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, interweaving to show how his work built on his previous experience. Anstey skilfully mixes his career and personal biography with fascinating historical insights, the influences of influential medical thinkers and his many achievements and explains how these fused in his later career to inform and inspire his attempts to reshape one corner of the NHS. And the author does not flinch from describing some of the emotional difficulties that he encountered and overcame, bring the book further to life. Anstey explains how he became addicted to writing, and his years as a leading academic editor have clearly honed his skills in writing succinctly, clearly and interestingly.
Anstey’s range of expertise and most importantly novel thinking that he applied to his clinical work, teaching, research, administration, editorship is brilliantly explained in a way accessible to all. The writing is enlivened by many lovely touches and the impressive list of great pop concerts and opera events he attended. 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, insight, with a drive to understand, to pass on knowledge and insights 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 focussing down on a particular type of disease (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 of communication 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 international 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 co-operative 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 and 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, provide 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 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.
Julia Schofield, Consultant Dermatologist United Lincolnshire Hospitals NHS Trust, Associate Professor University of Hertfordshire, Joint Clinical Lead National Outpatient Transformation Programme (NOTP)
Julia grew up in Lincoln and trained in Medicine in Manchester. Like Professor Anstey she completed GP training in Salford and for a while worked in Primary Care and Dermatology before deciding to train as a Consultant Dermatologist. She completed Dermatology training in Hertfordshire and the Royal London Hospital and was appointed as a Consultant Dermatologist in Hertfordshire in 1995. In 2006 she set up a Masters programme in Clinical Dermatology at the University of Hertfordshire which is the only multi-professional educational programme in dermatology of it’s type. The programme has been pivotal in the training and development of extended role practitioners, particularly nurse surgeons. A second very successful Masters programme in Skin Lesion Management was established in 2020. In 2008 Julia moved her NHS work to Lincolnshire choosing to return to the town of her childhood to support her elderly parents.
Julia has been very much involved in service redesign since the early 2000’s when she was clinical lead for the NHS Modernisation Agency Action on Dermatology and Plastic Surgery programmes. She has worked closely with a broad range of stakeholders developing national guidance documents relating to service improvement in dermatology. More recently she has been seconded to NHSE&I as joint clinical lead for the National Outpatient Transformation programme where she was delighted to hear of Professor Anstey’s exciting successful new model of care in North Wales. She is a trustee of the Psoriasis Association UK and was awarded an MBE for services to Dermatology in 2012.
Andrew Finlay, Professor of Dermatology, School of Medicine, Cardiff University.
Andrew trained in Medicine at St Mary’s Hospital Medical School, long before it was swallowed up by Imperial College. He trained in general medicine around London before moving to Cardiff to take advantage of the excellent dermatology training there under Professor Ronnie Marks. He spent a year at Mount Sinai Hospital, Miami Beach, and moved to Glasgow for five years for his first post as consultant dermatologist. Moving back to Cardiff as Senior Lecturer, he was eventually appointed Professor of Dermatology after Ronnie retired. Andrew first met Alex Anstey when Alex also chose to come to Cardiff for training, and worked with Alex in South Wales over many years.
Andrew’s service innovations included creating in Glasgow one of the first integrated outpatient/inpatient dermatology care centres. Responding to the still absurdly little dermatology education required (or available) for general practice, he created the international distance learning Diploma in Practical Dermatology which over 4,000 GPs have successfully completed.
His main research interest has been in developing ways to understand and measure the impact that skin diseases have on people’s lives. Several of the quality-of-life measures that his team created are now used worldwide, most notably the DLQI which is embedded in national guidelines and registries in over 40 countries. His current research focus is on measuring the huge burden from the secondary impact of disease on patients’ partners and family members, using the Family Reported Outcome Measure (FROM-16). He was appointed CBE in 2010.
Alex Anstey 