From GP Magazine: NICE chairman outlines basic qualities of a good GP. David Millett 7/10/16
“An evidence base is incredibly important but if you don’t take people’s hearts with you, then you’re lost.”
Sir David Haslam was a GP in Cambridgeshire for 36 years and is a past Chair of the National Institute for Health and Care Excellence (NICE), past-President and past Chairman of Council of the RCGP, past-President of the BMA, and former Professor of General Practice at the University of Nicosia, Cyprus.
He is currently chair of the charity “Young Lives vs Cancer”, Non-Executive Chair of Itecho Health, and an Associate with Kaleidoscope Health and Care. He has written 14 books, mainly on health topics for the lay public and translated into 13 languages, and has been invited as keynote speaker to Conferences in 33 different countries. Every year for over ten years he was listed by the HSJ as one of the most influential people in the NHS and was named by Debretts and the Sunday Times as one of the 500 most influential and inspirational people in the UK.
David was awarded CBE in 2004 for services to Medicine and Health Care, and knighted in 2018 for services to NHS Leadership.
“Side Effects: How Our Healthcare Lost Its Way– And How We Fix It” – was made Book of the Week in the Observer and listed in Waterstones Best Books of the year.
Watch the video of the interview below or on Youtube or listen to the podcast on Spotify and all the major platforms
“…the key thing that happened in my life was my dad dying when I was 14. I remember going to his funeral, packed with all of his patients and just seeing the extraordinary….love. The love that they felt for him, the esteem in which he was held, the value in which he was seen by the community.”
Hello, I’m Domhnall MacAuley, and welcome to MedicsVoices.com, where we talk to the key opinion leaders in health and medicine around the world. Today we’re in the UK and I’m talking to David Haslam.
While many might see you as an establishment figure, you started off in public life, writing a column for Word Medicine, edited by the irrepressible Michael O’Donnell…
David Haslam: That’s absolutely right. World Medicine was a magazine that, when I first started in medicine, was circulated to all doctors, not just GP’s, not just hospital doctors, but across the whole spectrum, and it was wonderfully iconoclastic. It was challenging. It was a cross between Private Eye and… I don’t quite know how to describe it, because there’s nothing like it. It was packed with humour and it struck me, right from the start, that one way to get ideas across was with humour. An evidence base is incredibly important but if you don’t take people’s hearts with you, then you’re lost. It seemed to me to be a really interesting way of communicating with my fellow clinicians. And it was fun, and it was such a joy. One of the very few regrets in my life is that I cashed the first cheque I had from World Medicine, because I would love to have that framed on the wall; 35 pounds for an article, I was thrilled.
DMacA: Let’s take it back now to the very beginning, because you went to Monkton Combe School, a well known rowing school in Somerset. Were you interested in sport?
DH: Only cricket. Cricket was my passion and still is. I’m still a member of Somerset. I live now in Dorset, where we sadly don’t have a first class team, but I still follow Somerset. I wasn’t desperately sporty at school. If anyone who ever knew me thought of me as sporty, they’d be laughing now.
DMacA: So, when did the academic interest start?
DH: Well, I guess, I always wanted to be a doctor, and I often pondered about whether that was genetics. My dad was a doctor. My brother was a doctor. Both my sisters were nurses. Was it genetics or was it a complete lack of imagination? I guess probably the key thing that happened in my life was my dad dying when I was 14.I remember going to his funeral, packed with all of his patients and just seeing the extraordinary….love. The love that they felt for him, the esteem in which he was held, the value in which he was seen by the community. My brother was also a general practitioner and he died when I was a medical student. He died of leukaemia. And, the thing that got me most passionate about things like communication in medicine was the fact that the doctors in the hospital where my brother was being cared for, lied to me repeatedly about what was wrong with him because they didn’t want to upset me. And it just set me on my career with this passion for honesty, communication, patient centeredness, and so on. It’s complicated but I think those are probably the two drivers behind my career. Perhaps I’m over-analyzing my past, but it feels that those were the two critical events that put me on the path that I’m on now.
“And many of us, most of us, end up in parts of the profession that are packed with uncertainty; mental health issues, general practice, journalism, paediatrics, psychiatry and so on. And I just wonder if sometimes we select exactly the wrong people.”
DMacA: One of the criticisms of medicine is that in the past it was a bit of a closed shop for the children of doctors. What’s your view?
DH: I find this whole topic absolutely fascinating because the simple fact is that nowadays I would have never got anywhere near medical school with my A-levels. I’ve got a granddaughter who’s starting her GCSEs. She wants to be a doctor. Gosh, if I was as clever as she is, I’d be in another world altogether. But I know an awful lot of very high achieving, high profile doctors, who would be quite embarrassed if I told you their A-level results. My best subjects at school were very definitely the arts, but I wanted to be a doctor. That meant I had to focus on in physics, chemistry, biology which, to be honest, I wasn’t terribly good at. But it’s also fascinated me that physics, chemistry, biology, maths, the main subjects that most medics do, are packed with certainty. They have correct answers, even when the science is still asking questions. And many of us, most of us, end up in parts of the profession that are packed with uncertainty; mental health issues, general practice, journalism, paediatrics, psychiatry and so on. And I just wonder if sometimes we select exactly the wrong people. But you’re absolutely right about diversity and inclusion, and that would have taken me out of it right away and probably quite rightly.
DMacA: Lets move on a little to medical school at Birmingham, your training in general practice, and then to practice in Cambridgeshire. Tell us about that progression.
DH: At medical school, I really struggled through the pre-clinical years. It was probably because of my rotten science A-levels but then, when it became clinical, it became much more straightforward for me. When I looked at some of the behaviours of some of my consultants and, remember I went to medical school 1967 to 72, the past is a different country, they do things differently there, but some of the behaviours that I witnessed of some of the senior doctors just so appalled me that it drove this passion for communication. I went through vocational training in Birmingham. It wasn’t mandatory at that stage, but I felt it was really important. I didn’t feel equipped coming out of medical school, even though many people in my year went straight into partnerships from house jobs. And then I worked as a general practitioner in rural Cambridgeshire for 36 years. What was it that John Lennon said- that life is what happens when you’re busy making other plans? I would never have predicted the way my career has gone, but that’s what makes it fun.
“He might have been right scientifically but you don’t treat people as objects to experiment on, and I felt that was what he was doing.”
DMacA: You’ve talked about your passion for communication, when did that all start?
DH: As I say, it started when seeing some fairly dreadful role modelling at university. And I remember one of my consultants had this passion for celiac disease, which in those days could only be diagnosed with a jejunal biopsy. There was none of the current testing. So, he did a jejunal biopsy on any female patient that he saw with a haemoglobin less than 12, with no explanation of the necessity. It was his research interest. And it really struck me that there’s something very un-patient focused here. He might have been right scientifically but you don’t treat people as objects to experiment on, and I felt that was what he was doing. One of my first articles was actually a spoof article about a research doctor who was behaving in that sort of way, and I tried to tackle it in a humorous way, and that’s when Michael O’Donnell snapped me up for World Medicine.
DMacA: So it was this passion, I guess, that brought you into politics, or medical politics in the broader sense. When did this evolution happen?
DH: Again, none of this is planned. I’m very aware that my career makes complete sense retrospectively, but not prospectively. None of it was planned. I became an RCGP examiner fairly early in my career. I’d got distinction in the MRCGP, which put me on the shortlist to be invited to be an examiner. I learned so much from being an examiner. It was just so useful for the rest of my career. But one of the key things I learned was the importance of mixing with enthusiasts. There’s a tremendous tendency in medicine, very understandably, to moan, to have the negativity of the job forced on you. And we all feel that at times. But working with this panel of examiners, people who were depressingly excellent in so many ways, was just inspirational and fun, and realising the importance of working with people who made you laugh. And I’m still friends with some of them, including Peter Tate, who was the guru of consultation, who lives up the road from me. We meet that once a month. These things really matter. These human things really matter.
DMacA: Through this evolution, you took on leadership roles in many medical organisations (BMA, RCGP, NICE etc). Tell us about that experience and what you learned from leading all these different organizations.
DH: When I was first elected to the Council of the Royal College of General Practitioners, and I think that probably happened because of name recognition because by then I’d been writing a weekly column in one of the medical newspapers- I wrote a weekly column for “GP” for six years and I wrote a monthly column for “The Practitioner” for 26 years- so people knew my name and they probably knew what I stood for, which is how I could get elected. And I remember when I was first on the council looking at the then Chair of Council, probably Denis Pereira Gray, and thinking, wild horses would not drag me into that role, it looked so intimidating. A few years later someone suggested I stand for election, and I did a thing that I’ve always thought- imagine myself on my deathbed, imagine myself dying, hopefully at the age of 99, and looking back saying- would I have wished that I had tried? If you try and you don’t succeed, so what? The saddest words in the English language are ‘if only’. And I stood for election, and to my surprise, got elected. And then it sort of spirals. The world of medical leadership is quite small, and when you start doing stuff, if you show any talent, people invite you to do other things. As I say, almost nothing along that route was predictable.
“To do everything was impossible so, stop beating yourself up if you can’t do it. And the other thing that struck me subsequently is that now I can’t actually remember what that particular crisis was that was keeping me awake.”
DMacA: During that long career in high office, you must have come across some pretty difficult tasks and some controversies. What are the ones that stand out for you?
DH: A lot is difficult. I remember at one stage when I was chairman of the Royal College of GP’s going through several sleepless nights because the job seemed so difficult. And then I had two really quite profound learning experiences. One is that I realized it actually was impossible. To do everything was impossible so, stop beating yourself up if you can’t do it. And the other thing that struck me subsequently is that now I can’t actually remember what that particular crisis was that was keeping me awake. These things shall pass. Don’t sweat the small stuff. These are all terrible clichés, but it’s true. And the thing I learned more than anything was what the skills of being a doctor gives you for these other worlds. We all know the mantra about the consultation, as David Pendleton discussed fairly recently, the idea of exploring ideas, concerns and expectations. I realized that was the way to approach the Secretary of State for Health when I met him- to explore his ideas, his concerns, his expectations. It put me in a position that I’m comfortable in being. And, it always used to make ministers slightly unnerved when I would say, “How can I help you?” Because, it wasn’t what were they expecting. If you’ve got any skill at this, you can then turn the debate round. As every GP knows, you can turn around the consultation- there is a giveaway in calling it a consultation- in the way that you want.
You asked me about the things that were the most difficult. None of it was difficult compared to medicine. I remember a particular two-day spell. I was still a practicing GP at the time. On the Monday I got a blood test result back on a close friend of mine showing that he had a pretty aggressive leukaemia and I went around to his house, sat in his kitchen, talked to him and his wife about the outcome. The next day I had a meeting with Tony Blair (Prime Minister at the time) about something. Which was the hardest of those? It was a no-brainer. Medicine really keeps you grounded. It doesn’t mean that the politics isn’t important, of course it is. But from a human difficulty perspective, it’s medicine that is a challenging and fascinating.
DMacA: The BMA and the College were, I guess, essentially political roles. But then you became Chair of the National Institute for Health and Care Excellence (NICE) and moved into the effectiveness component. Those were tricky decisions you had to make.
DH: When it was suggested that I might put my name forward to chair NICE I think my jaw hit the floor and I was silent for quite a long time because my predecessor, Sir Michael Rawlins, was an academic clinical pharmacologist with a brain the size of a planet. I couldn’t have been more different. But I applied my deathbed test- would I have regretted not trying? The more I looked at what NICE was doing, the more I realized that it was fantastically valuable. It used evidence in all the right ways but it was also problematic when it started applying single condition guidelines to people with multimorbidity and at my interview I talked more about multimorbidity than almost anything else- about the need to ensure the delivery of health care is genuinely patient centred, not disease centred. These two things sometimes contrast with each other. So, there were lots of difficult and challenging issues. I could understand, of course, how if one of my family was seriously ill and there was an incredibly expensive drug that could treat them, I would want that drug to be provided for them. Of course I would. But that’s not the question. The question is more objective, whether I would want that to be provided for my next door neighbour, or for the homeless guy down the street, or whoever. It’s how we cope with these things as a society? How do we ensure the most equitable distribution of resource for society? And so I felt the use of evidence, and involving patients in absolutely everything that we did, was really critical to these really difficult decisions. And then, because that’s what we were doing, I felt reasonably comfortable with the difficult decisions because they were made with all the right motivations. I have a concern in retrospect and it’s not the fault of NICE. NICE was asked very good questions- if the price of expensive drug is justified compared to this other expensive drug? But there’s another question which is, where should we put the money in health care anyway? And, there is a complete imbalance. The reason that primary care has been so neglected over the years, despite the fact that every Secretary of State over my entire professional lifetime has talked about a primary care led NHS and has failed to deliver. The nonsense they talk, and fail to deliver. The number of specialties and specialists goes up and up and up. The number of primary care docs goes down and yet the mantra and the evidence is all in the different direction. And I that’s the thing that I felt really passionate about over my career.
“We’ve got expanding demand. We’ve definitely got finite resources. We’ve got uncertain clarity about what we’re trying to achieve. Is it any wonder we’re in a mess?”
DMacA: That brings us very nicely into discussing your latest book, “Side Effects. How healthcare lost its way- and how we fix it”
DH: Being with NICE really made me focus on this whole question of what are we trying to do? And it struck me that I can’t find an answer to the question- what is the NHS for- that isn’t a load of platitudes. If we’re not absolutely sure what it is we’re trying to achieve, and if we’ve got the boundaries constantly changing and evolving, frequently driven by the pharmaceutical industry who discover therapies in search of a problem to treat rather than the other way around, and if expectations change all the time. I’m not criticizing this, I’m just saying that expectations, around mental health for instance, the expectations of who can help, change all the time. We’ve got expanding demand. We’ve definitely got finite resources. We’ve got uncertain clarity about what we’re trying to achieve. Is it any wonder we’re in a mess? And I really just wanted to try and stimulate some discussion around what we are trying to do, where the boundaries are, and where should the prioritization be? It’s really encouraging to hear Wes Streeting, the Secretary of State in the UK, talking about focusing on primary care and prevention and the tech potential. But I have heard this repeatedly for as long as I can remember. So the proof will be in the delivery.
DMacA: There is a line in the book that asks, do we know what the end game is? What do you think the end game is?
DH: I’m really not sure. If we think that the evolution of medicine is going to result in all of us living to the age of 125, perfectly healthy and happy and then suddenly dropping dead, that ain’t going to happen. I personally am the most wonderful example of the problems facing health care. My dad died when I was 14 and he died because he was overweight, was a smoker, had high blood pressure and he had the pressure of being a GP and so on. God bless the NHS as it’s given me all the treatments that are needed to make sure I didn’t die. Dad was 15 years younger than I am now when he died. In the 15 years since I passed the age at which my father died, I’ve had the opportunity to have tonsil cancer needing radiotherapy and chemotherapy and gastrostomy and all the rest, I’ve had treatment for atrial fibrillation, I’ve had a hip replacement. The wonderful success of the treatments, the preventative treatments that I’ve had, have caused an absolute escalation in activity for the health service. So, don’t kid ourselves that there’s some simple solution that, if you put it all in prevention, the problem goes away. The problem just becomes different. And so, I don’t have an answer. And, indeed, I don’t think I should have an answer but I am passionate about citizens assemblies, for instance, to begin looking at these issues, the question of what are we trying to achieve, what is the end game, where are the boundaries, when do we say no? And I think there do have to be boundaries otherwise the problems that we’ve got, and this isn’t just a UK problem this is a global problem and if you look at primary care, health care everywhere in the world they’re facing exactly these same problems. And no one seems to be facing up to up to the issues. So I’ve been thrilled at the response to my book, which seems to be summed up as- David is asking all the right questions. It’d be quite nice now if someone could help us with the answers.
DMacA: You are still searching for those answers, because you’re involved in many organizations at the moment. Is there any particular one that stands out for you?
DH: I’ve mentioned that I had cancer six years ago. That taught me that, even after 36 years as a GP, 50 years as a doctor, I knew nothing about what it was like to go through cancer. I became chair of an organization called Young Lives Versus Cancer that used to be known as CLIC Sargent Cancer Care for Children, which does wonderful work for people up to the age of 25 who go through cancer. It was a bad enough experience for me. Imagine if it was your child or your grandchild. It’s just horrific. The supporting work that we can do there is really important and I’ve enjoyed doing that. I’m involved with a small medtech company that’s trying to look at some of the digital solutions. I’m just standing down as Professor of General Practice from the University of Nicosia in Cyprus, which has been a fascinating link for the last couple of decades. So, life is interesting.
DMacA: It’s been fascinating going through the evolution of your career from, dare I say, a quiet subdued revolutionary at the beginning to perhaps not quite the full establishment figure, but you were awarded the CBE and a Knighthood. That must have been very rewarding in itself.
DH: It is. I can’t deny it. It’s lovely to be acknowledged in that way. I look at many others and think, why me and not them? I’m thrilled for me and I’m thrilled for, as everyone always says, the teams I’ve worked with, but there are so many great people, wonderful people, who’ve worked in medicine who deserve recognition. And, gosh, the NHS. I don’t know about healthcare systems around the world, but the NHS is very poor at saying thank you. So, it’s just lovely to have an offer of thanks or recognition.
DMacA: …and can I say thank you for sharing so much of your life and your career and for being such an inspiration. Sir David Haslam, thank you very much indeed.
