Your name now. So could you start by giving your name and your position?
So Richard helps out of academic primary care at the University of Oxford and was until fairly recently a part time GP.
Thank you. So first of all, can you tell me a little about yourself.
Without going into your entire life story? Because we haven't got time for that.
Can you just give me the sort of headlines of how you got to be where you are now?
Well, I initially trained for cardiology, but decided to actually qualify for general practice.
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.
But having actually trained for it, I was surprised to discover that you could do a lot of general medicine out of hospital.
Is it is it featured very little on my undergraduate teaching programme and enjoyed the general physician role and thought,
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,
ended up in an inner city practice in Birmingham and in fact I practised there for 38 years as an inner city GP,
initially full time, and then as I took on some academic roles, became really quite part time as a, as a GP.
In my sphere, most academics actually do carry on doing some clinical work as well.
And I became a senior lecturer in about 1985 and then in 91 was appointed as as a professor and had in
Birmingham and then built up a very large department there before moving here in 2011 and doing the same here.
It was quite a small unit in 2011, very high quality unit.
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.
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.
What would it be?
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.
It's perceived often by colleagues either in hospitals or indeed in medical schools as a bit of a.
Dropping off the ladder, discipline and although patience,
I think by and large in the UK really value their relationship with GPS and and
often score it amongst the highest of all the NHS services that they write.
They nonetheless probably think that they're lucky with their GP and the average GP is not very good really.
And going to see a nurse hospital consultant is probably much better.
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
highly ranked discipline of cardiology and choosing a relatively low ranked discipline that's of general practice.
So I suppose that's got me out of bed.
I won't methods for the main sort of methods that used to explore questions in terms of general practice,
I mean rather similar actually to what you do in clinical practice.
I there's a lot of both questions that are relevant to individuals to that sort of advocacy role for the individual,
but also to the sort of population level and that dynamic.
How you balance benefit for the majority against benefit for the individual I think is
a is a dynamic that both presents problems for clinical practice but also for research.
So my main methodological interests have been largely epidemiological,
the sorts of things that highlight risk of major disorders, perhaps not surprisingly,
because my background, most of my research interests have been in cardiovascular disease, but across the populations at Sandwich Hospital.
So how do we diagnose diseases more reliably and earlier?
And then what are more appropriate treatments? So both using epidemiological studies but also clinical trials where we're testing one
intervention against another and trying to determine what what's the best option.
So the epidemiology is that largely based on medical records,
some of it is so big data has become a much more important tool, partly in the UK quite early on actually,
because general practice is the most computerised area of the NHS and the NHS until
comparatively recently was amongst the most digitised health system in the world.
So we actually have very rich and the fact that we have the single registered list
is that everybody's registered on the system is actually pretty powerful really.
And until, as I say, a few years ago we were definitely ahead internationally in the ability to use routine
clinical records for research and we do a lot of that in risk identification.
Can you determine what phenotype, what clinical characteristics are more predictive of worse outcomes?
But some of it is also screening studies where you go out and actually try and identify particular disorders within the general population.
That's quite important when there aren't the data that well, I a lot of patients are diagnosed when they get to hospital,
but of course, that is often at the end of a disease trajectory.
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.
So what you really want to do is if you are unfortunate enough to be developing,
a major problem is to get it diagnosed early and if there are preventative treatments,
then initiate those early and that can only occur in the community.
So hence the importance of data relevant to community populations, which is complementary to data presence in hospital populations.
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,
mostly answered it, really wise research in primary care important.
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,
about 90 plus percent of all contacts occur in the community.
The hospital care is very much the visible part of the iceberg, but there's a huge floating amount of ice below it.
And really that's where we're operating, is to try and bring a bit more sunlight onto that submerged iceberg.
So how is the funding balance between those two things?
Well, what do you think? That's my question.
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%.
Possibly 65% is spent in hospital care.
There's quite a large amount spent on community care.
Believe it or not, although we obviously worry about community and social care, currently general practice in terms of its clinical provision.
That's all the stuff practice staff, practice nurses, GP's, etc. is around six and a half percent.
And then there's the drug bill, which is about 15%.
So I mean, most drugs are prescribed in general practice, although obviously many of them are initiated in hospital.
But it's been fairly constant as well. So one of the problems you run into during my I mean,
it's been interesting during a career as long as mine is that the one thing that you can guarantee
is that unfortunately politicians will not learn lessons from history and will repeat things.
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.
So the current one of course is that the. There just aren't enough people in the community.
And so a lot of health care professionals in the community.
Sorry, I'm just clarifying for future. Yeah. Yes. Yes.
Which is going to be a big problem because there's a lack of time to creating the workforce you need.
And I mean, in my political career industry enough, the number of hospital doctors is tripled.
But the number of jeeps is the same as it was when I went in to practice.
And there was a big attempt actually over the last about five or six years, but three secretaries of state.
I wanted to increase numbers of Jeeps by 10,000.
But we're actually now minus three. Sorry, plus 6000.
Sorry, but we're minus three. So we're by 3000. We're -3000 since they wanted to add six.
So that's on government owned estimates of what they need.
So we're -10,000 jeeps and there are only 28,000 of them.
So you've lost you basically down a third of the workforce.
And then you wonder there are problems with. Access and provision and stuff like that.
Mm hmm. So let's move on to Clovis.
So. Oh, no, sorry. I've got another question. Important question. And that's nothing to do with my academic group.
These are the observations, but it's the world within which you operate.
I think it's very much.
Well, it does create tensions for us because, of course, we want to spend some of that time teaching and undergraduate students and researching.
And of course, they're rammed with everything else. You know, it's more difficult for them.
Mm hmm. So can you just run over what your main area of research interest was before I became.
Yeah. So before COVID, my principal area was.
Was cardiovascular disease, particularly heart failure and stroke in relation to atrial fibrillation and hypertension.
So. So what can you unpack that a little bit?
So this is the question, the sorts of thing I spent about 15 years or so doing quite a lot of work around
identifying that heart failure is much more common than we thought it was.
The its impact and quality of life was much more dramatic.
What is heart failure as opposed to heart attack? I mean, pe lots of people.
So heart failure is where the heart pump is, works less efficiently and it's syndrome.
Also, there are many different causes of it.
And basically by not working as efficiently as a pump, then you get a variety of consequences,
including shortness of breath and lethargy, and you can start getting volume overload.
Things like fluid retention, but often in early stages, it mainly manifests with feeling tired and more short of breath.
And since it's obviously or as we get older, it's often ascribed to getting older.
So patients will often tolerate symptoms because they think it's just them getting less fit and less active.
There are a number of predisposing factors. Heart attack is actually a very significant cause of one type of heart failure,
where the left ventricle, the left side of the heart pump works less effectively.
That's more associated with fluid retention. But the other big cause is arrhythmias, things like atrial fibrillation,
because that makes the heartbeat less effectively and stiffening of the heart as it ages.
So you can imagine if it's stiffer, it contracts less effectively.
It's a bit unfortunate because it's the term itself, I think is rather dramatic.
So many patients who do actually have impaired cardiac function, which is a heart failure, is effectively.
It's not necessarily discussed as openly as it perhaps should be, because it sounds pretty dramatic.
If somebody said to you you've got heart failure, you'd probably think that that was a pretty terminal diagnosis.
So that's been a feature of it is that is is perhaps talked about.
Less than it should with patients.
But it's an important diagnosis because it does mean that things if you don't do things that reduce its advancement,
then it will show up in your life and it will cause gradually increasing symptoms and poor quality of life.
But there are things that you can do that can slow down that progression.
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.
So we now have a blood test that can help determine whether somebody has got elements of pump failure.
And because it's syndrome, well, it's not necessarily easy to diagnose.
You need a number of different factors. But then putting those together,
you can be more certain that somebody does or doesn't have heart failure to explain their symptoms and then you can initiate treatments.
So there's been a big change in my time.
I mean, when I was in hospital treating heart failure patients in the distant past, we had no treatments for failure at all.
And in advanced states, patients, you know, would really be incredibly symptomatic.
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.
And you can't imagine I mean,
that was like 19th century medicine compared to now where we have quite a number of effective treatments that will slow things down.
Mm hmm. So I was doing that, and I also did quite a lot of work around.
Atrial fibrillation, particularly some early trials about the effectiveness of anticoagulants like warfarin.
Blood thinners, which had been shown to be effective in younger people.
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.
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.
And that changed quite rapidly, change world guidelines.
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,
which stole all the glory, really. But. But that's still, I think, my.
Third or fourth most cited. Piper.
So it's still. He cited a lot, even though.
Hmm. So right now, we will get on to Kobe.
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?
Well, I remember reading the reports about the Chinese whistleblower doctor terribly.
I can't remember his name, but that was back in December.
Yes, 2019, I think. And.
It was clearly there were some concerns then that it effectively re-emerged in East Asia.
And so I think. The first time.
I probably encodes a bit.
Difficult to remember the distant past now, but certainly would have been early January.
Of that, I think the Lancet paper came out towards the end of January.
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.
And I can't remember exactly when we had a first meeting, but there was a sort of meeting.
A weekly meeting established in late January.
Of a variety of different people that might contribute to thinking about what we should be doing across the whole medical school.
Across the medical school, it was there were about but it started off with being with 25 or 30.
Parties were convened and then it grew.
And this involved basic scientists, epidemiologists and.
And Triallists and both hospital and community peers.
About what it was likely to mean, and I think certainly by February.
I think I've taken on board that this was going to be a global pandemic and.
We should be starting to think about our response to it, perhaps mid-February.
So. And then by.
Late February, certainly beyond the first week in March, I.
Took the decision with the senior department staff that we needed to hibernate our main research programs,
and so we were actively doing that as quickly as we could.
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?
Because initially we were thinking about people not coming to work.
But infection is one of our themes in the department.
We've got cardiovascular disease, cancer, health behaviours and infection are all big interest themes.
And so in parallel to that, we were working up a number of clinical trial proposals around COVID.
So that was in early March when they then announced that they were going to be these rapid funding schemes.
And we basically set up the repurposed medicines in the community platform alongside the hospital,
one which is recovery, which is that the repurposed mat.
Is that the same thing as principle? Yeah. Right. Okay.
So principle was that if you like the community urgent public health trial platform recovery was the hospital one.
Yeah. And, and where did that rapid funding come from.
That came from UK Ukraine. Yeah. So I to remember exactly.
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.
It all started incredibly quickly then though because the closed dates for all those
early programs were like two weeks and there was a degree of negotiation about them.
And then we started doing that.
We recruited the first patients, I think, in about ten days after the decision was taken to fund the trial.
But you just explain a little bit more about the trials. So what was the thinking behind?
So the thinking on that was that the were likely to be drugs.
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.
So observational data suggesting that this drug might work.
Hydroxychloroquine was the first time we put into principle and lots of theoretical reasons why some
drugs might be better because they've been used in other viral illnesses and things like dengue fever,
plague, etc. So there were quite a number of candidates of drugs that might work.
And then you obviously are thinking Masami work in a more ill patients or might something need to be given early?
And if it's given early, you'd need to be given before somebody was ill enough to be admitted to hospital.
That was thinking behind that in parallel to that that we also just by chance
run the national screening programme for then it was Public Health England,
but it's now the National Protection Agency on flu surveillance.
So we've been running that for 55 years. And how does that work?
That basically works on what was then about 300 practices who who basically take the blood samples of
patients with syndromic flu and come up with the incidence and prevalence rate into that population.
So that had been running for quite a long number of years and obviously in early 2020,
we test that onto COVID as well and agreed with Public Health England,
we'd supplement that and also doing serology in the general population,
just looking at antibodies to see if people have been infected who hadn't realised they had been.
And is this the Royal College of General Practitioners study. So that's, it's that's jointly with the Royal College GP's.
It moved to Oxford about three years ago and which was probably lucky because it was creaking at
the seams then and we made a strategic decision to increase the size of it to 500 practices.
In 2019. And and I did that very quickly in 2020 because of the impending pandemic and then continued to expand it.
So it's just every patient to who comes in with symptoms of a sample taken or.
No, not all. So now we've expanded the sort of observational elements to around 1500 practices,
but the blood taking aggregate is supplemented, blood taking is done in 500 sentinel practices.
So as I say, we scaled up in early 2020.
So that's been quite important as well. In fact, the first UK case within the network was 29th of January of 2020.
As it turned out, it wasn't being tested full then,
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.
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.
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,
rapidly emerging evidence base and published a lot of rapid reviews on.
Weather. Things that people worried about early on, though, with there were views that, for example,
certain types of drugs used for common diseases like hypertension might be harmful because theoretical grounds.
So doing systematic reviews around that also happened quite a lot.
And then the whole digital science bit of the department.
Sort of refocused entirely around COVID.
So there were a lot of rapid papers around the associated risk factors to worse outcomes.
And this is working from patient health records.
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.
Gradually coalesced into what eventually was commissioned.
From the CMO. To produce a COVID risk score, which was operationalised in just a few months in mid 2022.
What was the well that that was then used to to produce a better a better more
discriminating score for who should shield rather than just using age and also produced.
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.
In what order? Mm hmm. And what were the main factors that came into that?
Well, age is obvious. Yes, the single most important factor. But things like obesity came out that hadn't been thought about ethnicity,
having significant degrees of renal dysfunction or cardiovascular dysfunction, which is what you'd expect.
Really a lot of the fatal outcomes associated with COVID are cardiovascular.
You might clot who it might precipitate.
A heart attack and things because you get big. Well,
some individuals for some reason get this massive inflammatory response and that has all sorts of detrimental secondary effects on health systems.
So if you've got a predisposing chronic problem, then you're more susceptible to worse outcomes.
But we still don't really know why some individuals are much worse than others because obviously.
There are a lot of people out there have got vascular disease, but not everybody has vascular disease, has a bad.
Mikovits And there's still some genetic makeup that we haven't identified that causes that.
But at least if you're going on the phenotype,
which is what you can measure without looking at somebody's DNA, then you can become a bit more predictive.
And so that was another platform was also engineered very quickly and safely.
And the advantage of that is that that by within about three,
four months was effectively looking at the health records of everybody in the United Kingdom.
So I'm hoping to talk to Ben Goldacre as well.
So, yeah, you needn't expand the safety. Yeah, I think there's a huge amount to say about this.
I think I'll probably get Ben to do that if I. If he hadn't read to me.
Let's just go back to the drug trials. So what were the the candidates?
So what were the outcomes? The first one we looked at was hydroxychloroquine,
which was stopped by the MHRA after a fraudulent big data paper was published that suggested it was harmful.
And although that was exposed as a fraudulent paper within about ten days, they didn't reverse that decision.
But we did also look at antibiotics at that point.
It was thought that through muscle nucleus, myosin, which are long acting macrolides.
Would be beneficial and we showed it to be of no benefit at all.
That was really quite important because a lot of patients were getting antibiotics.
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,
that the actually secondary bacterial infection opportunistic could be quite a big factor in deterioration.
So it is a reasonable hypothesis. I mean, there is some observational animal data to suggest they have antiviral effects as well.
But, you know, as you'd think, just having some basic observational science isn't enough.
You need to test it empirically and it doesn't matter how convincing.
The evidence from Trump is that these things are affected.
It's better to have randomised controlled trial evidence in in a larger proportion of the population.
So those were shown not to be effective. We did show that inhaled budesonide, which is just an inhaled steroid was effective.
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.
It shortened illness both three days, but also within the the contemporary control population actually reduce hospital admissions as well.
We're very disappointed that nice though have not recommended.
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
evidence is not yet strong enough for them to recommend that everybody's given it which.
Well, it is interesting, but we are exploring whether we reopen.
But it's it hasn't been announced yet,
but it will be announced shortly that we actually are going to be running the new community viral, new antiviral platform.
So all our efforts at the moment are operationalising that course, hoping that that which is called panoramic,
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.
And then that will be testing all the new antivirals that might appear.
So at the moment we're operationalising that,
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.
And obviously if it does, which we think it does, reduce the risk of being admitted, then that's an important intervention,
given that there's nothing currently other than dexamethasone or monoclonal antibodies.
And the point about the monoclonal is they're very effective, but they're sort of three, four,
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.
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,
I actually was the PII on the AstraZeneca monoclonal antibody trial tackle,
which which is just reported very positive findings, but you have to treat.
So we've done the trial in the community looking at very early use.
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.
So you can imagine complicated that was organised and in fact it was really problematic for us to get that trial approved operating across.
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
just managed to recruit virtually all the patients they needed for the very start,
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.
And then but after that it became virtually impossible to recruit to because the immunisation programme was at full steam ahead and,
and you weren't going to give it to people who were vaccinated or rather if you were in the tackle trial then,
then it was you had to wait a month before you could have your vaccine and obviously people didn't want to do that.
So, so then became impossible to run it. But that was another thing that we did on top of everything else.
So I suppose for from really March of last year to now and probably around 50% of the
department was was just completely devoted to urgent COVID research of one sort or other,
although we've continued doing most of the other studies that we do, continued at a reduced rate,
although we've been trying to bring most of those back on stream in the last few months as well.
I've got another one. That was an ivermectin.
Did you. Yeah, we've got that in language. Yes, of course.
I couldn't find a report on that. Well, that's because we haven't been able to do on that.
So we've got favipiravir, which is an antiviral. Yeah.
And Ivermectin are still in.
Yeah. Which is that creates a little bit of a response.
So there are two arms of principle that are ongoing.
We're slightly surprised that we haven't had any report because the other ones have stopped reasonably quickly.
I mean, now approaching 7000 people in. In principle.
So. Quite what it means. Who knows?
But but we have quite sophisticated futility or benefit algorithms that are operating in the trial.
So. So the kind of flag that comes up.
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.
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.
But we haven't had anything yet, so I'm not quite sure what that means.
But obviously we will be particularly concerned about the ivermectin because of the sort of huge controversies that have been associated with that.
Um. I probably ought to just get you to say what that controversy was, because we can't assume that people will know.
Oh, it's the one remarkable thing about COVID has been quite how it's exposed divisions in societies.
I mean, if I was if that's me as a sort of more.
A human level commentator, but.
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.
So it's a corporate approach.
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.
The world and our selves get after this.
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.
Resource pushed aside. Really. We were all on the common agenda and you sort of felt that that might permeate society.
And certainly early on I think you did because I think people seemed to adopt mask
wearing fairly early on and and and people were pretty compliant with the first lockdown.
I mean, if I had to come into the department, that didn't really affect me.
Work was, I think coming in right from the start,
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.
24/7 for one period and it felt inappropriate for staff to be in without the seniors in.
But I felt for example, I'd throw up at a gun, get permission from the police,
didn't really want to get the embarrassment stops on the motorway and stuff because it was legal then going about your way normally.
But fairly soon it you know, things started to deteriorate.
You know the aggro in house, in shops about people who wouldn't wear masks who.
The. I don't have to wear a mask sort of response to things.
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.
And you think this is just crazy? This is such a minor.
Bit of your infringement of your personal.
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,
because inevitably there are scientists who don't necessarily agree with other scientists, and that's a good thing.
That's always been one of the exciting things about being somewhere like Oxford, which actually has an incredibly profound sense of academic freedom.
So in our employment contracts, there are several pages of the contract that talk about academic freedom.
Really bizarre. Frankly, I was shocked when I first came.
But I think that that that public debate has been difficult because I think it's been used a lot by anti.
Think groups. Lot of pressure groups for one reason or another, even if goodness knows what.
But presumably there's a commercial gain somewhere along the way or a political gain or something that results in people.
And people forming civil pressure groups around these questions that have attempted to undermine the science consensus.
So how did this apply specifically to ivermectin? Well, in ivermectin, I think there's a few.
I was written to soon as we announced within the trial that we were we were committing manslaughter,
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.
That the very existence of the trial undermines the unequivocal evidence base that says it's effective.
Which is interesting because obviously we'd reviewed the literature and come to an alternative conclusion.
We felt that we potentially could be effective, otherwise, obviously it would have been an effort to do the job.
It's a it's an anti-parasitic drug which is not licensed actually in the UK except in veterinary use.
It is used though for some. Rare skin disorders and you can use it of licence in those conditions.
But like any drug, you know it, it isn't without risk.
The vaccines and unbelievably tiny risk has resulted in mass hysteria about the likelihood that an individual may suffer an alternative response.
I think this balance between risk and benefit is really quite a difficult one.
I think in retrospect. I think there was mistakes made in how the.
Evidence bases being used during the pandemic to make decisions that in retrospect, I think,
have contributed to some of the some of the sorts of consequences that we've seen within society.
Can you give an example? Well, I think just I think the science debate has has been won because I think.
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.
I mean, you could argue.
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.
Right. I wanted to get scientists to see whether they could come up with a balanced view.
With people who disagree with what was happening and those who agree, at least initially.
And I think so on the whole, this is disagreeing that there should be any kind of.
Yes. Response that restricts public freedom of economic activity.
Yes. Yeah. Of which, I mean, that's a perfectly legitimate starting point that the long term consequences of things,
the decisions you make may be worse than the disease itself.
That is entirely fallible. Sweden took that position, but they had a really big death right in the first wave.
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.
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.
I think it would have been very difficult not to have done an initial lockdown.
Although I think that was partly because of what China did, because, frankly, I don't think anybody would have thought about it.
Otherwise, I think if the Chinese hadn't done that and completely well,
virtually completely succeeded in Wuhan, nobody would have thought that would have done it, I don't think.
It wasn't in any of the sort of pandemic planning documents.
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.
Because I think people want to think about it. But the Chinese did bring a massive epidemic under control.
And but the Chinese have a completely different social structure to us.
They were able to completely impose lockdown on the community.
And by and large, the population wanted as well because they didn't want to be infected.
And so the scenes in Wuhan and didn't want it to happen to them.
So because they live in these very large communities which have effectively
community services that also enable you to effectively secure the communities.
They could do it and it worked.
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,
I think was the right decision personally because I think the scenes in Italy shocked everybody
here and I think we would have had those scenes in the UK had we not gone into lockdown.
And I think that the only time during the crisis where I thought the NHS is going to get
overwhelmed was just in the new year to 2021 where actually we thought things were looking up.
But then Delta arrived and I was part of a couple of group meetings, second or 3rd of January or something,
and that was the first time I thought that I heard fear amongst hospital leaders that they were going to get swamped,
which is when we went back into that hard lockdown again at the beginning of the year.
And they were exaggerating. You could tell that they were a bit fearful.
And I've got some friends as well who were in, I think very early on in the first wave.
There were some parts of the UK where they were full in ICU and things and and they thought that they, they might be,
you know, effectively having to just palliative care for people who were basically going to die in a hospital bed.
But I think that that sort of ease the pressure as soon as we went into lockdown, did ease the pressure there.
But I think there was a rising panic at the beginning of this year that it was going to get swamped again.
And all the hospital the extra hospital bed provision was all.
It just, you know, it was never going to work because there aren't enough staff.
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.
So. So that I think was. So things.
But having said that, if I was in government, I think you can have to make these sorts of decisions.
And yeah, they wasted unbelievable amounts of money,
but they wasted them in retrospect and they probably had to do what they did, like build, build capacity,
because I think the population expected it really,
and it probably frightened the populations about which they needed to do, otherwise it wouldn't have gone into lockdown.
But you can only get away with that once. It doesn't it's not working anymore.
People just don't believe that it's that bad now. All sections of the community don't think it's that bad.
So that was always the danger of, you know,
potentially exaggerating the risk first time around is that is the it's then quite difficult to get people back to normal again,
which I think we've got you know, there are a lot fearful people about it,
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,
you've got another group who are completely unfair and think that it's conspiracy theory, I mean, where it all comes from.
But so we've got really we're not in a good place at the moment, I don't think.
And and early on I thought we this could be good for the planet in a weird way.
Mm. Oh, I understand.
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.
Yeah. How, how do they work and how well do they work?
Well, things like the trials and surveillance platforms are partnerships.
I mean, we provide the infrastructure and the design of how you answer a question efficiently but reliably.
And then we'll obviously need to have partnerships with quite a number of groups.
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.
So we started off principle, for example, thinking that we'd run it through practices.
But of course practices weren't seeing patients with COVID because they were trying to keep match surgery, so they went to assessment centres.
So we engaged the assessment centres and then they were slow to get going and so we developed much more direct to patient
relationships and we recruited a lot of patients for the principle who effectively have recruited themselves into the trial.
So we still had to check that they didn't have any reasons why they couldn't take part,
which meant we still had to have relationships so that practices.
But we've had a much more direct relationship with patients, both for recruitment and follow up,
which has been very interesting because that's very different than what we'd normally do.
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.
And that would be the same for the viral antiviral study.
But it's been really big partnerships with the, with the research networks which are run by.
National Institute for Health Research and a regionalised. They liaison practices locally.
Direct relationships it practices threat relationships with.
Different bits of the NHS structure.
But it's been very hard work, to be honest. It's been very hard work because.
We've had to overcome all sorts of difficulties that were created by the pandemic.
There was much less testing initially in the community,
so it was often difficult to discover with somebody was COVID was actually stopped at one point, wasn't it?
But it was, yeah. And you know, early on in the trial, for example.
The Post Office refused to handle samples that were being sent in case they infected all the workers.
So we had loads of problems early on that we had to overcome.
We seemed to spend the whole 18 months just trying to engineer.
Out of crises, constant crises. We also didn't get the sort of.
National endorsement of the same. The recovery has a mean recovery.
The recovery is another. The whole story explained. Yeah, which which?
I mean, you probably interviewed yourself in the Hobby Lobby.
Sorry, I've been postponed once. I'm supposed to be seeing him next Monday.
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
trial and all the hospital trusts were pretty much mandated to recruit into it.
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.
But it achieved unbelievable numbers,
patient numbers very quickly because of the way it was sort of regimented in it in one
bit of the NHS hospital care and they were able to get all the ascertainment as well.
So I mean obviously the data on dexamethasone, which was very important early on,
but for all sorts of reasons probably back to the sort of cultural reasons we started off with.
It's it's although it is up to trial, principle has always struggled to get that sort of central C needed.
You need to support this trial blah blah. So it's all been a bit of an uphill struggle, to be honest with.
I think that the new antiviral platform will have more central support.
Expectation of the service that people do support it.
But we'll see. But. So you're talking about from the Department of Health.
From the Department of Health, from the government, from the NHS, England, from the CCGs,
from from the sorts of political structures saying that this should be supported and indeed,
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,
how they can rapidly engage. It's important because for antivirals, definitely, you know, you've got a relatively narrow window.
Are you going to use them early on? They probably won't be effective.
So one of your interests before COVID came along was the interaction between respiratory infection and cardiovascular disease.
Has the work you've done on COVID advance that understanding all?
No, not really.
We've got a dphil at the moment, actually, where he's interested in whether infections per say, a trigger for subsequent vascular events.
But that pre-dates COVID, really. So no, I don't think it would have really helped our thinking around disease.
So what long term problems do you think the pandemic poses for general practice?
I think for general practice, I think. The difficulty is trying to get back to a more normal service provision.
That's still I mean, the one thing the pandemic did, which I never thought I'd see in my lifetime,
was introduced the concept of digital consulting in a completely unparalleled way.
So if you look at UK general practice, it switched from being 9090 4% face to face.
To to around 50% face to face in a month.
And I think that the online provision.
Warts and all, has been amazing, to be honest. And that's persisted.
So still, around 40% of consultations are digital.
Most of them are because that's what the patients want is convenient. It's it's more rapid.
Doesn't involve you having to go anywhere.
I mean, it isn't appropriate for some types of consultations, but for some consultations is clearly better than a telephone call.
Which call which was the, you know, the alternative way of not doing face to face.
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.
And of course, some MPs, ministers, ministers are quite happy to undermine the employees by saying how outrageous it is.
But I think for most GP it is based on clinical need and patient preference not.
So there's always going to be some room providing the services should, but I think for most.
So that's been an interesting dimension. But I think it's.
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
deaths in the UK now on Non-covid related and it's what you would have predicted a year ago,
which is that it's cancers and vascular disease. So it's people.
We did some work in the autumn to look at how general practice recovered.
And it was remarkable actually that by September of last year.
British jeeps had recovered about 75% of the sorts of simple prevention stuff that they normally do.
Blood pressure checks, glucose checks, cancelled checks.
Which we thought was pretty remarkable because if you looked at the figures in April,
it went to virtually zero and then by September it was 70%, but it's still obviously a big backlog.
And we were also a bit worried that there might be difficulties getting GP that was affecting two week weights because you know,
if you've got potential cancer, you're supposed to refer them in within two weeks and that was dramatic reductions there.
But actually looking at the data that we were able to report it, it looked as if it was patients.
Patients were not presenting when they presented. They were getting the two week wait.
But so there's a big gap there in trying to get people to think again about presenting when, you know,
they've got their rectal or vaginal bleeding that they shouldn't be having or if they're losing weight for no obvious reasons.
I mean, those sorts of things. I think we've got to restore that if the NHS is capable of responding to course.
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.
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.
So I think that's going to be a big problem and that's going to be a big issue for general
practice because a lot of these preventive or early triaging activity happens in the community.
So tell me about your role in national and global policymaking around public health in the community?
I don't really I mean, I liaise quite a lot with external parties when it's appropriate.
We do quite a lot of work with the College of GPS and trying to support their interests.
But but actually, I, I have largely withdrawn from my sort of more political roles over the last few years.
I do some international work in relation to the advancement of primary care and digital health.
So I think most health systems actually, interestingly enough,
over the last ten years have realised that if they don't invest in primary care, they will bankrupt the, the health GDP.
So and I think the model, the UK model, it's interesting that for a third of my clinical lifetime,
I think the NHS was looking overseas for better models of clinical provision,
but in fact actually quite accidentally we ended up with probably the most controlled
global health system model and one where most general physician general medical
care occurs in the community and a lot of the sort of prevention and disease follow
that occurs in the community and it enables super specialisation hospitals.
So the other thing especially is to become more specialised and that model,
I think most health systems and I recognise that that model in the registered list.
Rather than the source of private provision is the most equitable and cost effective.
So there's lots of health systems are trying to orientate more to the way we do things here.
And of course, digital health, which we do a lot of work around as well, is quite an important part of that.
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.
I remember having American friends who were astonished that as a woman who had two children,
I've never seen either a paediatrician or a gynaecologist.
Yeah, well, they proliferate community care that they're going to general practice is actually not exactly the same.
But that family doctor is definitely I mean, they're paid less and objectively have a much lower status.
So you tend to add community specialists to your provision as well.
But even the U.S., the managed care in the US recognises they need a more general population approach to things.
Otherwise, you know, they won't they won't stop a lot of expense.
They might be doing it for economic reasons, but they're still driving towards a similar model.
And there's things we can learn from the U.S. because it's effectively a for profit environment.
In most cases, they are pretty efficient about investing in cost effective management programs,
and we can learn from those is once you determine that people got problems, how can you look after them more effectively?
He covered this a little bit because you mentioned you went in.
So how did the first lockdown impact on moving now more to your national living, living through the the pandemic?
How did the first lockdown impact on on what you were able to do?
Did it did it change the way you were?
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.
So I was commuting down from Birmingham, so it was a lot easier commute, that's for sure.
It was a bit it was a bit weird. I mean, you felt like it was a Hollywood pandemic film because, you know,
they weren't mowing the grass outside and it stopped and the streets were completely empty.
And, you know, I could across the road here with my eyes closed, I needed to look for traffic.
And I think there were two or three of us in this building,
but I think we didn't actually close this building or the other building we go, which is 100 metres away.
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.
So yeah, that was that was a bit weird.
A huge increase in meetings actually already had a lot of meetings in my diary, but far more meetings, most of them online.
Even though I've been taking them here. I think the other thing that was which I've missed, I have to say, although.
I did not think about my eco credentials is travel.
So I think I've had. One flight in the last 20 months where normally I'd probably I don't know.
I'll probably be twice a month beginning somewhere.
So that's been bad. Because I think you are often meeting interesting people, different parts of the world,
different perspectives, as well as doing whatever you're going to do.
Normally he was giving a lecture or examining or something, so that's gone.
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.
But I've stopped attending Congresses. I think online Congress is a.
Not for me anyway, so I don't know what that's going to be like.
And I think it's you know, I think it's been difficult, but domestically as well,
because my wife is in a similar area to me and, you know, we just it just ramped all the time.
Yeah. So you're working hours went out just ridiculous.
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.
But, you know, I'll just miss something if I'm feeling a bit overwhelmed that day or whatever.
And yeah, we still publish a lot and still have to bring the grants in for the next stuff
and still cope with more people in the department and all the rest of it.
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.
So that really increased as well the the sort of because obviously the university response was.
From a senior management team was big. So that's been quite time consuming as well.
And do you think the provisions that were brought in across the university to protect people were adequate?
And I think when implemented did a good job, really.
I mean, and I think, you know, we tried to make. Quite a few departments did.
We certainly tried to make people still feel they were part of a department, even if they were working from home.
So virtual coffee mornings and.
We normally have a big fancy dress Christmas party every year.
Last year we didn't, but we did a online pantomime, which was awful for those having to be in the Pentagon.
But I think when you think why you in the pantomime. Yes.
So so do you think the well-being of the people in your department held up fairly well?
I think it probably did.
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.
Yes, it still feels like it cares about stuff.
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.
And I think I don't know where we're going to end up, really.
So I think the university I mean, we obviously predicting a big loss over the last financial year and to Columbia's decisions there.
But as it turned out, you know, the university is actually. Financially done well because it's done so much stuff.
It's obviously increased this grant income. There's been a lot more legacy.
I think it's boosted its international status. As an institution even more than it was already so.
It. It hasn't been bad for the institution. I mean, I think we'll have to wait and see where it settles.
I mean, I think it has been it has made a tangible contribution to the world, actually, in the last 20 months.
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.
But. But that's still the most used vaccine on the planet.
And goodness knows how many lives have been saved through that.
And, you know, it should. It should actually be.
By far the most used vaccine because it's cheap and cheerful and easy to use.
And it's risks, albeit, unfortunately, does have some risks.
In the scheme of things,
and they are no greater than the alternatives and much less than getting the disease and massively less than getting the disease.
And who knows the people? I mean, you can speculate, but the people who get these rare thrombotic effects,
I think you could reasonably surmise that they would be more likely to get those same effects if they had the.
Um. You know, if I could walk over the. Because there's obviously some weird predisposition to a thrombocytopenic reaction.
I mean, there is the disorder is actually it just shows how odd science is that because actually
it's a known risk factor with vaccines to get a immunological thrombocytopenia response.
This means blood. Blood clots. Yeah. Sorry, I'm just. It's. Yeah. And then as part of it, you.
You drop your platelets, which makes you more likely then to get a bleed associated with the clot.
So it's both a clot and bleed at the same time.
And there are one or two vaccines, which I'm not going to name, which have this associated with them.
And I never knew that. And no vaccine for the disease, not for COVID.
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.
So it is just one of the potential risks associated with vaccination.
But you're talking about converting a sort of one in a million background risk into two in a million.
Well, if you were that one in a million person. It's obviously tragic and awful and all that, but.
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.
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.
So but that that's been very unfortunate because I think it and it's for some countries have been devastating.
So because some of the countries have very, very low vaccine uptake.
Romania, Russia, Japan are going to really get hit badly in this current wave.
So. Did you personally ever feel threatened by the virus or.
Yeah, I did, actually, because not without going into it. You know, I'm old and have a number of risk factors.
And actually so it was weirdly early on when this had been.
I did actually think that if I get it. It might kill me.
And I sort of thought to myself how either way and because I could just work from home,
just decided that I wasn't going to let it dictate how I lived my life, really,
and then stop thinking about it other than, you know, sensible precautions.
But yeah, so that's what I did think about it deep down.
But as it turned out, I was infected quite early on this thing as my.
Oh, you were? Yeah. So. Oh, right. Was my wife caught it in mid-March.
She was teaching on a master's program in work and quite a few.
The top two exhausted old doctors and they've got a few of them have been skiing and
and two of them and subsequently the whole cohort were infected with COVID in March.
That was before the first week before in first look. Right.
And and so I know that I was infected at some point because I got I did my antibodies at the end of 2020,
which showed I'd had been infected, and I'm almost certain I was infected then, although I wasn't actually particularly ill.
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.
I didn't lose your sense of taste and smell that I didn't.
I had really given. Well, I've been thinking in retrospect, stupidly, I got off remarkably mild things with symptoms.
There were another couple of occasions when I was ill later in the year where it could have been then.
It's just I mean obviously once we realised she got COVID effectively Barry a nurse to at home but,
but there was at least 24, 36 hours before we knew she was positive when she would have been infectious.
So I think the chance of me not having caught it then were negligible and obviously caught it at some point.
So I think it was there. So so yeah, it you can get it and survive it.
A lot of people do. That's the weird thing about it. It, it's, it's unpredictable.
Even amongst people with risk factors, the majority don't want to get seriously ill, but some will.
So I need to move to wrap up because I think we have to time.
And so has the work you've done on COVID raised questions that you'd be interested in exploring in the future?
Yeah. I mean, I think the particular area that will want to look at as soon as we can actually is long COVID,
and we'll be looking at whether any of the treatments which might all be infected with COVID keightley might be effective.
In terms of long COVID. That's a completely separate and important question,
where you might use treatments not for the initial illness, but because it might alter the illness trajectory.
So that, I think is an important area. I think we're still thinking about how we can integrate all of our digital assets.
We've got quite a number of parallel digital assets and whether we can actually be using those more efficiently,
I think is is quite a big consideration for us and also our relationship with the
software suppliers who actually generate the clinical systems that extract the data.
That's been the relationship with them has been really quite important and much, much stronger over the last year or so.
Yeah. So those are two obvious areas I think trying to resurrect Non-covid research is also important.
I mean, obviously, you know, we are not going to eradicate this virus and we therefore need to learn to live with it.
And I think that'll become a feature really. Which is,
which is how you can reduce its impact on society and try and return to a more semblance of normality at
the same time as focus on the next or perhaps the overwhelming issue facing society of climate change.
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,
um, where we go with the world I think is going to be a bit of a.
You know, this is a slightly different question, but related.
Has the experience of COVID changed your attitude or approach to your work?
And how would you like things to change in the future? Well, I really enjoy my job, actually.
I wouldn't necessarily admit that, but I do enjoy its variety.
The amount of control I have over what I spend time doing, etc.
But I do feel a bit wary now.
So I don't know really. It I mean,
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,
you know, generational stuff. So I suppose I, I think more about whether I should be thinking like that.
I don't know whether I will or not, but I think I should think more about that.
And I think quite a lot of people of my sort generation thinking more like that.
And, you know, worrying about, well, because it's really the next generation and certainly the grandchildren who are really going to.
I've suffered the economic consequences of that.
So once again, I think I've been fortunate enough to live at a time when we never had it so good.
Frankly, as a society, the adults in society, even the ones who.
You know, need support from the state to survive.
They've actually never had it so good either, because I think I think things are going to get tougher and.
So I don't really know what is going to happen. I'm clearly, you know, the world's in a terrible state.
When you look at equity and distribution and population and simple stuff, like enough food to eat and.
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,
but we're not very advanced in terms of our governance structures or anything.
Mm hmm.
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.
Well, no, we probably we'd have slavery like they had it.
And I think, you know, Greek and Roman and.
Societies that were probably as advanced as ours and more durable really.
But yeah, so I don't know. What do you think?
Where do you think we're going to end? I think we're going to [INAUDIBLE] of that and stuff.
Yeah. No, it's difficult to feel optimistic. Well, I think that's the point.
I'm going to stop. I think.