From the highlands of Scotland to the Welsh Valleys…bringing the core values of family medicine to the world.
Professor Graham Watt was the Norie Miller Professor of General Practice in Glasgow University from 1994-2016 and Head of the Department/Section of General Practice from 1994-2009. He is Emeritus Professor and Honorary Senior Research Fellow at Glasgow University
After graduating from the University of Aberdeen in 1976, he trained in epidemiology and general practice, and worked with Dr Julian Tudor Hart at Glyncorrwg in South Wales.He completed vocational training at Townhead Health Centre in Glasgow and in the following decade, he established the Glasgow WHO MONICA Project Centre, then worked in the Scottish Chief Scientist Office and as a senior lecturer in public health at Glasgow University.
His research interest in health and disease in families began at Glyncorrwg and continued with the Ladywell Blood Pressure Study in Edinburgh and the MIDSPAN Family Study in the west of Scotland. He coordinated and led the Deep End Project from 2009-2016, based on the 100 most deprived general practice populations in Scotland, and remains closely involved.
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“As Tennyson said, “I am part of all that I have met” and a lot of it is in this book.” GW
Today, we’re in Glasgow and I’m talking to Graham Watt. You’ve done lots of very interesting things in your academic career, but let’s bring you back to the very beginning, what got you interested in medicine?
Graham Watt: I’m not sure how well thought out it was. I had a broad idea that it was to do with people, and that was the direction I wanted to go. It was also a very respectable thing to do. There weren’t medics in my family, apart from an uncle who died in the war. While I wouldn’t say that I stumbled into medicine, I didn’t go into it with a very clear set of ideas.
I did go on quite a long and convoluted journey to get from there to where I ended up. I was always aware of an instinct or a plan guiding my decisions although it was only when I retired that I started to work out what the plan was.
And I’m not sure that the path that I followed is one can you can follow now because things are much tighter in terms of the options, but I had an instinctive interest in generalism and also, I think, in inclusion and fairness and the idea that medicine included everybody. The key to that was epidemiology, because that involves the denominator of everyone and the challenge was to get everybody into the numerator or, at least, to know who was missing.
A group of us in the British Medical Student Association, many of whom became professors, wrote a letter to the Lancet asking – how do you train in clinical epidemiology when epidemiology belongs to public health medicine which, as an article of faith in those days, prevented you from seeing patients.
As a student, I found reading the Julian Tudor Hart stuff in the Lancet and BMJ just exhilarating. It was iconoclastic. It didn’t take any prisoners. It was very lucid writing and intoxicating stuff to read if you were instinctively against the establishment. And medical schools were certainly establishment organizations in those days. And Julian was also, with what he called anticipatory care, pioneering population medicine. It was what he would call shoe leather epidemiology, as opposed to desk based epidemiology. I was a medical student on GP attachment down there (in Glyncorrwg), the first Scot to go there and, gosh, that was a life changing two weeks.
Julian Tudor Hart, Mary Hart and Graham Watt lunching al fresco at Glyncorrwg
Life was lived large in the Hart household, a complete mixture of life and work because there were two of them, not just Julian, but also Mary Hart, who had worked with him at the MRC Epidemiology Unit. He couldn’t have done what he did without her. She was his anchor and research manager and the chair of the board of the local school So, they were thoroughly into the local community. When I left Glyncorrwg, I was determined that whatever I did in medicine, I was going back there. It was just a very rich experience which energized me for the next 40 years, and still does. I’ve got pictures of the visitors’ book from Glyncorrwg. It comes to about 30 pages. There must be about 700 or 800 people who visited and it’s a list of the movers and shakers on the radical side of medicine.
DMacA: You’ve gone as a medical student to Glyncorrwg and then you did various jobs. Aberdeen University is in the far north but then you went further and did a hospital job in Shetland.
GW: Well, I’d been on holiday there and I knew I wasn’t going to do surgery ever again, so I wanted to do it in an interesting place. Being a houseman in the Gilbert Bain Hospital in Lerwick I worked with an Egyptian SHO who, when applying for the job, had thought Shetland was in the Thames Estuary, and Ronnie Cumming, the surgeon, who was the last of a breed, who could do absolutely everything. When he retired it took three people to replace him.
I had a huge escape, after getting the MRCP, when I applied for a medical registrar job at the Royal Infirmary of Edinburgh. Thank goodness I didn’t get that. That would have set me on a completely different path. I went into health care for the elderly at Nottingham, attracted by Tom Arie, a charismatic professor. He wrote things like, ‘the House of Lords was an ideal care home for the elderly, because it gave them a sense of purpose and warmth and food and a stipend. It was just a pity that most elderly people couldn’t enjoy that’. I went from there to the Glyncorrwg job as a MRC Research Registrar for two years, following people like John Robson and Andy Haines, who’d been there before me.
“The reunion of alumni of the unofficial ‘University of Glyncorrwg’. There are about 20 of us who have worked at Glyncorrwg as trainees or researchers. We talk about the unofficial ‘University of Glyncorrwg’, with a one man Faculty of Julian.”
We didn’t tell him we were arranging a reunion but, one Friday night, while sitting in the ‘Queen’s’, which was a converted small hotel that they made their family home, someone would arrive out of nowhere, unexplained. And Julian thought, this is wonderful. And then ten minutes later, somebody else would appear out of nowhere. And it was only when the third or fourth person arrived, that he realised what was happening and that this wasn’t just a series of coincidences. There were many of us – John Frey, who went to Chapel Hill and then Madison, Wisconsin was another. We were all fired by this experience. As a student and as a visitor to the practice, and being able to sit in on his surgeries, you saw him being a family doctor which was inspiring. He was didactic to begin with because he was trying to do things quickly. But he evolved into “co-production”, his own words, “moving from initially face to face to gradually side by side”.
DMacA: You’ve recorded a fabulous interview where you discuss Julian in great detail and we’ll put a link to this interview, but what I’m really interested in is the influence that Julian had on you and your career.
GW: When I became the Norie Miller Professor of General Practice at the University of Glasgow, I wouldn’t say it was missionary work, but I was advocating, using his example, for looking after a whole population, using your denominator to measure what you hadn’t done and then filling the gaps. On reflection, the world then wasn’t ready for that. It was about 15 years later that Julian became much more acceptable as a flag bearer.
Julian Tudor Hart, the only GP to have received an Honorary Degree from the University of Glasgow, in 1998, with Graham Watt and future Professors Jill Morrison, Phil Cotton, Kate O’Donnell and Lisa Schwartz.
DMacA: After you’ve done these jobs, and been to Glyncorrwg, you then took a job in epidemiology and you were very involved in the MONICA project.
GW: I came to Glasgow University and the MONICA project which was a big study registering coronary heart attacks under 65, fatal and non-fatal, to look at trends. Were the trends in coronary heart disease due to changes in incidence, was the disease becoming more common or disappearing, or was it due to changes in case fatality, better treatment or less severity? And that needed forty countries and different settings around the world to record coronary events. I was working with Hugh Tunstall-Pedoe in Dundee, and there was another centre in Edinburgh which never got off the ground. The good thing, from my point of view was that, while it was a full time job, I could do it in half the time so I could do other things. And one of the other things was the Ladywell Family Blood Pressure Study. I found myself doing community paediatrics at Ladywell Medical Centre in Edinburgh, which had taken part in the MRC, Mild Hypertension Trial. I knew Bill Miall who led that trial so I asked if I could get the initial screening cards, matching the blue cards for men and pink cards for women by age and address to identify married couples who had both been screened. We didn’t need very much money from the Scottish Chief Scientist Office to measure blood pressures on their adolescent and young adult children, over a thousand of them. After selecting young people on the basis of their parental blood pressures taken at Ladywell for the MRC Trial, we did a whole series of studies with the MRC Blood Pressure Unit in Glasgow, who had never previously been exposed to that kind of opportunity.
And then I moved on. I was never formally trained in epidemiology and, apart from shoe leather epidemiology in Glyncorrwg and the big data collection exercise at MONICA, I didn’t have any sort of training and I always felt slightly deficient in that respect. I’ve always been dependent on statisticians as a result for the number crunching. One of my skills has been to maintain productive relationships with a whole variety of statisticians, which is sometimes a bit of a challenge.
By that time I’d got married, my wife is a lecturer at the Glasgow School of Art, we were starting a family, so I had to start thinking about how I was going to earn a salary. I completed GP training at the Townhead Health Centre, underneath Glasgow Royal Infirmary. I had the option of going into practice, but felt it would be too confining and went, rather reluctantly, into community medicine training. Fortunately, I was headhunted, to become the professional secretary of the Health Services Research Committee at the Chief Scientist Office in Edinburgh, which was a great two years in government as a civil servant – signing the Official Secrets Act and all of that. Being at the centre of Health Services Research in Scotland was great in terms of contacts, information, and also the business of getting grants. Later on I became quite efficient at getting grants. But working as a civil servant was only ever going to be a temporary thing. Then I jumped into public health academia in Glasgow. I n retrospect I did a series of jobs for which I had no training at all, including environmental medicine studies of lead in water, chromium contamination of land, and air pollution, with the MidSpan studies on the on the side. I thought I’d burnt my books in terms of academic general practice because I had giving up clinical work to go into academic public medicine. And then the vacant Chair in Glasgow came up.
Woodside Health Centre in 1994
I wasn’t thinking of applying and then John Howie, Professor of General Practice at Edinburgh University, who was on the search committee, bless him, knew I’d been at Glyncorrwg and that I would have something to offer. I didn’t need a second invitation, I just went for it. And, in retrospect, I wasn’t a typical professor of general practice. The first wave of professors were plucked from practice and they were an amazing group of people. They wouldn’t pass muster in terms of what universities expect of academics these days which is both a positive and a negative. But the irony is, and I used to enjoy irritating colleagues in public health by pointing out that if you’ve got public health in your job title, you probably didn’t have any contact with the public, whereas if you did have contact with the public, the last thing you think about is public health. Often people talk about the marriage of general practice and public health as if they were one and the same. But actually in terms of a marriage, they haven’t really done very much dating and don’t necessarily understand each other very well. For me the most interesting aspects of public health could be addressed via academic general practice.
DMacA: In fact, Graham, you brought that marriage together with your experience in public health, general practice, your experience in Glyncorrwg and your epidemiology, and that all came to fruition in the Deep End.
GW: It did. But I think that the other advantage I had as a new professor was that I was fairly senior in a small department. That allowed me to do it in the way that I wanted, and I had some very good younger colleagues. In the 15 years that I was head of department, of the people who were there, 23 became professors so, there must have been something. It was a good place to work and I feel quite proud of that.
In 2007 RCGP Scotland and the Scottish Government wanted to match a UK RCGP report on what GPs could do to address health inequalities. So they asked Public Health in Glasgow to set up a meeting. We had a very conventional conference with various speakers. Iona Heath was there, and GP’s were in the back row and not contributing. Two weeks later, that meeting might as well not have taken place. It was a false start. Two years later we had the opportunity to do it in our own way. We had identified the 100 most deprived Scottish general practices on paper and had the opportunity to invite them to a conference. It took a lot of effort to get two thirds of them to come. We had locum funding to get them out of practice for the day, funding which originally came from RCGP Scotland, and then, remarkably, the government matched it.
We made three decisions. One was that we wouldn’t produce a report on health inequalities because there were already far too many of them. We wouldn’t give GP’s a toolkit because that was patronizing. And we would listen to what they had to say. We didn’t invite anybody else who could be a lightning conductor for whining or negativity. That was an unnecessary precaution because there was an immediate buzz in the room. It was the first time they had been convened or consulted, and we never really looked back.
The Deep End projects are oases of positivity and energy and passion about the future of general practice in particular types of areas. It is quite against the current tide of doom and gloom. And, indeed, there’s plenty to be gloomy about in terms of general practice and the pressures that it’s under. There are 20 projects worldwide now and there’s something generic about each of them. I see it as a resistance movement of like-minded colleagues committed to the future, determined to influence the future, and riding out bad times.
The Deep End Movement has expanded from the start of the Scottish Deep End Project in 2009 to 20 projects in 9 countries on 4 continents by 2024
The leaders of 12 Deep End Projects at the Deep End Conference in Glasgow, April 2024
Graham with Tim Senior, profiled on MedicsVoices, in August 2024.
DMacA: When I listen to you talk about the Deep End as a resistance movement, and the redistribution of resources, there are echoes of Julian Tudor Hart from the very beginning of your career.
GW: There’s a very explicit link. There’s a lot of Julian in the early Deep End literature. He was very keen about it and gave us some great quotes to use because, by his own admission, he didn’t have a big local impact in terms of influencing general practice in Wales. There is a Welsh Deep End project now but it took ten years for it to happen. I think it was a ‘prophet in your own land’ type of thing. And his example was also, I think, very threatening to local GP’s because he put so much energy into it and not everyone was up for that kind of input. I think that the strength of the Deep End movement is that it connects people who would otherwise be isolated. And that is empowering- being part of something bigger than yourself that’s moving in the direction that you want to go in. Colleagues said that yesterday at the steering group of the Scottish Project.
“Sharing a platform with Noam Chomsky from MIT and Rita Giacaman from Birzeit University (BZU), following publication in 2009 of the Lancet Series on Health in the Occupied Palestinian Territory. I was a co-author, based on longstanding links with BZU, and chaired the Steering Group of the Lancet Palestinian Health Alliance (LPHA) for 12 years.”
A photograph, taken by Professor John Yudkin from UCL after a LPHA conference in Cairo
Daniel Pink, the American writer, said there are three sources of professional satisfaction: autonomy; having some control over your what you do; mastery, being good at what you do and being valued for that and purpose, in the sense of moving towards some longer term aim in the company of others. The combination is an antidote to burnout in deprived areas.
The Deep End messages are very simple. I think of it as three building programs, based not on bricks and mortar, but relationships. One is building strong patient narratives based on their experience and wishes; Two is building strong local health systems around the hub of a general practice because it’s got the contact, coverage and continuity that few public services have. And the third thing is building a network of such systems.
People have an idea about the challenge of building long term relationships with patients, but building relationships with colleagues and with other practices is a similar kind of challenge. And you wouldn’t presume to do it fast. One of the challenges in the Deep End is that you’re trying to build all these relationships in parallel. Within the limits of energy and time that’s available to you, you can really only do it in series.
Something that I’ve learned is if you want to change things, it’s much easier if you don’t want credit for it. Allow other people to have credit because they must have ownership. And I think of Julian’s influence now is not as a sort of the figurehead or champion of change, but as the person who lit the fuse a long time ago and we are carrying it on now.
DMacA: We’ve talked about General Practice, we’ve talked about the Deep End and now going to talk about something much more serious…your interest in football!
GW: I’m Vice Chairman of the Scottish Professional Football League Trust, which is a charity which coordinates and supports the charitable wings of the 42 professional football clubs in Scotland (https://spfltrust.org.uk). It’s harnessing the social power of football because football clubs do generate passion – even when you leave an area, people quite often continue to support their local club because it’s a source of memory and history and locality. There’s a flagship study called FFIT – Football Fans In Training, which targets men and women with waistlines more than 38in and gives them a 12 week course on nutrition and exercise, done in a group at the football ground of their choice. Unusually for such an intervention, people lose weight and keep it off. And there’s nothing original about the intervention other than the fact that it takes place at a football club of their choice. What it’s doing is that it is harnessing the emotional energy that’s linked to football clubs in order to turbo charge a public health intervention. And there are other activities such as addressing mental health issues in young men. Festive Friends gives people with dementia and their carers a Christmas lunch at their football club. It’s like the Deep End in the sense that it’s a network. Your only authority at the centre comes from whether you are valued as a source of advice and support. That’s certainly true of the Deep End.
My great grandfather William Watt was born in a croft and became the editor of the Aberdeen Free Press. And his son, my grandfather, was a printer. Obsolete now. He was secretary of the school former pupils club and produced three magazines a year for 40 years creating a worldwide network for former pupils. On reflection, I’m doing the same sort of thing. I’ve got myself into a number of roles at the centre of collegiate networks.
There’s a great quote from Montaigne, the French philosopher. “I have gathered a posy of other men’s flowers, and nothing but the thread that binds them is mine own.” (Michel de Montaigne.) I like that analogy and also the Robert Louis Stevenson quote “It is a better thing to travel hopefully than to arrive, and the true success is to labour.” I like that one a lot and used to advise colleagues, that the labour part means doing your best work now, not leaving it for the future. And then another Robert Louis Stevenson quote about what really matters: “Don’t judge each day by the harvest you reap but by the seeds that you sow”.
DMacA: Graham. It’s wonderful to finish off with those quotes that reflect your philosophy. Thank you very much for sharing your life, your academic career, and your influences.
GW: It’s a bit like Desert Island Discs, isn’t it? Thank you very much for the opportunity.
“Days like this are heavenly. I’ve climbed 256 of Scotland’s 282 Munros (mountains over 3000 feet high) and have 26 still to do.”
Some interesting and important links:
Professor Graham Watt talking about Julian Tudor Hart, a lecture given to the Royal Institution of South Wales in March 2022
https://www.youtube.com/watch?v=fjpJc6brNSw
Inequalities in Health in Scotland – Searching for Inclusion. A lecture given by Professor Graham Watt to the Royal Philosophical Society of Glasgow, in October 2024
General practice and the epidemiology of health and disease in families. William Pickles Lecture 2004. https://bjgp.org/content/bjgp/54/509/939.full.pdf
Not only scientists, but also responsible citizens. Milroy Lecture, Royal College of Physicians of London, 1998. https://pdfs.semanticscholar.org/cf31/4e2bcc8f5ae295dbdbfa2ff55b311d85b466.pdf
There is a great deal of information about the Scottish Deep End Project, including links to 12 Deep End International Bulletins at www.gla.ac.uk/deepend.
