| Description | Prof Sir LEWIS RITCHIE interview at the Sir Duncan Rice Library, University of Aberdeen on Monday July 31st, 2023. Interviewer Eric Crockart. Summary by Eric Crockart.
(0:00:00) LEWIS DUTHIE RITCHIE, born on the 26th of June, 1952 in Fraserburgh. Not yet retired, continues to hold the Mackenzie Chair of General Practice to which he was appointed in 1992; currently seconded on a part-time basis to the Scottish Government as a Clinical Advisor in Primary Care and in Public Health primarily; does research work, importantly recently the EAVEII project to examine the effectiveness and safety of the COVID vaccines. Speaks about his family background, no medics, family roots in fishing industry in Fraserburgh, explains. Father was a mechanical engineer, and manager of the Consolidated Pneumatic Tool company, in its heyday the biggest employer in Fraserburgh other than the fishing industry. Lewis decided he wanted to be an Analytical Chemist, converted his maternal grandmother’s cellar into a laboratory during his secondary school days, explains what this involved; at one point calculated the gold content of North Sea water, explains in detail. (0:04:49) Explains about his schooling; went to the Infant School and then the Central School in Fraserburgh, then on to Fraserburgh Academy, where he set his sight on Analytical Chemistry; subsequently applied to the Science Course at Aberdeen University, Chemistry one of three other first year subjects, explains in detail. He and some of his fellow students decided to study Computing Science, but there was a timetable clash, explains in detail how this was resolved by the Reader in Mathematics who was in charge of the Computing Science course; tells anecdote about how he later treated him as a patient. (0:08:48) (At this point in the interview a large mechanical grass cutter appeared outside the seminar room in the Sir Duncan Rice Library and its operator spent some time cutting the adjacent grass bank!) Recalls how his fellow digs mate in 1971 persuaded him to go to a Scotland v Belgium international football match at Pittodrie (football stadium in Aberdeen); a man in crowd collapsed, may have expired, Lewis felt singularly unable to help. Made him question his future, went to Medical Faculty office, then in Marischal College, talked about options, decided to finish his Chemistry degree at Junior Honours level; explains in detail, including length of time being a student, and question of fees. Three of the eight years he was at university did not have fees paid by then Scottish Home and Health Dept, did lots of summer jobs, explains. Talks also about how he came to think as a medic that they were missing the dimension of prevention, explains in detail; equally when it came to cardiovascular disease, his main clinical interest over the years, trying to stop it happening again. (0:13:02) Continued to nurture his interest in computers, explains. Computers did not feature much while he was an undergraduate in Medicine, graduated in 1978; first did surgical House job in Woodend (Woodend Hospital in Aberdeen), explains. Consultants there at the time were Mr Peter Jones, Mr James Kyle; Mr Iain Muir was the plastic surgeon who impressed Lewis, learned that medicine was not only about what you did, but how you did it. Perhaps most influential figure in that regard was in his second House job in Ward One of Aberdeen Royal Infirmary (ARI), the Regius Chair of Medicine whose specialty was Haematology, appreciated his caring as well as all of his medical expertise (later in interview names him as Prof Douglas - see below, following reference to Sir Dugald Baird), explains. Talks about importance of leadership in medicine. Explains he had fixed on probably being a rural practitioner. His second year jobs were firstly as an SHO (Senior House Officer) in Obstetrics, because he knew that rural GPs had to have a skill set. Was also able to get on to the medical rotation scheme, did Dermatology, Paediatrics and also Infectious Diseases. Again met very impressive people there, Prof Alex Campbell of Paediatrics; Chris Smith, Consultant in Infectious Diseases; Bob Main, the Reader in Dermatology; Prof Ian MacGillivray in Obstetrics, who followed on from Sir Dugald Baird, explains, Prof MacGillivray was a great clinical exemplar but also diffident, like Prof Douglas, the already mentioned Regius Professor of Medicine. (0:19:16) Explains he himself has tried to demonstrate wherever he has worked that we are all in this together; can achieve more if you give the credit to others. Decided how can we start doing things to give population benefit, as well as the individual? At the time a novel concept in General Practice, explains in detail; little activity, for example, in trying to prevent heart disease. Lewis was brought up (professionally) in Peterhead, which was the practice he went to for training purposes, based on the same site as the hospital. Peterhead had a population then of about twenty thousand, one practice in the town, unlike his home town of Fraserburgh where there were three, working separately rather than together, explains contrast with how Peterhead operated. Remembers being asked by his trainer Dr Michael Traynor if he had any questions after being given a tour of the hospital, he asked where the cardiac defibrillator was. Was told they did not have one in Peterhead, explains consequences of this. Describes how he persuaded Peterhead Round Table to buy three defibrillators. (0:23:41) Tells story of how it was not long before he used one of the defibrillators on a man who had collapsed at home at age 61, and who died 31 years later. That inspired him to look more at the preventive side of medicine. Barely a night passed by in Peterhead that on-call GPs were dealing with the effects of cardiovascular disease, explains, including his own interest in this area. Resolved to pursue joint vocational training in general practice and also public health. Expresses gratitude to Gordon Paterson, Consultant in Public Health, or Community Medicine as it was at the time, for opening a training post, went to Edinburgh University for a year to do a Masters degree in 1981-82. Explains his computing interests caught up with him then, choose to do his dissertation on the potential of microcomputers (in primary care), got his MSc (Master of Science degree). Returned to Peterhead as an Associate, while continuing to do the day job of Public Health at the time. In 1984 became a Partner (in the Peterhead practice) and published a book on the potential of computers for primary care [Computers in Primary Care: Practicalities and Prospects, 1984]. Explains that thereafter he has not really tied down one job, usually done several things at the same time. With some colleagues in Glasgow; Jim Shepherd, a Biochemistry professor; Chris Packard; with some pharmaceutical company support they developed a microcomputer-based model to determine cardiovascular risk, and then offered preventive treatment, explains. Mentions arrival of Statins, explains about this and dramatic cholesterol-lowering effect. (0:28:44) In 1987 finished his training in Public Health, where his interest was in Health Protection; before he completed his training he was Senior Registrar in Infection Disease Control in the community and in immunisation. These were his responsibilities for Grampian Health Board at the time. Applied for job in Grampian as Consultant (in Public Health Medicine) was offered the job, he asked to do it half time; said he knew what job needs were and would be able to balance a half time clinical commitment in Peterhead and this job, explains, it was agreed he could try this for a year, which was then continued. Explains how he came to be appointed to Chair of General Practice at Aberdeen University in 1992. Recalls speaking to previous incumbent Prof Ian Richardson, who shortly before he retired in 1984 offered Lewis a part-time lectureship in his department; pays tribute to Prof Richardson for this, teeing him up to apply for the Chair eight years later. Main research interests at the time were Cardiovascular prevention, and trying to exploit computers to extract data from general practices in Scotland. Explains about how at that point there was only one computer in each general practice, and what it did. (0:33:38) Now talk about computer hard disk capacity in terms of Terabytes, Peterhead Health Centre computer at that time had capacity of 10 Megabytes. Refers back to model he had developed earlier with colleagues from Glasgow, a nurse-led screening assessment of patients for their risk; five years later had extrapolated this to nineteen other health centres throughout the UK. So in 1989 Lewis went round all these practices gathering their data, explains this formed the basis of his MD, which he just managed to get over the line in 1992, a few weeks before he was interviewed for the Chair of General Practice. Remembers in detail the day he was interviewed for the Chair, including anecdote about shaving before the interview, suddenly having to deal with a collapsed student, arriving late as a result for the interview, and what happened. (0:39:02) Recalls being asked a question by a lay member of the interview panel about whether he had had a medical dilemma recently, and his answer being a pivotal point in his career, explaining in detail about resuscitating with nursing and ambulance colleagues a woman patient who arrested seven times; Lewis decided they should try to resuscitate her one more time. She survived. Explains the dilemma there was when should a doctor and colleagues stop striving officiously? Notes there were a number of medical colleagues on the interview panel, Lewis could see recognition that they had probably faced that dilemma at some point as doctors. He got the Chair, part of the requirement was to carry on doing clinical work, explains how this involved his work in Peterhead and how he felt it would help the department, which was very small at the time. Made it his business to continue to attend service committees supporting Grampian Health Board, explains this included them providing more accommodation at Foresterhill Health Centre, and three years later on his recommendation to support a new chair in General Practice Research. Lewis wanted to make General Practice in Aberdeen a genuine academic discipline. (0:46:03) Recalls status of General Practice within Medicine at time he was an undergraduate. Explains there has always been a dividing line between doctors working in General Practice, and specialists; Lewis takes the view that General Practice is a specialty in its own right, explains in detail, including distinction between General Practice and Primary Care. He recognised there were gaps in General Practice and Primary Care, addressed that by increasing their grant income as a department, from one Chair to six over the next fifteen years (1992-2007). Expertise we built in the department was not just medical general practice expertise, but expertise in nursing, pharmacy, sociology, behavioural therapy, statistical; and a computer project manager; very much a joint endeavour, explains. One of the highest medical school departments in terms of research grant income, publications; Lewis also keen to ensure they had robust examination techniques for undergraduates, explains. Talks about how the university had left the Chair vacant for eight years after Ian Richardson retired, resurrected by Prof (now Sir) Graeme Catto when he was Dean of Medicine, with the support of NHS Grampian; Dr Hamish Wilson, who was primary care lead at the time for NHS Grampian, was also instrumental, as was the Board General Manager at the time, Frank Hartnett; explains. (0:52:06) Recalls the department he led becoming the only GP department in Scotland to achieve the highest rating in the REF (Research Assessment Framework). His public health appointment had lapsed, but the Chief Administrative Medical Officer at the time, Dr Murdo Murchison, gave him an honorary contract as a Consultant (in Public Health Medicine). One of the committees he was asked to chair - the start of a number of committees and reviews - was a committee of the Chief Scientist Sir Graeme Catto, to try and increase the capacity and capability of general practice and primary care research in Scotland. We were able to establish the Scottish School of Primary Care (in 1999), explains. (0:56:13) Comments on observation by Dr Bill Reith, an earlier interviewee for this project, that diminution of the Dept of General Practice before Lewis’s appointment was down to a lack of support from Aberdeen University. Explains that the Chair had actually lapsed. Recalls that in the early 1980s the Principal was George MacNicol, a doctor (former haematologist) , university challenged financially. Explains how Ian Richardson had built up department, with himself and five Senior Lecturers [later corrected to three GP Senior Lecturers and Lecturer at peak]. Over course of the 1980s dwindled to one Senior Lecturer, Ross Taylor; agrees with Bill Reith that university did not during that period give due support and attention to General Practice. Lewis knew it was an onerous responsibility, had to give it his best shot, explains; mentions challenge of his inaugural lecture, explains what he spoke about. Dilemma of having his clinical base 40 miles away (in Peterhead) from his academic base. Talks about using ISDN (Integrated Services Digital Network) lines, managing to get some video teleconferencing equipment; revealed on screen an hour into his lecture at Kings Conference Centre in Aberdeen that his colleagues in Peterhead had been watching his lecture throughout down an ISDN line. Made point that in future you would not need to be present in the same room as the patient, explains, came into its own with COVID thirty years later. (1:02:24) Comments on Bill Reith’s suspicion (voiced in earlier project interview) that there was also a lack of support for the Dept of General Practice from the Medical Faculty. At its zenith in the recent past talking about more than a hundred people associated with the department. Says most of that was down to "hunger" (appetite for success), recounts conversation he had with Sir Graeme Catto on this. Growing the department was largely about getting resources from elsewhere, explains in detail. University did not invest many resources in his department, but highly supportive; mentions university principal Prof (later Sir) Duncan Rice, whose own father was a GP. Interesting days, the first five years, but regards the golden thread of his career as being at Peterhead, explains. Does not treat patients any more, but advises the government [later clarified: the Scottish Government part-time], so still indirectly influences their care. Was part-time for much of these years, pays tribute to the help of others in his career, says he owes them a great debt. (1:08:57) Clarifies that he was head of the Dept of General Practice from 1992 till 2007. Renamed the department from the Dept of General Practice to the Dept of General Practice and Primary Care. Decided fifteen years was a fair innings as a head of department, explains. Expresses gratitude to the fine leadership of Prof Steve Logan, who eventually became Senior Vice-Principal, who was the first non-medical Dean of Medicine in Aberdeen, explains. Talks in detail about his Scottish government advisory roles, starting in 1999 with leading the national introduction of the Meningitis C vaccination programme. Vaccination and immunisation his main interest within Public Health and Community Medicine; talks about deaths of young people in Scotland from Meningitis C, and how the vaccine programme virtually eliminated this. (1:13:53) Explains about Meningitis C and B, viral meningitis, and encephalitis. Subsequently led the introduction of the Adult Pneumococcal Vaccine in 2003; asked to lead the introduction of the Swine Flu vaccine during the pandemic in 2009-2010. Reflects on this, involving working together, recalls working on Swine Flu; much more straightforward than the recent COVID pandemic, explains in detail; pregnant women particularly at risk from Swine Flu, explains issues in detail. Recalls being asked to join the Board of NHS 24 at its inception, explains; first Vice-Chair and then Chair of the Board. Recalls that at one point he was Head of the Dept of General Practice, Senior Principal GP at Peterhead, Chair of NHS 24, and chair of some other national committees as well - multi-tasking! (1:19:57) Talks about becoming Director of Public Health NHS Grampian from 2012-14. Decided to step down as Principal and Senior Partner at Peterhead when he was 60, explains, including how this coincided with vacancy at NHS Grampian. Explains his part-time commitment to the role, wanting to continue to do some clinical work. Time of great tumult at the board, explains. All his work for the Scottish Government to this point had been done on pro bono basis. Was asked to lead the national review of Out of Hours Services in Scotland and had decided to step down from his Director of Public Health role at NHS Grampian. At the request of the Scottish Government he started a part-time contractual role between the university and the Government regarding his services. From 2016 to present he became a part-time advisor to the Scottish Govt (part-time Advisor in Primary Care and Public Health), explains. (1:24:05) Comments on the awards he has received, including Provost Medal from Grampian GPs, OBE (services to general practice and primary care) and Knighthood (services to the NHS in Scotland); tells story about how he learned of his knighthood via his mother, to whom he had unaware given the unread letter of nomination for her to read. (1:28:39) Comments on Prof Elizabeth Russell’s assessment that his particular skill has been in integrating public health approaches into primary care. Has had professional joy from both the "houses" (specialties) of General Practice and Public Health, explains in detail why he did it. During the COVID pandemic acted in a number of capacities behind the scenes, explains; applying Public Health expertise to the development of General Practice and Primary Care policy and its delivery in Scotland. Mentions Dr Bill Reith again. Remarks on paradox of spending much of his career on trying to prevent things, now spending a fair bit of his career on mending things that appear to be broken, explains. (1:33:36) Explains about EAVE, the Evaluation of Vaccine Effectiveness (research programme following the H1N1 Swine Flu Pandemic). Recalls that in 1987 he applied for a grant from the government and its arm ISD (Information and Statistics Division), to extract data from general practices with computers in Scotland. Explains that grant ran for 26 years till 2013. At peak they were extracting anonymous data from two-thirds of the GPs in Scotland; explains how originally this was done by sending them a Floppy Disk (a now largely obsolete computer medium for storing digital data that was read or written to by a computer when inserted into a Floppy Disk Drive). When he was asked to do the Swine Flu Vaccination Programme in 2009 spoke to his colleague Colin Simpson, who was the main analyst for the general practice data extraction programme that had been running for years. Together they set out to combine databases; general practice data, hospital data, laboratory data, vaccination uptake data, and other databases. Explains it was beginning to dwindle because GPASS (General Practice Administration System Scotland) was on its way out, the national computer system was being replaced by commercial alternatives; explains it originated with a Glasgow GP. The government, with the BMA (British Medical Association), decided to replace it with two commercial alternatives. With hindsight that had benefits for clinical functions, but did not help the secondary uses of data, hampered work of Lewis and his colleagues. Managed to do work showing the Swine Flu vaccine was safe and effective; that was EAVE, collaborating with other universities in Scotland and Health Protection Scotland (now part of Public Health Scotland). Explains the model was hibernated ready for the next pandemic. When COVID came along it was reinvented as EAVEII, with support from then Cabinet Secretary for Health, Jeane Freeman, and government colleagues and the Medical Research Council (MRC). Colin Simpson had moved to a promoted post in Edinburgh, and was main researcher on the project, he’s now a professor in New Zealand. Explains they now had permission to research in population of five and a half million, important for researching rare side effects, just in time for the arrival of the vaccine in December 2020. Principle investigator is Prof Sir Aziz Sheik in Edinburgh, Lewis, along with former EAVE colleagues, is one of the team, explains in detail what they have been able to do, feeding into national and international vaccine policy in virtually real time. Harks back to 10 MB computer in Peterhead in 1984, expresses great satisfaction. (1:42:43) Expands upon this, happy with the way that things have turned out. Tells two anecdotes. First concerns him noticing that you had a higher chance of dying from coronary heart disease in Peterhead if you had an inflammatory joint condition like rheumatoid arthritis; wishes he had made more of this at the time, always recommends to medical students that if they have a hunch, don’t suppress it (nurture curiosity). Recalls incident while he was working overnight in Peterhead in the late 1990s, involving a young man who had had a heart attack, being given a recently-introduced clot-busting drug before being sent to ARI (Aberdeen Royal Infirmary), followed by an older man who was similarly treated. Remembers afterwards a nurse observing that it was better to have a heart attack in Union Street in Aberdeen than in Queen Street in Peterhead. (1:47:00) Mentions that at the time there was a pioneering Cardiologist in Aberdeen, John Rawles, who was keen on this drug as a potential saver of lives; the quicker it was given the better. Lewis discussed this with John Rawles and others, came up with a study design looking at patients who had been given Thrombolysis in the community. Explains this was being given in some rural practices rather than Aberdeen City. Answer to the nurse’s question was that it was better to have your heart attack in Queen Street in Peterhead, explains reason for this in detail. Lewis and John Rawles wrote to the then Chief Medical Officer Sir David Carter, showing him their findings before they were published. Sir David wrote to all health boards in Scotland, saying there should be new streamlined pathways of coronary care, this involved early thrombolysis where indicated. Lewis remarks that one nurse changed (national acute coronary care) practise by that one question. Notes that Medicine tends to be a conservative profession, classic example of two doctors in Australia suggesting gastric/duodenal ulcers caused by bacteria, initially spurned then vindicated, explains. (1:51:30) Addresses question of whether he has achieved all his goals. Has done his best, great to see EAVEII coming to fruition, changes in patient care pathways. But any professional worth their salt has to say we can do better, we can do more, explains. Explains the circumstances of a photograph showing him being winched from a helicopter down to a vessel, with a huge wave behind him; one of several encounters he has had with helicopters in Peterhead during his career, including travelling with a woman about to give birth with twins when all the roads out of Peterhead were blocked by snow on Boxing night 1995. Incident involving him and an injured man on the vessel was in February 1981 in the Harbour of Refuge in Peterhead Bay, explains in detail, including how the photograph of him came to be taken. Lewis commissioned Aberdeen artist Eric Auld to paint a version of it, which he still has; commissioned another one when he retired, which sits in Peterhead health centre, alongside a plaque listing all the people that were involved in saving the man’s life. (2:02:05) Also explains his interest in the Royal National Lifeboat Institution and his ownership of the retired lifeboat RNLB Douglas Currie. Recalls coming back to Fraserburgh after giving his inaugural Mackenzie lecture, about leadership in General Practice, looking to the values of the RNLI, explains about his maternal grandfather being a lifeboatman in the town. Explains how he came to buy the former Peterhead lifeboat RNLB Julia Park Barry of Glasgow, which is now housed in its own shed in the former Peterhead Prison. Then understood that one of the former Fraserburgh lifeboats, the Douglas Currie, was up for sale, and bought it. (2:06:41) Comments on the current state of the Dept of General Practice. Department in Aberdeen undergoing a renaissance, led by Prof Peter Murchie, grown significantly in the last few years. Lewis sees his job now as to encourage people, to advise, and do his own research; but (government and the university) going through a challenging period in terms of scarce funding resource. (2:09:24) Comments on the issue of General Practitioners working in rural areas. Recounts history going back more than a century, Dewar Report commissioned, recommended changes to medical care in rural areas, many of which were later used for founding the NHS in 1948. Remote practitioners have to deal with more diverse cases than their colleagues in urban areas, explains, recruitment of GPs a concern, particularly remote and rural practitioners. Lewis asked to chair a committee in relation to the GP contract in 2018, which differentiated between practitioners working in rural circumstances compared to urban circumstances. He wrote a report with twelve recommendations, one of them for the establishment of a National Remote and Rural Centre, to be a beacon of excellence for training etc, explains he is hopeful this can be established [later added during correction process in Nov 2023: This has now been funded by the Scottish Government and is in the process of being established]. (2:13:19) Comments on the current state of the NHS, in particular the provision of GPs. Over his career General Practice has evolved from a cottage industry, where not uncommon for a GP to work from their own home. In mid-1960s it was recognised that model was no longer sustainable, explains. Over period 1980-2000 practice nurses and administrators mushroomed, there were increases in GP numbers. But over same period the numbers of hospital doctors began to overhaul the numbers of GPs. Lewis was able to plot this for a chapter of a book that came out in 2003, explains in detail. Additional investment in the health service has largely been in acute services over the years, thinks that pendulum has swung too far. Problem of length of time it takes to train GPs of the future. Population growing older. GP model is to look at what is best for the patient, while specialist model is looking at what is best for one condition. Need for more generalist skills, either involving GP or other members of the multi-disciplinary team. (ENDS 2:19:03)
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