It may be four decades since Willie Hamilton left his native Belfast but he has held on to the Irish ability to tell a great story. It was March 2019 and Willie, the Professor of Primary Care Diagnostics at University of Exeter Medical School, was at Buckingham Palace to receive a Commander of the Order of the British Empire (CBE) award for services to improving early cancer diagnosis. Prince Charles, then Prince of Wales and now King Charles III, was doing the honours, literally.
“What happens is you go forward and somebody whispers in Prince Charles’ ear: ‘Hamilton, Exeter, cancer diagnostics.’ Then Charlie puts a gong over your head and asks you an intelligent question,” says Willie, sketching the scene. “It was very well done – until he knocks your hearing aid off. Well, I spin around and, in perfect cricket fashion, do a superb first slip catch at my ankle. In my morning suit, in front of the next-to-be-king.”
The incident didn’t end there. “The funniest thing was, he was as taken aback as I was and he started talking,” Willie continues. “But I’ve got zero hearing. I have to put this thing back in the side of my head. So the very first thing I said to the future king was ‘HANG ON!’ in a very loud voice. My kids at the back were wetting themselves with laughter.”
It’s appropriate that Willie’s hearing loss almost hijacked his big day because it has proven to be a central character in his extraordinary medical career. A third-generation doctor, he qualified in Bristol before doing a stint in hospital medicine in Exeter and two years as a physician in Malawi in east Africa. Then he returned to Exeter, working as a GP for a decade.
“I was established as a GP but at the same time I was becoming increasingly deaf,” he says. “I was working with really powerful hearing aids and lip reading as well. I would be staring at the patient with 100% attention and they thought I was a brilliant doctor because I was never distracted. But by the late nineties, I became really as deaf as a post.”
A cochlear implant – “a widget into your brain and some wires that buzz” – in the year 2000 went badly wrong and became infected. “The joke I have is that patients whinge and say their doctor doesn’t listen to them. Well, I took it to the next level of not being able to hear them,” says Willie. “I was on the professional scrapheap at the age of 42.”
Ruled out of seeing patients, he started doing research work and joined the University of Bristol with two supporting fellowships in 2000. He credits his wife, then also a GP, and Professor Debbie Sharp, Professor of Primary Health Care at the University of Bristol, for backing him when an ad came up for funding into cancer research. “I got the money, £200,000, out of nowhere,” he says.
Willie’s initial work was on patterning out the symptoms of colorectal, lung and prostate cancers as they present in a GP’s consulting room. He gives the example of a patient who goes to the GP because they have coughed up blood. “If you’re over 40 and you cough up blood, I was able to work out using fairly complex stats that it was 2.4% risk – a one in 40 chance – of this being lung cancer. Therefore we should do a chest X-ray.”
The information was valuable for patients but also for the health service, which could begin to design diagnostic services around the expected need. Building on the initial work, Willie mapped other cancers, working down the scale in order of frequency. GPs across the UK got charts, calendars and mouse mats highlighting the symptoms of over a dozen potential cancers.
“There has been tremendous governmental support over the years I’ve been doing this,” he says. “This is not party political. All the governments we’ve had want to conquer the cancer problem.”
A second cochlear implant allowed Willie to return to GP work part-time in 2006, while also maintaining his research. He moved to the University of Exeter in 2010. “Part of the enjoyment of research is that I know some figures that nobody else in the world knows. There’s something pleasant about that but it’s only pleasant if you use it,” he says.
In 2012, Willie was asked to be clinical lead on an update of referral guidelines for suspected cancer by the UK National Institute for Health and Care Excellence (NICE). It decides what services and treatments the NHS should provide to patients across all health areas. The two-and-a-half years of committee work was “hell”, he says, and the NICE guidance was published in 2015.
“That’s important because it governs over £1 billion of NHS spending,” he says, with some understatement. “Of the 220 recommendations in NICE, 100 are at least partly from work that I’ve published and 50 are totally from work I’ve published.”
The 2015 guidance incorporated many new cancer symptoms that had been discovered since the previous guidance in 2005. Comparison of cancer stats from 2005 to 2015 and post-2015, including time-to-diagnosis, shows the guidance is working: earlier this year, NHS research confirmed the UK had its highest-ever percentage of cancers diagnosed in Stage 1 and 2, at 57%.
“I don't want you for one minute writing that it's all due to me,” says Willie. “It's not. There are lots of other things going on but it is clear that I was part of it.”
His work has continued into researching how and where patients should be tested for cancers, including the efficacy of tests and balancing between GP and hospital settings. “The health economics are significant. You shouldn’t spend a billion quid of anybody’s money without knowing if it works,” he says.
Since that initial £200,000 funding, Willie has been involved in research that has attracted a total of £79 million and counting.
Now approaching 66 and on his third cochlear implant, he is slowing down to “part-retirement”. Still, a sample day involves teaching PhD students, giving careers advice to the next generation, discussions with the NHS about new cancer testing, sitting on steering committees and supporting other groups. “Two of my PhD students are already professors and that’s a lovely feeling,” he says.
Willie is also instrumental in raising philanthropic donations for university research. “I’ve had a lot of really good support from philanthropists, which we appreciate,” he says. “The crucial thing is, you can have all these bright ideas, you can put all these things in place to identify [potential cancer] patients, but if they’re not used, they’re useless.”
Philanthropic funding is supporting a large-scale ongoing trial to integrate the cancer-identifying formulas into GP software systems in the UK. Clanwilliam’s primary care predictive analytics technology is a key partner in the trial introduction of the electronic clinical decision support tools.
Willie explains: “If I go into the GP surgery and there’s something in my GP record that equates to a risk of cancer of greater than 2%, a little pop-up comes up on the [GP’s computer] screen. It’s up to the GP then to initiate a conversation with the patient.” For example, unexpected weight loss and anaemia could suggest colorectal cancer.
The data collection stage of the trial, which spans nearly 500 UK GP practices, finished this spring and the project could move to a national roll-out in 2025. “The technology is so important. I can give the cancer risk numbers but I leave the other part to IT experts. It’s a massive electronic exercise,” says Willie.
Getting to this point has required stamina: the average time from a researcher’s light-bulb moment to implementation into NHS care is 17 years, he explains. “I started this in 2000 so it’s 24 years so far. I feel it’s gone quickly. GPs really have signed up to the idea that it’s their job to identify cancer. The number of referrals for possible cancer has gone up 10% year-on-year for the last decade.”
Retirement may be on the cards but Willie will scarcely be slowing down. He lives on 40 acres with his wife, who has retired from her clinical practice and is studying for a PhD in English. Their three adult children have established careers in academia, anaesthesia and finance.
A keen hill-walker, Willie has climbed the highest point in every county in Ireland, England and Wales, with just nine left to climb in Scotland. He plays tennis and supports Irish rugby; in fact, he reveals, he has the symbol of the Irish Rugby Football Union – three shamrocks around a rugby ball – tattooed on his leg.
Like many accomplished people, he downplays his achievements and impact. “It’s a funny story because it’s driven by my health as much as anything,” he says. “I just happened to be in the right place at the right time and I wasn’t working. I just stumbled into an open pasture.”
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