From the Elizabethan to Carolean era
The death of Her Majesty Queen Elizabeth II and the accession of Charles III has thrown us into a mourning period for which, whilst the ceremonies have been rehearsed for years, has struck many of us by a degree of surprise emotion and reflection. There we were, watching our new Prime Minister, Liz Truss, being appointed and shaking the hand of our smiling monarch and 48 hours later we heard the news of the Queen’s demise.
All the newsletters and reflections I have read from college Presidents this week started with memories of when they personally met the Queen, or when their college had a visit from her. However, apart from ex-FPM President, Alan Boyd, meeting her for the 500th anniversary of RCP London, the FPM had little direct contact. Personally, I can only claim that I once nearly met her! She came to visit the hospital where I was working. I was in line with many others to shake her hand, but just as she arrived – my bleep went off and I had to run! However remote she may have been to us physically, most of us have felt an emotional connection and have felt deeply moved by the death of a women who set the most extraordinary example of national caring, with an extraordinary work ethic.
Achievements in health in the Elizabethan era
The changes in healthcare Queen Elizabeth II oversaw in her reign are worth reflecting on and impressive. I was born 4 months after she came to the throne and three years after the NHS was launched. A year later, my parents invited the neighbours to watch the coronation on a tiny television as we had mains electricity and most rural houses then had none and were still lit by gas. Health care was delivered predominantly by the GP and cottage hospitals – our local one still had an open fireplace in the operating theatre! My elder brother was disabled, being born with sagittal craniosynostosis, and was given a hydrocephalic shunt in one of the first NHS hospitals. Whilst he lived long enough to start school, the shunt eventually became infected and, as most bacteria were then resistant to the very limited number of antibiotics available, he died. Whilst it devasted our family, I had many friends whose siblings died, and this perhaps is the most marked difference we have seen in health care. The infant mortality rate in the United Kingdom was 31.7 deaths per 1000 births in 1950 and in 2020 was 4 per 1000 births (1). Average life expectancy has also climbed from 67.66y in 1950 to 81.15y in 2020 (2). Such statistics are a tribute to improved standards in public health, hygiene and living conditions, but also dramatically improved standards in the delivery of healthcare and technology. The Queen’s ongoing support for both medical standards and life science innovation is well-known.
In 1950 most families expected untreatable illness and premature death as inevitable, and patients absolutely trusted their doctors and were rarely engaged in influencing health care in any way. Public health was almost entirely devoted to infectious disease control and such issues as maintaining appropriate diets during post war times. Public education and attitudes and public health have changed out of all recognition. This is an enormous advantage when it comes to innovation, regulation and access to medicines and devices. Now, most aspects of pharmaceutical medicines development and deployment strategies involve input from the public, either as healthy individuals or patients.
The evolving role of the “Royal College”
Royal influence on the standards in medical practice was limited until the late 19th century. In England the Royal College of physicians was limited regionally to London. Surgeons simply had a society. Scotland had their own colleges and included surgeons. The first royal colleges, set up in the 16th century, were predominantly to protect medical professional status. The surgeons in England took almost 300 years to persuade the medical profession that their discipline, surgery seen then as trade, could be accepted and could receive the Royal Charter in 1800. There was recognition, however, of the need for standards and in 1858 the General Medical Council was formed under the UK Medical Act by Queen Victoria. In 1950 there were only seven medical colleges with Royal charters, the English and Scottish Colleges for physicians and surgeons and additionally, psychiatrists were given a Royal Charter under King George. It took more than 100 years from the GMC formation for most of our medical specialties to emerge and be recognised. In the Elizabethan era we have seen five Royal Colleges and 11 Faculties formed. Whilst protecting medical professional status is now less pronounced for colleges, it still remains a goal to communicate and defend the role of physicians for colleges, including for the Faculty of Pharmaceutical Medicine. However, the perceived need for physician exclusivity has declined and now all but four Royal Colleges and their Faculties admit non-physicians (FPM being one the four that does not).
Now, the royal colleges, as well as defending recognition of their specialities, the organisations are strongly aligned with the GMC, setting and governing standards for predominantly physicians and they have a much stronger role in vocalising public health need and offering strategies for resolution in their own specialties. The independence of the colleges means that essential support and, where needed, challenge to the government, DHSC, NHS and other bodies such as NICE and MHRA are constantly made. The colleges and faculties collaborate more across specialties and evolution of what is now the Academy of Medical Royal Colleges gives a more powerful voice in the challenge as can be seen by their latest publication on needs for change in the NHS (Fixing the NHS: Why we must stop normalising the unacceptable). In the context of FPM, a global organisation, this means challenging and influencing strategies not just in the UK, but globally, as innovation, regulation and equitable access to medicines and devices cannot be controlled simply in one country.
When the FPM was inaugurated in 1989, I joked in my speech that I hoped, as some of our members worked for “trade”, it would not take 300y, like it had done for the surgeons, to be accepted by other colleges and the rest of the medical profession! Whilst few of our members work for the NHS as their primary job, the skills of our members touch almost every branch of it. Our role, however, is still relatively little understood and I still have comments made to me such as “at what point in your career did you decide to leave medicine” as I am sure all pharmaceutical physicians have. This lack of understanding truly handicaps our ability to influence when you compare pharmaceutical medicine to, for example, a specialty where no one can imagine it is not heavily doctor influenced, the Royal College of Emergency Medicine, which only received its Royal Charter in 2008.
The Carolean era – our future
The upward trend in health indicators from the Elizabethan era are predicted to continue. However, perhaps the most rapid change will be in public attitudes and understanding driven by media, and the risk that some will be left behind, leading to inequity in health outcomes. The desire for healthy quality of life is increasing and particularly as there will be longer periods of retirement during which people want to be active. The public will understand their own health even more than they do now and want to make their own decisions in terms of what healthcare they receive, where they receive it from and even if they want to stay alive. This poses both opportunity and challenge for translating science into practice to support fair evidence-based medicine.
To deliver effective health, the range of public and private sectors will continue to come even closer together – not just pharma, but other privately delivered health and social care organisations. The changes will confront the UK regulation basis and clinical guidance for prescribing, which currently, arguably, leaves little choice for patients in some treatment indications. The guidance is targeted predominantly at physicians, not even to other health care professionals, let alone patients. The private sector still struggles to be trusted by the medical profession, as illustrated by the article in the BMJ Investigation of 2 July (‘Led astray? Industry’s influence on drug and device watchdogs’) to which a few of the FPM Policy and Communications Group and other colleagues wrote a rigorous response on why medicines regulators must provide ‘an unbiased, rigorous assessment of investigational medicines before they hit the market’, published in August (https://www.bmj.com/content/377/bmj.o1538/rr-4).
Other critical changes in the future of course relate to the dramatic evolution of medical science. There is an ever-changing set of disease profiles, in part due to an aging population and emerging infectious diseases, but also in relation to diagnostics and medicines themselves identifying new diseases. We are also much better at diagnosing the inevitable adverse event consequences of use of treatments.
As we have heard so much about in this last week from the new UK Secretary of State for Health and Social Care, pharmaceutical medicine is now going to have a significant role in the emergence from NHS backlog issues. A reduction in people going into hospital and an increase in support with digital technology and better delivery of remote medicines to get people out sooner is urgently required. The opportunities for primary prevention, secondary prevention and treatment are going through massive change, with both the backlog issues and the introduction of cell and gene therapy alongside biologicals and small molecules. All will change health care dramatically.
The expansion of Royal Charters for medical standards overseen by our late Queen has underpinned so much of the improvement in health and no doubt will continue under the new King. FPM is involved with all aspects of these changes as we represent Innovation, regulation and equitable access for patients for medicines and devices and touch all specialities in medicine. It is important to evolve our FPM role to support these changes not just for our own members but supporting and working with all colleagues across healthcare.