Foreword

Under the Skin: A Dermatologist’s Fight to Save the NHS

Foreword by Dr Julia Schofield and Professor Andrew Finlay

This is an outstanding reflection on prevailing attitudes and
possible solutions to the systemic failures of the NHS.
It is also a great read, engaging, fast-paced and based around
multiple short true-life stories. It is difficult to put down as Alex
Anstey takes the reader at breakneck speed with him across his
forty-year career, jumping from the present to the past to show
how his work built on his previous experience. Anstey skilfully
interweaves his own biography with fascinating historical
insights and profiles of influential medical thinkers, explaining
how these fused in his later career to inform and inspire his
attempts to reshape one corner of the NHS. And he does not
flinch from describing some of the emotional difficulties that he
encountered and overcame, bringing the book further to life.

Anstey is a succinct, clear and engaging writer, having spent
years as a leading academic editor honing his skills.
Anstey’s range of expertise and most importantly the novel
thinking that he applied to his clinical work, teaching, research,
administration and editorship is brilliantly explained in a way
accessible to all. The reader is left somewhat exhausted by the
sheer breadth of his achievements, but in great admiration of
him and inspired to think more imaginatively about their own
career and lives.

Anstey combines humanity and insight with a drive to understand,
to pass on knowledge and to improve the patient’s lot. He
explains how the doctor establishing a closer relationship with a
patient by itself helps that patient.

Research

Most clinical academics admit that they are unable to achieve at
the highest level in all four of their key responsibilities, as clinician,
teacher, researcher, and administrator, and tend to focus on
one or two aspects, with perfunctory activity in the others. But
not so with Anstey, who demonstrates a Renaissance Man attitude
to his work and life, excelling across the board. We learn how
Anstey recognised the importance of being involved in research
at the very start of his career, and how he succeeded despite working
in a department that did not support him. His early interests
in two patients who developed severe drug reactions led him to
publicise information about a test to identify those at risk and to
lead international guidance over the use of that drug. This practical
outcome, benefitting patients worldwide, was an excellent
example of translational research, developing laboratory findings
to enhance clinical practice. Later Anstey showed how focusing
on a particular type of disease (e.g. skin conditions caused by or
made worse by sunlight) can lead to further translational benefit,
both for rare and common conditions.

Clinicians every week see a vast range of presentations of
disease, but it takes an inquiring and prepared mind to recognise
the really novel and potentially game changing cases. Meeting
a profoundly affected child whose life was being ruined by his
light-induced condition led to Anstey describing for the first
time a previously ignored condition, and being able to help those
affected. By mentoring and supervising younger clinical researchers
in the same areas of light-induced skin disease, Anstey was
able to influence another generation of doctors in developing
research skills as well as contributing to the scientific literature.
Anstey describes the difficulties in gaining funding for
clinical research, and the imaginative ways that he has used to
overcome these.

Integral to carrying out successful research is the ability
to communicate the results, in other words to publish articles
and publicise the work to researchers and clinicians. Anstey
had become a clear and skilled writer before being appointed
as editor of the British Journal of Dermatology, but his writing
skills were clearly developed to a very high standard in his years
as editor. The reader of this book benefits in every paragraph
from Anstey’s clarity, lack of verbosity and ability to hold the
reader’s interest. As editor Anstey transformed the BJD, creating
a huge international editorial team that has resulted in the
BJD enhancing its prestige and value. Anstey was a transformational
editor, arguably the best BJD editor ever, though on this
achievement at least he is remarkably modest.

NHS service change

Perhaps the most astonishing achievement related by Anstey is
the dramatic increase in efficiency that he brought to his NHS
clinical service, with no extra funding. His book describes the
importance of putting patients at the centre of care and harnessing
the knowledge and skills of all those involved in providing
the service in order to make things work best for the patient.

His team approach is not just about including all those
involved in providing the specialist service but demonstrates
the powerful impact of breaking down the unhelpful barrier
that exists between generalists (primary care clinicians) and
specialists. Underpinned by the importance of recognising
mutual respect for each other’s skills, his creation of a cooperative
integrated approach to skin disease management across
primary and secondary care is now being used as an exemplar
model across the NHS in England and Wales. The development
of his specialist-led ‘advice and guidance’ model enables
patients to receive high quality care from the appropriate health
care worker at the right time. This story is too dramatic to
ignore, and lessons must be learnt from Anstey’s experience
to inspire others to generate change and make a difference
for myriads of other patients. Indeed, other centres who have
independently developed a similar approach in response to the
COVID-19 pandemic are reporting a similarly positive impact
on waiting times.

It is all too easy for clinicians to accept long-held patterns of
providing unsatisfactory models of clinical care, especially if for
some there may be unacknowledged benefit in maintaining the
status quo. Anstey’s description of his ability to give as much
importance to the non-medical members of his local team as
to the great names in healthcare gives a very powerful message
to the reader. He describes very clearly the benefit to patients
of clinicians getting involved in service design and developing
pragmatic local solutions for local problems. His description of
all of these interactions, and the not entirely supportive reactions
of other colleagues, provides a fascinating insight into the
joys and hazards of provoking change.

Teaching

As Anstey reminds us, it was Hippocrates who emphasised the responsibility that doctors have to teach others. And as with other aspects of his career, Anstey has never done things by halves. Enjoying teaching, he ensured that he became properly educated himself in teaching techniques, but then went on to take advantage of and further develop a range of new approaches to educating health professionals. He contributed to the transformation of dermatology nursing education in the UK by organising a national teaching/training programme. He set up a training course in photodermatology that complemented (and possibly overshadowed) an established national course. This was made more accessible by using novel distance learning techniques that involved his team creating a sound studio on a shoestring.

He created imaginative links with other disciplines. We learn how Anstey, by thinking and acting laterally, brought together seemingly totally disparate disciplines of mathematical modelling, and dermatology to create much greater efficiency in clinic organisation, as well as enhancing the education and career prospects of mathematics students.

He played a leading role in the organisation and delivery of medical student teaching in his university and contributed to the training of many junior skin specialists. His successful and well related attempts to inspire some students by taking them to visit the homes of Jenner and Osler illustrate his imaginative approach to his educational responsibilities. Another example of “that’s an excellent idea, why didn’t I think of that?”.

Conclusion

This is a once in a generation blending of biography, history, personal experiences and suggestions for change: it may inspire similar efforts from others but they are fated to be viewed as derivatives. It follows in the historical tradition of Mikhail Bulgakov’s “A country doctor’s notebook”, Clement Gunn’s “Leaves from the life of a country doctor” and Mirna Situm’s “Oranges and dead flesh” in successfully letting the reader experience the realities of medical practice “at the coal-face”, but offers much more besides. This book is strongly recommended to every medical student and junior doctor, but it is fascinating to anyone with a passing interest in the realities of clinical medicine and how the NHS might be improved. I wish that I had been able to read this book when I was a medical student or as a junior doctor. It would have been a great inspiration.

This is a unique account of how the career of dermatology can be endlessly interesting and satisfying. It should be required reading for all dermatology trainees and a great read for all medical students or junior doctors, or any doctor looking for inspiration. This book will contribute to influencing a generation of future dermatologists and make the competition to get into the specialty even fiercer.

• Dr Julia Schofield and Professor Andrew Finlay

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