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Critical thinking


Critical thinking

A shock diagnosis has not dimmed Professor David Taylor’s passion for healthcare improvement – or his curiosity. By Arthur Walsh

Last summer, University College London emeritus professor DavidTaylor published an NPA-backed report with LSE professor Panos Kanavos looking at the impact of funding cuts and runaway inflation on England’s community pharmacies and the potential threat to patients if the network is allowed to shrink much further. 

The report, one of many published over a lengthy career that has held a magnifying glass not only to pharmacy but also to the wider health service, brought together several of the themes that have loomed large in Taylor’s wide ranging career: the interaction between public health and economics, evolving technologies and service provision, and the question of whether policy decisions made in boardrooms help or hinder the patients on the receiving end.

While working on the report, Taylor noticed “some slight dyspepsia and burping”. He thought little of it initially, having lived in relatively good health for most of his 75 years, he tells P3pharmacy in September. “Little did I know that for older men, that’s a red warning sign that you might have gastric cancer.”

Now, having been diagnosed with cancers in both the stomach and colon, Taylor is living in the aftermath of a colectomy and total gastrectomy, in addition to receiving chemotherapy. Sounding surprisingly relaxed and philosophical, he says he’s “feeling okay”.

Post-surgery, his day-to-day quality of life is “much better than the textbooks say”, but his new reality has taken “weeks and months” to adjust to, and chemotherapy has been at times brutal. This adjustment was perhaps not helped by a regrettable lack of mental health support at the time of diagnosis, he says. “There’s a big gap between saying we’ve got patient-centred services and the reality I and others have experienced.”

Recurrence is common with gastric cancer. “The probability of it returning will be significantly greater than the probability of it being cured,” he says. “The ambition is to make 80, and I will feel very short-changed if I don’t.”

He’s in good company, he adds wryly. Aneurin Bevan, under whose ministry the National Health Service Act 1947 was passed, died of stomach cancer in 1960.

Born into pharmacy

Speaking to me from his north London home shortly before receiving a lifetime achievement garland in the Independent Pharmacy Awards, Taylor looks back on a career that has kept pace with a constantly evolving health sector, and considers where we might be headed in the years to come.

“I was born into pharmacy,” he laughs when I ask how he first took an interest in the sector. Both his parents trained in the profession, as did his wife Jean. He describes the loss of his father to lung cancer as a pivotal moment in his life that influenced his decision to study social sciences. 

“I became aware of the need for good sociology and good economics to go alongside good medicine,” he says. The intention was always to apply these research skills to healthcare, Taylor says. “I’ve always been interested in improving cancer outcomes – that means better medicines and better use of medicines. It also means understanding the way healthcare systems and professional bodies work and how they are funded.”

Roles in organisations like the Office of Health Economics and King’s Fund followed before Taylor joined UCL. He has also held numerous chairmanships and other positions in NHS trusts, health committees and related organisations.

A glance at the titles of the articles Taylor has authored and co-authored over the years suggest a wide breadth of interests, including pharmacy’s role in tobacco harm reduction, evolving health technology and UK prescribing trends. Is it fair to say that intellectual curiosity has been a key motivator in his career? “I think that’s true,” he agrees. “I suppose the truth is that I’ve never worked for anyone but me. What’s rewarding is finding out how things work, along of course with meeting interesting people and making friends. Also, translating that understanding into influencing improvements.”

One of these people has been Nicholas Wald, the epidemiologist known for his pioneering work on folic acid deficiency in pregnancy and smoking cessation. 

Has Taylor felt that topics that may seem disparate are in fact connected to one another? “I suppose the effect of losing my father was to make me no longer want to join any one group,” he says. “I’ve been on the margins of lots of things and tried to link them together. I think an awful lot of inefficiencies in society are because people shelter within one group in one boundary area, rather than being able to look across. That’s what I’ve tried to do, either consciously or unconsciously.”

The case for pharmacy

When making the case for itself, has community pharmacy made the best use of the available research on public health impacts? Taylor muses: “In a healthy society, if you’re arguing for something which is in the public interest and the groups you’re connected to contribute to that, then you’re on strong ground. If you’re arguing for the viewpoint of a group which is just saying more money for us, then I think you’re on very weak ground and it’s not something I wish to do.”

I press him: how has pharmacy fared on that measure? “I think a weakness of community pharmacy groups and bodies purporting to represent pharmacy has on occasions been that they’ve sounded like they’re just defending something sectional rather than looking to the future. When you look at the medical profession, the best of the BMA has been when it’s genuinely defending public interest, say on smoking cessation. I want to see pharmacy leading struggles for health improvement – and being defended and rewarded appropriately.”

Progress has arrived in the shape of a growing clinical role for pharmacists and the wider team. Recognition of this fact has come in the form of new national services and a commitment to review funding models – but there are still hills to climb, believes Taylor.

“You’re talking about a sector that derives its income from the supply of medicines,” he says. “There’s a huge task to be done in health promotion and disease prevention, but the skill of the group itself has not often been in psychological support and understanding the broader social determinants of disease.”

There is much potential in pharmacy’s nascent health improvement function, says Taylor, not only in prevention but also in case finding and onward referrals. But he warns that there is a job to be done in bringing along those who still want to focus on supply. “I think the message to pharmacies is that if you stick to supply alone then eventually automation will reduce the size of the sector and dehumanise it, and that potential clinical contribution will be lost.” 

Taylor is enthusiastic about the independent prescribing agenda championed by Keith Ridge during his tenure as chief pharmaceutical officer. However, he believes we could have got here a lot sooner.

The much-touted accessibility of pharmacy, which has been an important topic in the national conversation since Covid, would be at risk if we neglect the clinical role and “simply strip down to a lowest cost supply process,” he warns, although he stresses that the supply function must not be undermined. 

Both individual businesses and whole systems must be enabled to face change head on, he argues: “Success for any group lies in adapting to the changing environment. At one stage, one business model may be successful, but that inevitably changes.”

He would have preferred if pharmacy had seen the writing on the wall much earlier, arguing that while the thalidomide scandal led to sweeping changes in hospital pharmacy, it has taken decades for community pharmacists to move out of the dispensary.

Among others, he cites Welsh chief pharmacist Andrew Evans and Hemant Patel, formerly head of North East London LPC, as individuals who have laid the groundwork and “opened the way to political debate”.

How to influence

In his NHS roles, did Taylor encounter a prevailing view of pharmacy? “I think to many parts of the NHS, community pharmacy is invisible,” he says. “The danger is that, historically, many have dismissed it as simply high street shops.” But that’s not the whole story, because “there’s also support and awareness of the potential role in many circumstances”.

How should pharmacy influence these decisionmakers? “NHS policy, at the highest levels, is relatively secret. The first thing to remember is that the broad public debate really matters. Contributing effectively to what is said in the newspapers and on television matters,” he says, stressing the importance of promoting the community interest, not just the sector’s. “When you’ve got that overall vision, you’re in a better place to take things forward.” 

Taylor has witnessed a number of critical junctures in health policy, the first being the implementation of the Family Doctor Charter as his career began. Others have included the creation of primary care trusts in the 1990s and their abolition with Andrew Lansley’s reforms, which he describes as “tragically inept”, bemoaning successive shakeups that have “created whole bodies of people whose job it is to reorganise things rather than get on with them”. 

For many, the 2015 funding cuts in England – also under Keith Ridge – are the pivotal moment in the sector’s recent history, with the five-year contract that locked them in possibly coming in as a close second. While Taylor is strongly critical of the impact the cuts have had on the network, he believes it is more important to ask how we got there, and why pharmacies and the NHS “failed to resolve things in a constructive manner”.

While he and Kanavos found that funding levels were down by about a third in real terms compared to 2015, there have been some glimmers of hope, such as the anxiously awaited £645m investment. The coming general election offers a chance to articulate how a new contractual settlement could address the needs of primary care. All parties need to sit down and decide on a service the public wants and which is efficient, “not just in the short term expedient of saving cash, but in developing a healthy society in the long term,” Taylor says.

Those involved in the debate have not always been scrupulous about maintaining that ultimate focus on public health priorities, but Taylor is cautious about laying the blame on particular people in the pharmacy sector.

“It’s easy to blame leaders; sometimes groups get the leadership they deserve,” he says. The NHS is in a challenging period, and “what passes for leadership is often not very thoughtful or focused on the real understanding of welfare by politicians, health service managers or professional groups. They can all do better.” 

Dialogue will also be crucial in tackling supply chain issues, he adds: “There has been a disastrous division between people who think the pharmaceutical industry is doing a great job and those who see it as terrible and corrupt.

“For me the pharmaceutical industry is a research-based industry that has been one of humanity’s finer achievements, and we need a system that reflects that and understands the role of generics companies in providing low cost products in a safe, stable way, along with understanding the public desire for reasonable economy.

“We’ve got to do better in developing a fixed economy which has challenge within it but at the same time respect for each other.” 

What areas of science should pharmacy be looking at? “Medicines will change fundamentally as we understand genetics further,” Taylor says. “The next 50 years will see dramatic advances. I know from personal experience, some of the treatments we have for cancer are still pretty barbaric. We will get better, there will be more ways of influencing immune response, for example, understanding autoimmune disease, not just cancer and heart disease, in ways which will improve outcomes. That’s got to be central to pharmacy.”

Technological improvements around efficient dispensing and diagnostics will form another key pillar. And he argues that if pharmacy is to stay relevant for its service users, it has to understand psychology: “Understanding, for example, when people have the shock of a diagnosis, how to help them accommodate their disease, understanding the help people with chronic conditions need. “Being a force in society which makes sure we don’t just invest in things like highly complex surgery, but also support for individuals. Becoming a more educated, more multidisciplinary profession seems to me to be at the core of what needs to be achieved.”

Having that mental health awareness available on the high street could touch many lives, he suggests. “My daughter Annie, who I adopted many years ago, has learning difficulties. Understanding areas like this, mental health problems and how they relate to inequalities.”

But the primary focus must remain on medicines themselves. “As pharmaceuticals continue to advance, we will get progressively more effective and more benign treatments,” Taylor says. “If humanity is to survive, we will need that scientific and industrial development alongside the development of good universal healthcare.”

“We often think we live safely now and that the healthcare technologies we have are adequate. They’re not. There’s still so much avoidable suffering we could do better at reducing.”

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