
01:03:15,990 --> 01:03:21,750
And of course, digital health, which we do a lot of work around as well, is quite an important part of that.

540
01:03:21,750 --> 01:03:32,190
And letting you know where you are in in terms of of the provision of health care and who you need to focus on first and in what order.

541
01:03:33,390 --> 01:03:38,549
I remember having American friends who were astonished that as a woman who had two children,

542
01:03:38,550 --> 01:03:41,070
I've never seen either a paediatrician or a gynaecologist.

543
01:03:41,390 --> 01:03:47,850
Yeah, well, they proliferate community care that they're going to general practice is actually not exactly the same.

544
01:03:47,850 --> 01:03:56,610
But that family doctor is definitely I mean, they're paid less and objectively have a much lower status.

545
01:03:56,610 --> 01:04:02,310
So you tend to add community specialists to your provision as well.

546
01:04:02,460 --> 01:04:10,170
But even the U.S., the managed care in the US recognises they need a more general population approach to things.

547
01:04:10,170 --> 01:04:14,660
Otherwise, you know, they won't they won't stop a lot of expense.

548
01:04:14,910 --> 01:04:19,920
They might be doing it for economic reasons, but they're still driving towards a similar model.

549
01:04:21,120 --> 01:04:27,750
And there's things we can learn from the U.S. because it's effectively a for profit environment.

550
01:04:28,080 --> 01:04:36,719
In most cases, they are pretty efficient about investing in cost effective management programs,

551
01:04:36,720 --> 01:04:43,650
and we can learn from those is once you determine that people got problems, how can you look after them more effectively?

552
01:04:50,790 --> 01:04:53,040
He covered this a little bit because you mentioned you went in.

553
01:04:53,040 --> 01:05:01,790
So how did the first lockdown impact on moving now more to your national living, living through the the pandemic?

554
01:05:01,800 --> 01:05:04,860
How did the first lockdown impact on on what you were able to do?

555
01:05:04,920 --> 01:05:06,660
Did it did it change the way you were?

556
01:05:06,900 --> 01:05:16,229
Well, I mean, for me, it impacted rather less because I basically I don't actually live in Oxford, so I live most of the time Birmingham.

557
01:05:16,230 --> 01:05:21,300
So I was commuting down from Birmingham, so it was a lot easier commute, that's for sure.

558
01:05:22,830 --> 01:05:30,750
It was a bit it was a bit weird. I mean, you felt like it was a Hollywood pandemic film because, you know,

559
01:05:30,840 --> 01:05:36,030
they weren't mowing the grass outside and it stopped and the streets were completely empty.

560
01:05:36,030 --> 01:05:42,989
And, you know, I could across the road here with my eyes closed, I needed to look for traffic.

561
01:05:42,990 --> 01:05:45,870
And I think there were two or three of us in this building,

562
01:05:46,860 --> 01:05:54,000
but I think we didn't actually close this building or the other building we go, which is 100 metres away.

563
01:05:55,290 --> 01:06:02,730
But this building and very few people in it, the other one at about 25 or 30 or normally would have about 100 people in it.

564
01:06:04,470 --> 01:06:06,330
So yeah, that was that was a bit weird.

565
01:06:08,150 --> 01:06:17,070
A huge increase in meetings actually already had a lot of meetings in my diary, but far more meetings, most of them online.

566
01:06:17,670 --> 01:06:27,130
Even though I've been taking them here. I think the other thing that was which I've missed, I have to say, although.

567
01:06:28,220 --> 01:06:31,610
I did not think about my eco credentials is travel.

568
01:06:32,780 --> 01:06:41,120
So I think I've had. One flight in the last 20 months where normally I'd probably I don't know.

569
01:06:42,060 --> 01:06:45,690
I'll probably be twice a month beginning somewhere.

570
01:06:46,860 --> 01:06:56,349
So that's been bad. Because I think you are often meeting interesting people, different parts of the world,

571
01:06:56,350 --> 01:07:00,129
different perspectives, as well as doing whatever you're going to do.

572
01:07:00,130 --> 01:07:06,790
Normally he was giving a lecture or examining or something, so that's gone.

573
01:07:07,210 --> 01:07:16,150
Whether that will ever come back, I'm not quite sure. So more of the conferences I've attended have been you know, I've just been given a video talk.

574
01:07:20,340 --> 01:07:24,000
But I've stopped attending Congresses. I think online Congress is a.

575
01:07:25,660 --> 01:07:30,670
Not for me anyway, so I don't know what that's going to be like.

576
01:07:32,900 --> 01:07:39,229
And I think it's you know, I think it's been difficult, but domestically as well,

577
01:07:39,230 --> 01:07:45,680
because my wife is in a similar area to me and, you know, we just it just ramped all the time.

578
01:07:45,920 --> 01:07:48,980
Yeah. So you're working hours went out just ridiculous.

579
01:07:49,200 --> 01:07:59,029
Yeah. And I, I've actually taken more space and she hasn't been she's not in a well, she takes it even more seriously than I do.

580
01:07:59,030 --> 01:08:05,690
But, you know, I'll just miss something if I'm feeling a bit overwhelmed that day or whatever.

581
01:08:05,900 --> 01:08:13,639
And yeah, we still publish a lot and still have to bring the grants in for the next stuff

582
01:08:13,640 --> 01:08:18,230
and still cope with more people in the department and all the rest of it.

583
01:08:18,770 --> 01:08:29,540
I'm quite embedded into the university as well, so I sit on council and sit on quite a few of the council subcommittees and stuff.

584
01:08:30,950 --> 01:08:37,430
So that really increased as well the the sort of because obviously the university response was.

585
01:08:38,480 --> 01:08:43,330
From a senior management team was big. So that's been quite time consuming as well.

586
01:08:45,450 --> 01:08:51,120
And do you think the provisions that were brought in across the university to protect people were adequate?

587
01:08:51,150 --> 01:08:54,420
And I think when implemented did a good job, really.

588
01:08:54,570 --> 01:09:00,270
I mean, and I think, you know, we tried to make. Quite a few departments did.

589
01:09:00,270 --> 01:09:06,550
We certainly tried to make people still feel they were part of a department, even if they were working from home.

590
01:09:06,650 --> 01:09:10,140
So virtual coffee mornings and.

591
01:09:11,230 --> 01:09:14,420
We normally have a big fancy dress Christmas party every year.

592
01:09:14,440 --> 01:09:21,480
Last year we didn't, but we did a online pantomime, which was awful for those having to be in the Pentagon.

593
01:09:21,500 --> 01:09:24,820
But I think when you think why you in the pantomime. Yes.

594
01:09:27,800 --> 01:09:33,220
So so do you think the well-being of the people in your department held up fairly well?

595
01:09:33,280 --> 01:09:34,600
I think it probably did.

596
01:09:34,630 --> 01:09:47,570
We've got a fantastic team here who are, you know, really dedicated and took the responsibility to try and keep the eye of a big department.

597
01:09:47,590 --> 01:09:51,580
Yes, it still feels like it cares about stuff.

598
01:09:52,690 --> 01:10:03,380
I think they got that right. I think it's going to get more difficult there because that length of time is going for is just not sustainable, frankly.

599
01:10:03,650 --> 01:10:07,550
And I think I don't know where we're going to end up, really.

600
01:10:10,550 --> 01:10:18,800
So I think the university I mean, we obviously predicting a big loss over the last financial year and to Columbia's decisions there.

601
01:10:19,760 --> 01:10:27,969
But as it turned out, you know, the university is actually. Financially done well because it's done so much stuff.

602
01:10:27,970 --> 01:10:32,860
It's obviously increased this grant income. There's been a lot more legacy.

603
01:10:32,860 --> 01:10:41,140
I think it's boosted its international status. As an institution even more than it was already so.

604
01:10:42,160 --> 01:10:50,090
It. It hasn't been bad for the institution. I mean, I think we'll have to wait and see where it settles.

605
01:10:50,090 --> 01:10:58,340
I mean, I think it has been it has made a tangible contribution to the world, actually, in the last 20 months.

606
01:10:58,790 --> 01:11:08,660
Way above its station. Not least of which was the vaccine, which is a tragedy that it's been as blighted as it has been latterly.

607
01:11:08,920 --> 01:11:14,600
But. But that's still the most used vaccine on the planet.

608
01:11:15,200 --> 01:11:18,260
And goodness knows how many lives have been saved through that.

609
01:11:20,910 --> 01:11:24,240
And, you know, it should. It should actually be.

610
01:11:26,620 --> 01:11:32,230
By far the most used vaccine because it's cheap and cheerful and easy to use.

611
01:11:32,440 --> 01:11:36,940
And it's risks, albeit, unfortunately, does have some risks.

612
01:11:38,170 --> 01:11:39,079
In the scheme of things,

613
01:11:39,080 --> 01:11:47,110
and they are no greater than the alternatives and much less than getting the disease and massively less than getting the disease.

614
01:11:47,350 --> 01:11:54,520
And who knows the people? I mean, you can speculate, but the people who get these rare thrombotic effects,

615
01:11:55,180 --> 01:12:03,790
I think you could reasonably surmise that they would be more likely to get those same effects if they had the.

616
01:12:05,300 --> 01:12:15,450
Um. You know, if I could walk over the. Because there's obviously some weird predisposition to a thrombocytopenic reaction.

617
01:12:15,480 --> 01:12:24,180
I mean, there is the disorder is actually it just shows how odd science is that because actually

618
01:12:24,180 --> 01:12:31,170
it's a known risk factor with vaccines to get a immunological thrombocytopenia response.

619
01:12:32,430 --> 01:12:36,650
This means blood. Blood clots. Yeah. Sorry, I'm just. It's. Yeah. And then as part of it, you.

620
01:12:36,990 --> 01:12:43,290
You drop your platelets, which makes you more likely then to get a bleed associated with the clot.

621
01:12:43,380 --> 01:12:46,530
So it's both a clot and bleed at the same time.

622
01:12:49,330 --> 01:12:54,549
And there are one or two vaccines, which I'm not going to name, which have this associated with them.

623
01:12:54,550 --> 01:12:59,140
And I never knew that. And no vaccine for the disease, not for COVID.

624
01:12:59,170 --> 01:13:08,770
Yeah, yeah, yeah. I it is a known rare effect of immunisation and has actually happened with the marinades as well, but in lower numbers.

625
01:13:09,340 --> 01:13:12,640
So it is just one of the potential risks associated with vaccination.

626
01:13:13,000 --> 01:13:18,340
But you're talking about converting a sort of one in a million background risk into two in a million.

627
01:13:19,000 --> 01:13:25,380
Well, if you were that one in a million person. It's obviously tragic and awful and all that, but.

628
01:13:26,870 --> 01:13:36,980
If you're going to get 12, 15 in a million, if you get COVID and you've got all the other risks on top, then it seems like a no brainer.

629
01:13:36,990 --> 01:13:48,950
Really? Yeah. And no, COVID vaccination does not sterilise you and it doesn't introduce a microbe bot that then allows you to be tracked.

630
01:13:49,550 --> 01:13:58,230
So but that that's been very unfortunate because I think it and it's for some countries have been devastating.

631
01:13:58,240 --> 01:14:02,510
So because some of the countries have very, very low vaccine uptake.

632
01:14:02,810 --> 01:14:09,950
Romania, Russia, Japan are going to really get hit badly in this current wave.

633
01:14:09,950 --> 01:14:15,590
So. Did you personally ever feel threatened by the virus or.

634
01:14:16,100 --> 01:14:24,920
Yeah, I did, actually, because not without going into it. You know, I'm old and have a number of risk factors.

635
01:14:25,670 --> 01:14:31,070
And actually so it was weirdly early on when this had been.

636
01:14:33,180 --> 01:14:36,750
I did actually think that if I get it. It might kill me.

637
01:14:37,970 --> 01:14:43,080
And I sort of thought to myself how either way and because I could just work from home,

638
01:14:43,100 --> 01:14:49,940
just decided that I wasn't going to let it dictate how I lived my life, really,

639
01:14:50,600 --> 01:14:56,600
and then stop thinking about it other than, you know, sensible precautions.

640
01:14:56,840 --> 01:15:00,350
But yeah, so that's what I did think about it deep down.

641
01:15:02,240 --> 01:15:05,690
But as it turned out, I was infected quite early on this thing as my.

642
01:15:06,170 --> 01:15:12,980
Oh, you were? Yeah. So. Oh, right. Was my wife caught it in mid-March.

643
01:15:13,730 --> 01:15:20,830
She was teaching on a master's program in work and quite a few.

644
01:15:20,840 --> 01:15:27,470
The top two exhausted old doctors and they've got a few of them have been skiing and

645
01:15:28,130 --> 01:15:33,800
and two of them and subsequently the whole cohort were infected with COVID in March.

646
01:15:33,800 --> 01:15:36,620
That was before the first week before in first look. Right.

647
01:15:37,610 --> 01:15:47,780
And and so I know that I was infected at some point because I got I did my antibodies at the end of 2020,

648
01:15:48,620 --> 01:15:54,379
which showed I'd had been infected, and I'm almost certain I was infected then, although I wasn't actually particularly ill.

649
01:15:54,380 --> 01:16:01,360
She was mostly older than me, but she was like you. I mean. Yeah. And I, I fell off colour and had horrendous headaches, which I don't normally get.

650
01:16:01,370 --> 01:16:08,010
I didn't lose your sense of taste and smell that I didn't.

651
01:16:08,030 --> 01:16:18,710
I had really given. Well, I've been thinking in retrospect, stupidly, I got off remarkably mild things with symptoms.

652
01:16:19,280 --> 01:16:23,240
There were another couple of occasions when I was ill later in the year where it could have been then.

653
01:16:23,300 --> 01:16:34,640
It's just I mean obviously once we realised she got COVID effectively Barry a nurse to at home but,

654
01:16:35,960 --> 01:16:43,220
but there was at least 24, 36 hours before we knew she was positive when she would have been infectious.

655
01:16:43,220 --> 01:16:49,610
So I think the chance of me not having caught it then were negligible and obviously caught it at some point.

656
01:16:49,610 --> 01:16:57,830
So I think it was there. So so yeah, it you can get it and survive it.

657
01:16:58,430 --> 01:17:05,030
A lot of people do. That's the weird thing about it. It, it's, it's unpredictable.

658
01:17:06,470 --> 01:17:12,230
Even amongst people with risk factors, the majority don't want to get seriously ill, but some will.

659
01:17:13,970 --> 01:17:16,490
So I need to move to wrap up because I think we have to time.

660
01:17:16,880 --> 01:17:22,700
And so has the work you've done on COVID raised questions that you'd be interested in exploring in the future?

661
01:17:22,880 --> 01:17:31,990
Yeah. I mean, I think the particular area that will want to look at as soon as we can actually is long COVID,

662
01:17:32,120 --> 01:17:39,529
and we'll be looking at whether any of the treatments which might all be infected with COVID keightley might be effective.

663
01:17:39,530 --> 01:17:44,030
In terms of long COVID. That's a completely separate and important question,

664
01:17:44,900 --> 01:17:51,110
where you might use treatments not for the initial illness, but because it might alter the illness trajectory.

665
01:17:51,170 --> 01:18:00,290
So that, I think is an important area. I think we're still thinking about how we can integrate all of our digital assets.

666
01:18:00,290 --> 01:18:11,209
We've got quite a number of parallel digital assets and whether we can actually be using those more efficiently,

667
01:18:11,210 --> 01:18:18,860
I think is is quite a big consideration for us and also our relationship with the

668
01:18:19,670 --> 01:18:27,170
software suppliers who actually generate the clinical systems that extract the data.

669
01:18:27,170 --> 01:18:34,730
That's been the relationship with them has been really quite important and much, much stronger over the last year or so.

670
01:18:36,710 --> 01:18:44,600
Yeah. So those are two obvious areas I think trying to resurrect Non-covid research is also important.

671
01:18:44,780 --> 01:18:52,490
I mean, obviously, you know, we are not going to eradicate this virus and we therefore need to learn to live with it.

672
01:18:55,340 --> 01:18:58,760
And I think that'll become a feature really. Which is,

673
01:18:58,760 --> 01:19:11,270
which is how you can reduce its impact on society and try and return to a more semblance of normality at

674
01:19:11,270 --> 01:19:19,070
the same time as focus on the next or perhaps the overwhelming issue facing society of climate change.

675
01:19:22,430 --> 01:19:30,950
But I think everybody's a bit knackered really, and how you can bring everybody round from that and make them feel more positive about the,

676
01:19:32,090 --> 01:19:37,300
um, where we go with the world I think is going to be a bit of a.

677
01:19:38,870 --> 01:19:42,919
You know, this is a slightly different question, but related.

678
01:19:42,920 --> 01:19:47,690
Has the experience of COVID changed your attitude or approach to your work?

679
01:19:48,080 --> 01:19:57,720
And how would you like things to change in the future? Well, I really enjoy my job, actually.

680
01:19:58,050 --> 01:20:02,640
I wouldn't necessarily admit that, but I do enjoy its variety.

681
01:20:02,970 --> 01:20:07,380
The amount of control I have over what I spend time doing, etc.

682
01:20:08,190 --> 01:20:12,240
But I do feel a bit wary now.

683
01:20:13,140 --> 01:20:15,990
So I don't know really. It I mean,

684
01:20:16,290 --> 01:20:28,620
what it's done for a lot of my colleagues is get them to decide to retire early and focus on other important things like grandchildren and the,

685
01:20:29,970 --> 01:20:39,810
you know, generational stuff. So I suppose I, I think more about whether I should be thinking like that.

686
01:20:40,470 --> 01:20:44,730
I don't know whether I will or not, but I think I should think more about that.

687
01:20:46,920 --> 01:20:51,690
And I think quite a lot of people of my sort generation thinking more like that.

688
01:20:54,560 --> 01:21:01,040
And, you know, worrying about, well, because it's really the next generation and certainly the grandchildren who are really going to.

689
01:21:02,060 --> 01:21:05,260
I've suffered the economic consequences of that.

690
01:21:05,930 --> 01:21:12,140
So once again, I think I've been fortunate enough to live at a time when we never had it so good.

691
01:21:12,470 --> 01:21:18,140
Frankly, as a society, the adults in society, even the ones who.

692
01:21:19,090 --> 01:21:22,680
You know, need support from the state to survive.

693
01:21:22,690 --> 01:21:30,400
They've actually never had it so good either, because I think I think things are going to get tougher and.

694
01:21:32,300 --> 01:21:38,120
So I don't really know what is going to happen. I'm clearly, you know, the world's in a terrible state.

695
01:21:38,120 --> 01:21:50,960
When you look at equity and distribution and population and simple stuff, like enough food to eat and.

696
01:21:52,180 --> 01:22:02,259
Whether you populations growing in a sustainable or non sustainable way it's yeah we're a bit we may not be very advanced technologically,

697
01:22:02,260 --> 01:22:07,690
but we're not very advanced in terms of our governance structures or anything.

698
01:22:07,960 --> 01:22:08,770
Mm hmm.

699
01:22:09,900 --> 01:22:19,270
Though I don't think we're advanced beyond where previous civilisations were several thousand years ago, but at least we haven't got slavery now.

700
01:22:19,300 --> 01:22:22,400
Well, no, we probably we'd have slavery like they had it.

701
01:22:22,430 --> 01:22:26,290
And I think, you know, Greek and Roman and.

702
01:22:28,240 --> 01:22:34,530
Societies that were probably as advanced as ours and more durable really.

703
01:22:34,540 --> 01:22:38,080
But yeah, so I don't know. What do you think?

704
01:22:38,680 --> 01:22:43,050
Where do you think we're going to end? I think we're going to [INAUDIBLE] of that and stuff.

705
01:22:44,950 --> 01:22:48,890
Yeah. No, it's difficult to feel optimistic. Well, I think that's the point.

706
01:22:49,150 --> 01:22:51,100
I'm going to stop. I think.