Chronology of the decade

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Each generation has expectations that cannot be fulfilled. Job security was no longer taken for granted, the concept of the family was less rigid, support in the form of Social Security was under threat, dreams of ever-increasing prosperity faded, and negative equity emerged with the decline of the housing market. Much to which people had believed themselves entitled was no longer guaranteed. Young adults born in 1961-1981, Generation X as some called it, had a different and sceptical view of society.¹ The NHS might not be there from cradle to grave. Their elders, in turn, discovered that young doctors and nurses sometimes lacked the vocational attitudes they expected. Although clinical medicine continued to advance inexorably, the health service was as ever in financial disarray. In its first issue of 1988 the BMJ called for a new health commission.

Let us be charitable. Let us assume that Mrs.Thatcher and her health ministers really do believe that the NHS is bigger and better funded than ever before and that the concern voiced by the health professions is whingeing in response to tough, effective management. Then how do we convince the government that the NHS is moving towards terminal decline, and that innovatory thinking is needed to solve the crisis? . . . The message is that after years of squeezing the NHS has finally no more juice to give . . . Britain is not alone in facing a health crisis; in every Western country each year brings new and better treatments for populations that are living longer than ever. This is the insatiable demand that politicians have been citing to excuse their refusal to find more money. But in fact there are many ways of skinning the cat.²

Bevan had said that the service must always be growing, changing and improving; Sir Patrick Nairne, a former Permanent Secretary at the Department of Health, doubted whether changes should include alteration in the basic organisation and financial structure.³ He saw three developments as desirable. First, the NHS was a most important public service, but no public service thought less about the public. The NHS should treat people as responsible individuals and take them into its confidence. Second, better links with private medicine and local authorities were desirable. Third, the distrust between every level from central government to the hospital should end. Clinicians, administrators, district teams and regional teams criticised each other, and ministers. The NHS was the largest glasshouse in the world, and risked its own survival if it could not resist throwing stones. Not surprisingly, health was a media favourite. Major ethical issues were raised by the tabloids, to the surprise of doctors who were sometimes naive in their comments.⁴ By 1996 the BBC was considering filming a natural death for a scientific programme. Dr Kildare and Emergency - Ward 10 had glamorised medicine. Newer soaps, for example Casualty and ER, did not.

New forces were at work in health care internationally:⁵

• The power of big buyers - governments, private payers and patients were demanding cost-effectiveness.

• The rise of sophisticated consumers - patients were more knowledgeable, changing the doctor-patient relationship.

•   New technology - including molecular biology.

• Shifts in the boundaries of health and medicine - with the recognition of the complex relationship between the environment and medicine.

• The ethics of controlling human biology - death and dying, and the legitimacy of rationing. From transplant surgery to fertility drugs, technology strained the ability of traditional morality to provide authoritative guides to behaviour.⁶

In 1988 the Department of Trade and Industry published a Green Paper on anti-competitive practices. Subsequently the Monopolies and Mergers Commission investigated whether the professionally imposed restrictions had an adverse effect on the public interest. The ethical code of the medical profession precluded advertising to the public. The Conservatives encouraged the provision of information to the public so that it could decide in a medical marketplace. The Commission supported an embargo on advertising by consultants, but considered that the restrictions on GP advertising operated against the public interest.⁷ There followed a series of organisational initiatives, which included a new GPs' contract, the NHS reforms, The health of the nation, the Patients' Charter and Community Care.⁸ Previously, major organisational changes had taken place on a single appointed day. Now change became continuous, varying from place to place. Central was a move towards a market, made possible by a hierarchical system of accountability from local management through regions to the Secretary of State.

Health promotion and illness prevention were increasingly seen as part of routine medical care and incorporated into the practice of many GPs. An emphasis on more targeted screening for problems and disease in its early stages replaced the earlier enthusiasm for a more general approach. Attention was paid to smoking, raised blood pressure, misuse of alcohol, diet, and cancer of the breast and cervix.⁹ The effectiveness of screening procedures and the problems of ensuring they were actually carried out were examined. Much remained contentious in the young science of health promotion and it seemed that, no sooner were proposals implemented, than a study would appear casting doubt on their merit or cost-effectiveness. A population-based approach aimed to reduce risk factors by influencing the price of alcohol and tobacco, reducing salt in processed food or attempting to reduce social inequality. Disasters could also alter attitudes: the fire at Kings' Cross Underground in 1987 was followed by a ban on smoking in public places. Finally came a focus on 'green' issues, the belief that life style, environment and ecology should be linked. We should look after the things that look after us, and design agricultural, industrial and social systems to prevent environmental hazards. Population and resources needed to be in balance.¹⁰ Public health physicians believed that health promotion spread wider than medicine into environmental issues and politics. The evidence that variations in health were correlated with income, both within nations and between them, was strong. Some people saw health promotion primarily in terms of social policies that redistributed income and believed that health care systems should be based on primary care, the participation of citizens and the principles of Health for all.¹¹ An increasing number of countries, including New Zealand and the USA, were publishing health strategies based on the World Health Organization's (WHO) Health for all 2000 targets. The British government was seen as slow in following suit. In 1988 an independent expert committee, assembled by the King's Fund, produced The nation's health, a strategy for the 1990s.¹² In 1991 the Faculty of Public Health Medicine produced a report on UK levels of health,¹³ centring its approach on risks, patterns of behaviour and how to alter them. In October 1990 Kenneth Clarke announced his intention to devise health targets and measure performance. The Chief Medical Officer, Donald Acheson, saw an opening for a project after his own heart. Clarke's successor, William Waldegrave, published The health of the nation in June 1991 as a consultative paper. It was timely because the WHO had provided a framework, the public were ready to hear the message not least because of the AIDS epidemic, the need for health care assessment was widely recognised with the publication of a report on the future of Public health in England,¹⁴ there was a political consensus that more needed to be done, and it was a good diversionary tactic at a time when the government was under much pressure on the NHS.

Some saw it as a rejection of the wider WHO Health for all strategy and the objective of redressing social inequalities and encouraging community participation.¹⁷ Although originating in the Department of Health (DoH), the strategy involved many government departments because significant improvement involved society as a whole. As time passed there were doubts about the achievements. Many targets had been set in line with trends that were already apparent. Mortality rates for stroke and heart disease continued to fall, but sometimes changes were in the wrong direction; for example, obesity was rising, as were teenage smoking, drinking by women and suicide.¹⁸ Although somewhat tardily, government now accepted that variations in health existed between different areas, ethnic and income groups, and that greater understanding was needed if effective action were to be taken. A working group looked at these variations, but did not stress the effect of poverty, which was, after all, not primarily the responsibility of the DoH.¹⁹

With advancing technology and shortening length of stay, patients in hospital now were likely to be very sick indeed or to be admitted briefly for investigation or minimally invasive surgery. New forms of treatment demanded mental and physical stamina from patients who were far better informed about what was happening. A 48-year-old man, after his third heart transplant, said 'I am just trying to enjoy life. It is not all a bed of roses.'²⁰ Patients with cancer were subjected to the most intensive protocols of chemotherapy, and emotional support might be lacking. Those with distressing or terminal illness were in need of comfort and continuity of care, difficult with continuously changing teams of doctors and nurses.²¹ At a time when they were ill and vulnerable, people might not like to be in mixed sex wards. Hospital surveys of patient satisfaction invariably showed high ratings, but systematic interviews in a large random sample of hospitals showed major problems in communication. Patients often did not receive information about the hospital, their condition or its treatment. Many were in pain and often they were not offered pain relief. Discharge planning and follow-up was poor.²² Since 1948 medical educators had urged the inclusion of social, ethical and non-technical issues into the student curriculum, hoping that this would produce more humane and self-motivated physicians. Although Sir Lancelot Spratts roamed the wards in fewer numbers, empathy was not always to be encountered.²³ The General Medical Council (GMC) issued new and clearer guidance to doctors, including advice on 'fly-on-the wall' TV programmes showing daily life in hospital or general practice. These were not always made with respect for the patients concerned. The GMC stressed the importance of informed consent by patients, and that doctors should be particularly vigilant where children, vulnerable people and the mentally ill or disabled were concerned.²⁴

Interest in complementary medicine grew; more people went to non-orthodox practitioners, spending substantial sums, but they did not turn their backs on conventional health care.²⁵ In the hierarchy of evidence from the anecdotal to the randomised controlled trial and the meta-analysis, complementary medicine ranked low, but there was increasing pressure to give patients what they asked for. The medical profession relaxed its attitude and increasingly complementary medicine became part of the NHS. It was estimated that 60 per cent of health authorities and 45 per cent of GPs were either commissioning or providing it. Because it might be cheap to the NHS, there was a temptation to offer it in the absence of any evidence of effectiveness, especially in areas of care where conventional medicine was unsuccessful, for example in the management of chronic low back pain.²⁶ Acupuncture and aromatherapy might be provided as part of mainstream care as in cancer, where patients facing rigorous types of treatment might find at least psychological benefit. Political parties supported its development as an issue of choice for patients, and bodies were established in 1996 to regulate and register chiropractors and osteopaths.²⁷ Because of the lack of evidence of its clinical effectiveness, the Nuffield Institute for Health in Leeds set in hand a literature review while in the USA the Agency for Health Care Policy and Research awarded a contract to Beth Israel Hospital to measure its effectiveness.

Interest increasingly centred on clinical guidelines. In 1990 an academic consortium of 12 US centres teamed up to develop guidelines on topics in which there was evidence of marked variability from place to place, and high costs. Cataract, aortic aneurysm resection and carotid resection were among those selected. John Wennberg, at Dartmouth, published an Atlas of health care in the USA, showing that operation rates and hospital beds were related more to the number of specialists than to any measure of clinical need. There was little evidence that populations receiving aggressive care lived longer. Supply appeared to drive demand, defying most people's basic economic beliefs.²⁸ Calls for a similar approach in Britain were often ignored. Health technology assessment threatened clinical freedom and although doctors did not want freedom to use ineffective forms of care, they wished to maintain the right to decide what was effective and not be delayed by procedures that slowed down innovation or might be overly concerned with cost containment.²⁹ The appointment of Michael Peckham as the first NHS Director of Research and Development in 1990 increased the momentum in the UK.³⁰ Peckham's position made it possible to establish a regional research strategy and network, and to obtain earmarked resources for research when new financial arrangements were under consideration.³¹

The influence of the enquiry into maternal deaths and the subsequent report by Lunn and Mushin on anaesthetic deaths was enhanced by the commitment of senior members of the specialties. A further report on 19,000 perioperative deaths in 1992/3 (National Confidential Enquiry into Perioperative Deaths, NCEPOD) showed a lack of high-dependency units in many of the hospitals in which deaths had occurred, and that patients were sometimes returned to ordinary ward areas too soon. Faults in care were revealed that could be remedied.³² Patients who were 'outliers', on a ward not normally dealing with their problem, had poorer outcomes. During 1992 three further studies began, into stillbirths and deaths in infancy (Confidential Enquiry into Stillbirths and Deaths in Infancy, CESDI), counselling for genetic disorders, and homicides and suicides by the mentally ill. However, the Royal Colleges only haltingly went ahead with audit, and did not always work with the other professions whose contribution was essential to a good outcome. It also became apparent that studies needed to consider long-term effects as well as the immediate results.

Evidence-based medicine

Archibald Cochrane had argued for randomised controlled trials in the belief that it was not known whether most clinical interventions did any good. Increasingly clinicians and those purchasing health care became interested in 'evidence-based medicine', the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.³³ Evidence-based medicine became a central health service policy, a new gospel for government ministers and clinicians. Previously it had been thought adequate to understand the process of a disease and use treatment known to interrupt or modify that process. However, if the outcome rather than the process was examined, some forms of care did not produce the expected improvement. Trials, now numbered in hundreds of thousands, revealed that some procedures, such as dilatation and curettage in women under 40 years of age, were either of doubtful value or harmful. How little of medical practice had a firm basis in evidence? How much of what was firmly based was applied in the front lines of patient care? New editions of textbooks were often out of date and doctors' knowledge even of the basics of disorders such as high blood pressure declined as they grew older. Evidence-based medicine was closely linked to continuing medical education.

There was little wrong with the proposition that the best available scientific evidence should be used in patient care, but there was an implication that the only medicine that should be practiced was based on controlled clinical trials. Yet despite years of study and huge financial investment the research to answer many questions, for example the best way to treat neck pain, was not available.³⁴ New technology, for example minimal access surgery, became established without such an assessment. Even if most people clearly do better with one form of treatment, there is no guarantee that every individual will react in the same way; patients have the right to make a choice between different forms of treatment. In primary health care many conditions are simple and self-limiting, no clear diagnosis may ever be reached and controlled trials are not always practicable.

Guidance on effectiveness drawn up by groups rooted in economics or public health was greeted by managers with enthusiasm.³⁵ It was not always accepted by clinicians as representing ultimate wisdom, particularly if authorities refused to fund new forms of treatment not yet shown to be good value. It was one thing for managers to challenge clinical decision-making; now management sometimes dictated it. Although evidence from trials was increasingly incorporated into guidelines, clinicians did not automatically behave in accordance with them. Experience showed that where they were developed locally, for example practice prescribing policies, they were more likely to be followed than if they were developed centrally.³⁶ Robert Brook found that the great motivators in the USA were one-to-one contact with respected colleagues, or money. The effort required to develop guidelines based on research findings was considerable. Centralisation of effort was worth while to prevent the local application of dubious patterns of care.

The DoH and the NHS Executive made improving clinical effectiveness a key priority and invested heavily in fostering evidence-based health care.³⁷ In 1991 a research and development strategy was launched in the hope that clinical, managerial and policy decisions would be based on sound and pertinent information. The UK Cochrane Collaboration was established in 1992 as part of an international network to prepare, maintain and disseminate systematic reviews of research on the effects of health care.³⁸ Its Director, Iain Chalmers, giving evidence to a House of Lords committee enquiring into medical research, told peers that his medical training was so out of date that in the first four years of his career he did more harm than good. Against some opposition from the Joint Consultants Committee (JCC), the DoH established a multiprofessional Clinical Outcomes Group and a subsidiary National Centre for Clinical Audit. Directorates of research and development were created in the regions. A standing committee on health technology was established to assess the methods.³⁹ Several forms of treatment, for example screening for colo-rectal cancer, were listed as priorities for assessment. Evidence-based medicine was turning into an industry with an NHS Centre for Reviews and Dissemination, the UK Clearing House on Health Outcomes, Effective Health Care Bulletins from the Universities of York and Leeds, and a CD-ROM providing a summary of systematic reviews. The impact at local level was patchy.

The NHS attempted to absorb and synthesise differing philosophies of quality improvement, effectiveness and audit. David Taylor, working at the Audit Commission, listed 25. Many followed quality philosophies from other sectors of public service and industry, particularly those pioneered by Deming and Juran, and used by Japanese industry in its search for reliability and market dominance.⁴⁰ These saw quality as organisation-wide and a responsibility of management, challenging traditional assumptions that it was largely a matter for the professionals. Quality was seen as a continuous process of evolution in which 'every defect was a treasure' enabling matters to be improved. Don Berwick, responsible for the quality programme at the Harvard Community Health Plan, contrasted traditional systems of inspection, discipline and penalties with the alternative, participation and incentives.⁴¹ Another approach, business process re-engineering, redesigned the way care was provided to improve matters for both patients and staff.

Hospital accreditation was also introduced. Britain had the Health Advisory Service, and accreditation had long been required in North America where independent assessment was a pre-condition for payment. The DoH was wary of introducing accreditation into the UK. Would major hospitals always reach an appropriate standard? In 1989 the King's Fund launched its own pilot study that examined hospital organisation and assessed the extent to which standards were being met, and action was taken when they were not. The pilot evolved into a national accreditation scheme and by 1995 a third of the country's hospitals had submitted themselves voluntarily to the procedure.⁴² To achieve accredited status a hospital had to demonstrate compliance with organisational standards that fulfilled legal obligations and respected the rights of patients. The standards were process-orientated, but covered every aspect of the hospital's systems and organisational procedures. An independent team of surveyors, for example a trust chief executive, a director of nursing, a consultant or clinical director and an operational manager then visited the hospital for two to five days, provided a verbal debriefing to its staff, and submitted their findings to the accreditation committee.⁴³ The standards were high and few hospital trusts met them in their entirety. The King's Fund extended the programme to general practice and primary health care, and to community and mental health services; other groups also entered the accreditation field.

In 1971 McKeown had suggested that health services had only a small effect on health or longevity.⁴⁴ While this might have been true in the nineteenth century, advances in treatment for some conditions had undoubtedly led to improvement in outcome. It was, however, difficult to disentangle the effects of health care and environmental improvement, for in most conditions improvements in diet and nutrition were also having an effect. Bunker challenged the McKeown hypothesis, attributing a gain of about 1.5 years to clinical preventive services, in particular diphtheria immunisation. The contribution of the curative services seemed twice as great. Cancer treatment had not had much effect but there had been major improvements in survival from heart disease and renal failure, a reduction in strokes probably from the treatment of high blood pressure, and far better results in diabetes, tuberculosis and maternity services. For the population as a whole Bunker considered that this meant that medical science could claim responsibility for an average gain of 3-4 years, out of about 7 years' total increase in life expectancy since 1950 in Britain and the USA. Bunker pointed out that the public demand was for improvement in the quality of life, not just survival. Well-being was a major goal of health care, for example the treatment of depression, osteoarthritis and cataract surgery.⁴⁵ There was pressure to develop measures reflecting the effect of medical intervention on morbidity.⁴⁶

The GMC had been created in the nineteenth century to identify professionals and protect the public from quackery. In 1997 it obtained new powers to deal with serious deficiency in clinical competence.

Self-medication with medicines bought over the counter (OTC) had long been a feature of people's lives. A report from the Nuffield Foundation in 1986 argued that pharmacists were an under-used resource.⁴⁷ They could make a greater contribution to primary health care, especially as the public increasingly looked to them for advice on the increasing range of OTC preparations. Sales were equivalent to a third of the NHS drugs bill, and governments world-wide saw self-medication as a way to shift some of the cost onto patients.⁴⁸ From the late 1980s it became easier to reclassify medicines from prescription-only status to allow counter sales when they were safe in use, had only minor side effects, and had well-defined indications. Among the medicines reclassified were ibuprofen for pain, acyclovir for cold sores, corticosteroid preparations for surface use, and H₂-antagonists such as cimetidine for indigestion. In 1992 the Medicines Control Agency, Britain's drug-licensing body, streamlined its procedures for deregulating drugs.

Since the introduction of streptomycin and drugs for major psychiatric disorders, improved medicines had meant that fewer patients needed to be in hospital.⁵⁰ This process was a continuing one; for example, cancer patients could often be treated as outpatients, and drugs that relieved nausea and vomiting associated with cancer chemotherapy meant that the length of hospital admission could be shorter. Patients undergoing surgery recovered more rapidly following an anaesthetic using new agents. The pharmaceutical industry was at pains to demonstrate that the savings achieved in hospital overheads were not outweighed by the cost of drugs. The industry tried to enter the wholesale distribution chain, to influence those providing health care or to become providers of health care themselves. 'Disease management' was pushed by the pharmaceutical industry, the proposal being that the care of patients with long-term conditions such as diabetes and asthma should be contracted out to the manufacturer supplying the product on which patients depended.⁵¹ An idea from the USA, its limitations on the choice of treatment patients might receive caused concern on both sides of the Atlantic. The need for blockbuster drugs to maintain profits was urgent. Firms overhauled their research programmes. It was predicted that by the turn of the century every new drug would be touched in its development by biotechnology and genetic manipulation.⁵² Greater knowledge of the functions of individual genes and their amino-acid sequences opened new therapeutic possibilities, and the possibility of designing new drugs. SmithKline Beecham spent $125 million on a stake in the Human Genome Sciences company in return for rights to develop products from its huge gene database. 'Combinatorial chemistry' made it possible to produce new chemical entities at a remarkable speed, and high-speed screening systems were developed to assess them. Alliances with university departments and biotechnology companies gave the large companies an expanded horizon.⁵³ Genetic engineering was now being used to produce large amounts of well-known proteins, including insulin, growth hormone, hepatitis vaccine, interferons and monoclonal antibodies, and drugs reducing the frequency and severity of relapse in multiple sclerosis. The production of eythropoietin in substantial quantities by recombinant DNA technology made it possible to treat the anaemia that commonly accompanied renal failure. Clinical trials showed substantial improvement in well-being but it was also used illicitly by athletes to improve performance.⁵⁴ In 1991 a monoclonal antibody, centoxin, was launched for the treatment of Gram-negative septicaemia. It bound and neutralised bacterial endotoxins and though costly could possibly save the lives of patients who would otherwise die of this infection after burns, trauma or gastrointestinal surgery.⁵⁵ The pharmaceutical industry developed derivatives of erythromycin, one of the earliest antibiotics, that were more stable, more active and had a more prolonged action. Originally held in reserve for penicillin-resistant infections, they were found useful particularly in respiratory diseases.⁵⁶ A new type of antimicrobial treatment emerged, the antiviral drugs, hitting herpes, shingles and AIDS, although there was a risk that viral resistance might occur.⁵⁷

One of the earliest of the synthetic drugs, aspirin, obtained a new lease of life. It was known to inhibit platelet function. Several reports suggested that it significantly reduced cardiovascular mortality and morbidity after heart attacks, and it also appeared to have a beneficial effect in cerebrovascular disease and strokes. Even a small daily dose seemed effective, and doctors regularly gave aspirin to any patient at risk of the two conditions.⁵⁸ Drugs that reduced serum lipid concentrations proved to be effective in reducing major coronary events in people with ischaemic heart disease.⁵⁹

Effective treatment was now available for acid-related disorders such as duodenal ulcer and oesophageal acid reflux. The H₂-receptor antagonists did not suppress acid secretion completely, and were challenged by omeprazole, a 'proton-pump inhibitor' that blocked the transport of hydrogen ions into the stomach, and healed most duodenal ulcers within two to four weeks.⁶⁰ This became the treatment of choice for resistant ulcers. The possibility that Helicobacter pylori might cause ulcers was open to a simple therapeutic test. Did eradication of the organism help? In 1988 Marshall and his co-workers announced that a combined antibiotic-bismuth regimen healed ulcers quicker and better than H₂-antagonists. Some improvement occurred when a single antibiotic was given, more when two were combined, and very substantial improvement with triple antibiotic therapy. Despite nearly universal initial scepticism, within a few years research workers had developed screening tests for the infection. There was progressive acceptance that there had been a major therapeutic advance that reduced the need for hospitalisation and for longer or more traumatic forms of treatment. When there was evidence of infection, eradication of Helicobacter became the accepted therapy in gastric and duodenal ulceration. The evidence of a link with stomach cancer also strengthened. The search was on for the simplest, shortest, most effective and best tolerated treatment.⁶¹

The first of a new generation of antidepressants, fluoxetine (Prozac), was introduced in 1987. These selective serotonin re-uptake inhibitors worked by increasing levels of serotonin, a neurotransmitter. Unlike previous antidepressants, they appeared to have fewer side effects, and by 1995 some 500,000 people in Britain were taking them, including children. Reserpine was found to be effective in schizophrenia. A new drug with some, albeit modest, effect on Alzheimer's disease (Aricept) was introduced.⁶² Sumatriptan helped migraine. The management of night-time asthma was improved by the introduction of salmeterol, a long-acting inhaled beta-2 agonist that produced effective relief for 12 hours.⁶³ In 1998 sildenafil (Viagra) achieved instant cult status as an effective treatment for male impotence. Since the introduction of oral contraception in 1961 attempts had been made to reduce the hazards from thrombo-embolic complications. The hormone content of modern pills was about a sixth of the early preparations, reduction having occurred in stages as new health risks emerged. Progestogen-only pills were also available for women in whom oestrogen was undesirable, as were injectable preparations. In 1995 evidence suggested that two of the newer 'third generation progestogens' were associated with an increased risk of venous thrombo-embolism and the Committee on Safety of Medicines issued a warning. The increased risk, though small, and less than the risk of thrombosis in pregnancy itself, received intense coverage in the media, alarming about half of the 3 million women using oral contraception.⁶⁴ Slimming drugs, given in combination also produced adverse reactions - heart disease.

With a public increasingly well informed, the greater popularity of alternative medicine fuelled melatonin mania in 1995. A secretion of the pineal gland, melatonin seemed to reset the body clock, and help sleep and jet-lag. In spite of little scientific evidence it suddenly became wildly popular, particularly in the USA, where articles appeared suggesting that it also prevented ageing.⁶⁵

The British National Formulary, which gave doctors and dentists updated information about medicines, went electronic in 1995. Tools for computer-based prescribing multiplied, and provided support for clinical decisions. They could check for potential interactions, calculate the appropriate dosage and suggest suitable preparations. Their use could also make for economy, increasing the number of prescriptions issued in generic form.⁶⁶

Radiology and diagnostic imaging

Improvements in scanner technology meant that both magnetic resonance imaging (MRI) and computed tomography (CT) scanning could be carried out more rapidly. The introduction of ultra-fast CT, with imaging times of 0.1 second, made it possible to show calcification in the coronary artery walls, which seemed to occur much earlier in the development of coronary artery disease than had been thought, opening the possibility of an early diagnostic test. Special scanners were developed, for example for sick newborn babies. Spiral CT scans combined with dye injections could show the rate of blood flow in the spleen and kidney. All general hospitals in the 1980s had wanted CT scanning; in the 1990s all wanted MRI. However, doctors sometimes had to be content with a visiting mobile unit operated by the private sector, which made it difficult for those undertaking the imaging to discuss patients with the clinicians.

Improved isotope techniques made it possible to image body functions as well as structure. White blood cells could be labelled with an isotope, and gamma camera pictures could show the areas of inflammation where cells were concentrated, which lit up like a neon sign. Monoclonal antibodies, similarly labelled, would be concentrated in the tissues for which they had been prepared, and then imaged. Sugar compounds, which were concentrated in metabolically active areas such as tumours, could be demonstrated by PET, making it possible to identify secondary cancer rapidly without further distress to the patient. Bone mineral density measurement was improved by the introduction of dual-energy absorptionometry in 1987. This provided an accurate and repeatable way of assessing osteoporosis. The technique used two different X-ray sources that could separate bone and soft tissue because of differential absorption. Measurement of total body composition (lean and fat body mass) was also possible, and because the radiation dose was low, serial readings could be obtained to demonstrate the need for, or effectiveness of, treatment for bone loss.

New and complex imaging systems - CT, radionuclide scanning, digital subtraction angiography and MRI - now accounted for up to a third of the examinations in modern radiology departments. They all yielded digital data and it was possible to transform other examinations into digital form. In 1985 the Hammersmith Hospital expressed a wish to develop a filmless radiography department, and over the next ten years the first such system in the UK was created, partly from central funding but mainly from charitable donations. All forms of imaging equipment were interfaced to the computer system. Straight X-ray images were recorded on special screens and read digitally by laser. The data created were vast, as each chest X-ray required more storage space than the Bible. Images were fed to immense computing facilities, for distribution by fibre optic cable to workstations throughout the hospital. The high definition of the images and the ability to magnify areas of interest and change their density and contrast were found by clinicians to be a substantial advance. More complex images, such as those produced by scanning, could be displayed, rotated and examined in three-dimensional form. Digital radiography opened immense possibilities for change and improvement in the NHS.⁶⁷

Although immunisation had made a substantial impact on infectious disease, the ultimate goal of the programmes was disease eradication. The global eradication of smallpox had been achieved, and in 1988 the WHO announced the goal of the global eradication of poliomyelitis by the year 2000. Individuals could be protected by immunisation, but when most of a population was protected, transmission of a disease from one person to another became uncommon, reducing the risk even to those who were not immunised (herd immunity). This had been achieved for poliomyelitis in the UK. To ensure that more babies were immunised while attending baby clinics, and before their mothers returned to work, the basic immunisation schedule was rescheduled in 1990, starting earlier, at two months.

Coverage of more than 90 per cent was achieved, with a dramatic effect on all three; clusters of cases were often importations. Immunisation against a common cause of meningitis, Haemophilus influenza type b (Hib), was introduced into the routine programme in 1992 and by 1996 a national coverage of 95 per cent had been achieved. The decline in notifications was dramatic and there was only one death in 1995.

Infectious disease

World-wide, new agents responsible for infectious disease were continuously being identified; 22 between 1973 and 1994.⁷⁰ Some such as Lyme disease, originally identified in other countries, were subsequently found in the UK. The European Commission became increasingly involved in public health issues, and established surveillance and information networks for individual diseases. As a result the guidance on the reporting and management of outbreaks was more consistent. Tuberculosis had seemed on the path to elimination. Cases declined tenfold between 1948 and 1987 although high levels of immigration from the Indian sub-continent in the late 1960s slowed the fall. In the UK there were about 5,000 new cases a year but the numbers started to rise again. Internationally a major cause of the rise was HIV infection, which when combined with resistant strains of Mycobacterium led to rapid death. Migration of people, poverty, deprivation and homelessness were also responsible for the increased number of patients. Drug resistance and poor clinical results were often caused by patients failing to take drugs as prescribed. An approach called 'directly observed therapy', in which health care workers made sure that patients took the proper medicines for six to eight months, emerged as a major breakthrough. Cure rates as high as 95 per cent were possible even in poor countries.

Reported episodes of food poisoning were also on the increase, some international in origin as food increasingly crossed national borders.⁷¹ Salmonella enteritidis infections had been rising for 25 years; by 1988 there were more than 20,000 cases annually. The problem appeared to be infected eggs.⁷² In December 1988 Edwina Currie, a junior health minister, warned people that most of the egg production was infected with Salmonella. Almost all chickens and eggs in Europe derived from two genetic strains, bred for food conversion efficiency and egg production rather than disease resistance. Although not clear at the time, the problem was world-wide, not just British. Mrs Currie's comments led to a food scare of then unparalleled intensity: a crisis in the industry, the slaughter of flocks and her own resignation. She was, in fact, largely correct. Her vivid presentation of important health education issues had been useful and her departure was regrettable. Subsequently, under the aegis of the European Union, a European surveillance system was established, Salm-Net, based at the Communicable Disease Surveillance Centre, Colindale, part of the PHLS. Other processed foods were also implicated. Pâté was found to be a significant cause of food-borne listeriosis. The largest recorded outbreak of food-borne botulism in the UK occurred in 1989: 27 people were affected and one died. They had eaten one brand of hazelnut yoghurt that contained hazelnut conserve sweetened with aspartamine rather than sugar. A combination of inadequate sterilisation and a changed composition had allowed Clostridium spores to survive.⁷³ In 1996 an outbreak of E. coli 0157 infection from contaminated meat products killed 17 people and affected a further 400.⁷⁴ A subsequent report called for the establishment of an independent Food Safety Agency, a proposal accepted by the Labour government in 1997.

In 1986 there had been an outbreak of a brain disease in cattle in southwest Britain.⁷⁵ The condition, bovine spongiform encephalopathy (BSE), was thought to be related to Creutzfeldt-Jakob disease (CJD), scrapie and kuru, all forms of degenerative brain disease transmissible by food; it appeared that the sick animals had been fed meat products. A working party recommended in 1988 that sick animals be destroyed and BSE was made a notifiable disease. The government banned feed products made from ground cattle and sheep remains and ordered the slaughter of infected livestock. How effectively these measures were carried out was open to question. The existence of the disease led many countries to restrict meat imports from Britain. A CJD Surveillance Unit was established in Edinburgh in 1990; the PHLS were not involved, there being no initial evidence of a human-animal relationship. A ten-year debate began, marked by contradiction, warning from meat producers against hysteria and unwavering reassurance from the government. Concern mounted in 1995 about transmission to humans when three farmers died of the disease; the media sounded alarm bells because it was a newsworthy story, government took a low key approach to prevent unwarranted panic, and medical scientists were divided in the evaluation of the possibility. In 1996 ten cases of a highly stereotyped variant of CJD in people below the age of 42 years pointed to a link between BSE and CJD, and strengthened the possibility of transmission from animals to humans. The credibility of government advice on public health issues had been undermined. The government, which for years had maintained that there was no evidence of transmission from animals or meat products to humans, had to revise its stance. There was public alarm, greater slaughter of cattle, government anxiety at the prospect of compensation for farmers and for victims' families who might argue that past reassurances were fallacious, and repercussions with the European Community after a worldwide ban on British beef was instituted.⁷⁶

Overshadowing the antibiotic treatment of infection was the escalating problem of antibiotic (and antiviral drug) resistance, thought by some to herald the dawn of the 'post-antibiotic' era. About one patient in ten in acute hospitals had an infection acquired after admission. Elderly patients, neonates and those on immunosuppressive treatment were particularly vulnerable, and multi-drug-resistant organisms such as Staphylococcus aureus, Gram-negative bacilli and enterococci were present in many hospitals. The development of new antibiotics had largely ceased and only one, vancomycin, remained of real value in the management of resistant infections.

Blood transfusion had long been known to lead, on occasions, to illness, for example to liver disease. In 1989 the virus for hepatitis C was isolated. The first test available gave many false-positive results and the blood transfusion service delayed screening donors until 1991 when a better one was introduced. During the interval a substantial number of recipients contracted the disease and it was necessary to look back to identify patients who, unknowingly, might have been infected.⁷⁷

Since surveillance of Legionnaire's disease had begun in 1979 there had been 100-200 cases every year, about half in travellers returning from overseas and the rest British in origin. Travel-related disease remained a problem. Malaria was a regular import with over 1,000 cases annually. In the former Soviet Union, where the immunisation rates were low, an epidemic of diphtheria accompanied the break-up. Ebola fever recurred in Zaire, and people were discouraged from going there.⁷⁸

Sexually transmitted disease and AIDS

Sexually transmitted diseases were now second only to respiratory tract infections as a cause of reported morbidity from communicable disease in Europe.⁷⁹ Travel and migration raised concerns about the international emergence and spread of resistant strains, possibly as a result of non-specific use of broad-spectrum antibiotics. Trichomoniasis decreased; syphilis remained constant. Genital wart infections, chlamydia and herpes simplex virus infections were increasing. Gonorrhoea had increased steadily during the first three decades of the NHS, but the ten years from 1977 had seen a decline in the number of cases. Then the number of cases levelled out for a decade, but began to fall again from 1990. Radical innovations in treatment could not take credit, for effective drugs had long been available and drug resistance did not produce substantial difficulties. Early treatment and contact tracing were probably responsible. Surveys demonstrated that in most countries there were small, definable, sexually active groups that maintained the endemicity of disease through intragroup sexual contact. Young and poor people, non-white ethnicity, inner city residents, prostitutes and their male clients were, in different countries, the most visible members of these groups.⁸⁰  The 1988 prediction had been for a rapid growth of epidemic of AIDS; it was taking only 11 months for the number of cases reported in the UK to double. The projections were revised down over the next few years as evidence suggested that transmission among homosexual and bisexual men declined markedly between 1983 and 1987, with the adoption of safer sexual practices.⁸¹  

Surgeons, who might puncture their gloves during an operation, became concerned about the risk to themselves. British and American authorities published guidelines on clinical practice. Some surgeons argued for compulsory testing of patients. Testing for anti-HIV-1 and 2 improved screening of blood donations in 1990.

A residential and support centre for people with AIDS, Lighthouse, opened in London in November 1988.⁸⁴ It harnessed a vast amount of unusual and lucrative support, particularly from the performing arts, and provided for skilled counselling, long-term support in the community, and provision for terminal care and respite admissions.

In the early 1990s attitudes began to change. AIDS had remained, in general, a disease of large cities. Ministers took a firmer line. When drugs that seemed to influence the disease began to appear, there were stronger scientific grounds for testing and contact tracing was given greater prominence.⁸⁵ Trials for the first major breakthrough in treatment, zidovudine (AZT), were hard to interpret. They suggested little benefit from use early in the disease, although there was some effect on fully established cases. The virus seemed to require a protein, reverse-transcriptase, to reproduce; additional drugs, for example 3TC and protease inhibitors, were developed to block its production. The Delta controlled trial showed that drug combinations prolonged life and delayed disease progression.⁸⁶ Some patients, believing that they were slowly dying, had to readjust to the possibility of continued life. Almost overnight clinical practice changed, although multiple drug regimens cost 50-75 per cent more than single drug regimens and perhaps over ,10,000 per year per patient. It was another pressure health authorities found difficult to resist. For the third world preventive measures remained the only viable approach. Slowly HIV infection came to be treated less as an exceptional condition to which different rules applied. Young people became used to intrusive questions from insurance companies. In 1996 the first over-the-counter HIV test was approved for sale in the USA, a doubtful advance as people might find themselves to be negative despite taking risks. Government-sponsored health promotion advertising had not specifically targeted the gay community - although the voluntary organisations did so. The gay community now argued that it had been neglected and for the first time government campaigns were directed towards it.

Genetic medicine

Genetic medicine developed rapidly.⁸⁷ The most important, and the largest, research programme of the decade was the human genome project, aimed at creating sequence maps of all the nucleotides in humans, in the hope that basic knowledge of structure would cast new light on the cases of disease. Three agencies in the USA and workers in Japan and Russia were working on the project, and Europe with smaller resources was doing what it could. More than 2,000 disorders were said to be caused by inheriting a single faulty gene. In 1995 alone over 60 disease genes were isolated. By 1996 the genes responsible for most common single-gene disorders had been isolated and characterised. There was increasing interest in conditions caused by the interaction of multiple genes, for example insulin-dependent diabetes, high blood pressure and atherosclerosis, although in the short term few such patients were likely to benefit from basic research. Several cancer susceptibility genes were identified from studies of families showing 'autosomal dominant inheritance', in particular breast cancer in which 10 per cent of patients had a family history of the disease in a close relative. In the USA genetic tests went on open sale. DNA analysis became a standard investigation for ever more disorders. The genetic state of family members and pregnancies at risk could be determined for an increasing number of conditions, including haemoglobinopathies, Duchenne muscular dystrophy, cystic fibrosis, Huntington's chorea and phenylketonuria. The main clinical impact was on the detection of 'carriers', presymptomatic and prenatal diagnosis. Information and counselling for women at risk was provided, often in an ad hoc way, in cancer genetics clinics that were often funded from research moneys.⁸⁸ These provided access to preventive services, screening, diagnosis and treatment, so those at increased risk might be identified and encouraged to act accordingly. Few doctors were knowledgeable in this new field and primary care teams required education and specialist support. Patients and relatives needed help and counselling from doctors, social services and voluntary organisations.⁸⁹ Because there was a possibility that in future genetic techniques would enable the identification of people at risk of developing a wide range of diseases, such as asthma, cancer, diabetes and heart disease, both before and after birth, genetic experts believed that advances in technology would have a major impact on health care, its costs and its ethics. There was a risk that genetic screening, because it identified those at high risk, might lead to their exclusion from insurance schemes, health benefits and even employment. Geneticists asked for a strict regulatory framework; the government instead set up the Human Genetics Advisory Commission.⁹⁰

In the previous 40 years there had been great improvement in the survival rate from cystic fibrosis, an inherited disease in which one person in 20 is a carrier, and which has an incidence of about 1 in 400. Cystic fibrosis produces progressive lung damage in childhood and adolescence, reduced by physiotherapy, antibiotics, better nutrition and the development of centres with a special interest in the disease.⁹¹ It became one of the most intensively researched of the simple genetic diseases, and the discovery of the gene responsible gave an insight into what went wrong.⁹² Several approaches to treatment were developed; none worked particularly well. Increased understanding of the basic science did not necessarily lead to cure, but it provided new starting points for the quest for practical treatment.

The excitement associated with surgical advance tends to distract attention from the more common procedures undertaken by the NHS. The number of operations performed was rising about 5 per cent per year. In 1992 the Royal College of Surgeons revised its guidance on day surgery, the conditions to which it might be applied and the information that should be given to patients.⁹³ Day surgery could be used more widely as a result of advances in anaesthetic techniques. Short-acting anaesthetics, such as propofol, and pain-relieving drugs provided good operating conditions and quick recovery, making it easier for patients to go home rapidly. The costs of day surgery were substantially less than admission, and purpose-built units increasingly provided an efficient environment for the staff and greater convenience for day patients. In 1994 the NHS Executive suggested that 60 per cent of all elective surgery could be conducted as day cases. Managers tried to persuade clinicians to deal with as many patients as they could in this way.

Laparoscopy was initially used largely for diagnostic purposes but the development of high-quality imaging systems, ever-smaller electronic chip cameras, versatile instruments and linear stapling devices opened new fields in gynaecological, urological and general surgery. Rapid adoption of minimal access surgical techniques followed pioneering work on laparoscopic removal of the gall-bladder (1989). The laparoscope was fitted with a high-resolution colour television camera; the average length of stay seemed shorter, and two weeks later it was difficult to see that an operation had been done at all.⁹⁴ Soon most cholecystectomies were carried out in this way. Heralded as a major advance in surgical therapy that reduced hospitalisation and quickened post-operative recovery, the escalation in its use was accompanied by increasing concern that it caused more deaths and debilitating post-operative morbidity than conventional surgery. The speed of the introduction of the techniques meant that clinical reports inevitably related to small series with only a short period of follow-up, comparative studies available were often flawed and the evidence that it was better than standard operations was uncertain.⁹⁵ However, district general hospitals (DGHs) rapidly took up the new approach. Endoscopically assisted hysterectomy, appendicectomy and hernia repair were also introduced, joining day-case arthroscopy and transurethral prostatic resection to reduce inpatient stays. Minimally invasive surgery was used to treat prolapsed intervertebral disks ("slipped disks') causing back pain. In spite of the emphasis on evidence-based medicine, minimal access surgery was adopted largely without formal assessment of its efficacy. The new procedures often took longer to perform and few surgeons had experience of the special methods. Even in the best hands there might be clinical disasters, and not all surgeons prepared themselves adequately for the new techniques. An entire generation of surgeons required training in the new methods. A minimal access surgery training unit was established at the Royal College of Surgeons of England and other Royal Colleges established guidelines for training in the new methods.⁹⁶

The pressure on orthopaedic units was increased by the steadily rising numbers of fractures of the femur; the main hope for reducing the load lay in prevention, perhaps by hormone replacement therapy. Greater numbers of total hip and knee replacements also increased the load on orthopaedic departments and the results of knee surgery were getting better all the time.⁹⁷ Although 60 different replacement hip joints were on the market, only for the Charnley pattern, widely regarded as the gold standard, had 20 years of follow-up results been published.⁹⁸ Hip replacement was increasing in younger patients and given enough time most would begin to wear. There was a case for some orthopaedic surgeons to specialise in revision operations, which were difficult and required familiarity with bone grafting techniques and the use of custom-made components.⁹⁹ Because of the risk of deep venous thrombosis complicating joint replacement, anticoagulant prophylaxis was increasingly used. Education in the management of fractures and the development of new techniques continued in Switzerland, and a new centre was established near Davos for experimental surgery and to provide training. Because of greater public participation in sport, sports injuries were becoming a large part of the work of orthopaedic departments, essentially self-inflicted injury proving expensive to the NHS. The management of backache, a major and long-standing problem, remained unsatisfactory. Neither orthodox nor alternative medicine offered any reliable form of treatment; normal activity might even be best.¹⁰⁰ Imaging procedures, in particular MRI, were increasingly adopted and began to replace arthroscopy in, for example, the diagnosis of sports injuries of the knee.¹⁰¹

Accident and emergency departments were under increasing pressure, and the beds required to support them were in short supply. On occasion they, and intensive care services, also had to cope with terrorist incidents, and disasters such as the air crash on the M1 motorway in January 1989, and the crush injuries and asphyxiation at Hillsborough football ground in April 1989 when 95 people died. The services were, however, increasingly well prepared. In 1988, when faulty signalling caused an express to plough into a packed commuter train in Clapham, 35 were killed and 500 injured but in general those alive when the rescue services arrived, survived. A policy of rapid transfer to hospital had been balanced by stabilisation before removal. Paramedics could maintain the airway and start intravenous fluids, and were helped by doctors trained in emergency medicine. In the belief that the management of patients with serious injuries would be improved if it were centralised on large trauma centres serving a population of 2 million, and seeing over 50,000 patients a year, the North Staffordshire Royal Infirmary, Stoke-on-Trent, was selected as a pilot centre in 1990. Six years later there was little evidence that it had improved survival. Doctors had argued for major trauma centres for 30 years,¹⁰² but closure of local accident departments aroused vociferous protests. Now, however, the general standard of accident departments had improved substantially and the additional gain from larger units seemed not so great. Helicopter evacuation was also explored. They had been used to evacuate battlefield casualties since the Korean war and the first civilian service was started in Cornwall in 1987. After that ten further services began, including one based at the Royal London Hospital. From the outset there were doubts about an expensive method of transport that was cramped and noisy, and made treatment on board difficult; weather conditions could also prevent the operation of the service.¹⁰³ A review suggested that the London service did not improve survival over the short distances involved. What mattered was the speed of getting trained people to the incident to control haemorrhage and maintain the airway, rather than the method of transport used.¹⁰⁴

Cardiology and cardiac surgery became ever more specialised; cardiologists might now specialise in cardiac imaging, interventional cardiology, or pacing and electrophysiology. Paediatric and fetal cardiology emerged as new specialties; children as well as adults could undergo cardiac catheterisation and operation through a catheter. Stenosis of the pulmonary valve could be treated in this way, and minimal access surgery also permitted the closure of heart septum defects in children. Cardiological services were increasingly decentralised, improving the access of the population. Much was being learned about the electrophysiology of the heart. Physiological pacing for disturbances of heart rhythm improved in sophistication. Dual chamber pacemakers, though more expensive, could sense heart activity, increase cardiac output and improve patient well-being.¹⁰⁵ The treatment of high blood pressure with diuretics and beta-blockers had been shown, beyond dispute, to reduce the risk of stroke. The impact on coronary heart disease seemed disappointingly small and there was inadequate evidence to say whether newer drugs, angiotensin-converting enzyme (ACE) inhibitors or calcium antagonists, had an effect on either condition.¹⁰⁶ After two studies of intravenous streptokinase, thrombolytic drugs (to break down clots) were widely adopted in 1988 for myocardial infarction, and aspirin was found to add to the benefit. The sooner blood flow could be restored, the more effective treatment was. Speed in diagnosis and transfer to hospital, and fast-tracking patients on arrival to minimise the delay in giving thrombolytics, was required.¹⁰⁷ Health promotion campaigns were given added impetus, such as 'Look after your heart!' launched by the Health Education Authority in 1989. Giving up smoking, lowering lipids, taking moderate exercise and controlling high blood pressure were their mainstays.

Whereas surgeons operated on about 1,000 patients with congenital heart disease and about 5,000 with heart valve problems, these numbers were now dwarfed by procedures for ischaemic heart disease. Angina pectoris and coronary thrombosis were amenable to the new surgical techniques, no longer the sole preserves of university hospitals. Simpler problems and younger cases tended to be managed by percutaneous transluminal angioplasty, which rose 15 per cent each year (13,000 in Britain in 1995), and was even more commonly used in continental Europe and the USA. New techniques included the use of intracoronary stents, metal mesh devices introduced with a balloon catheter to keep blood vessels open and reduce the chance of re-stenosis. Thrombosis around the stent was a common complication until the design was improved, and drugs were given to reduce the likelihood. Angioplasty during the early hours of a heart attack was an alternative to thrombolytic drugs. Where should it be undertaken - in sub-regional centres or in district hospitals where it would be more readily available? Coronary artery bypass grafting (CABG) was also increasing at 10 per cent a year, and showing no signs of reaching a plateau. The cardiovascular community had been studying the effectiveness of CABG for 25 years, and angioplasty for 15; large trials had been undertaken and it appeared that bypass surgery resulted in a reduction of mortality over four or five years compared with medical treatment, at least in those at moderate or high risk of death.¹⁰⁸ The pressure on cardiac surgical units was almost overwhelming, as patients on the waiting list were delayed because more urgent patients in hospital demanded attention. The stay in intensive care was shortened to the limit, and people were fast-tracked through progressive care and recovery facilities. Staff worked harder, longer and nearer the brink of safety.¹⁰⁹ New surgical techniques continued to be introduced, including heart transplantation and implantable mechanical pumps for heart failure.¹¹⁰

Several new immunosuppressive drugs were introduced that had different effects on the immune system, including tacrolimus and mycophenolate; combination therapy improved results. In January 1989 Papworth celebrated ten years of heart transplantation; surgeons there were now operating on 120 people a year and following up 260 survivors. The number of heart transplants carried out annually grew, as new centres were opened and the number of organs available for transplantation increased, assisted by publicity, including a special edition of BBC TV's That's life. However, a shortage of organs for transplantation meant that many who might benefit did not survive long enough to do so. Pigs were bred with genetic modifications to make them more suitable as a source of organs for transplantation, although some saw the risk that such organs might transmit retrovirus infection to humans.¹¹¹ Liver transplantation became more common, and techniques were developed that enabled the liver to be divided to transplant into two recipients. Small bowel transplantation had been attempted in the 1960s and 1970s without much success. The problems of long-term intravenous feeding, and better immunosuppressive drugs, led to further attempts. The success rate improved enough for it to become an option for the treatment of end-stage intestinal failure, mainly patients with anatomical abnormalities or intractable functional disorders. The survival rate was poorer than for many other transplant procedures, roughly two-thirds a year after operation, and a third after three years.¹¹²

Renal replacement therapy

The number of patients receiving renal replacement therapy rose steadily to about 65 per million, but a report prepared for the DoH in 1996 said that all patients with renal failure up to the age of 80 years should automatically be offered treatment, and those over 80 should be carefully considered for it. The target was now 75-80 new patients annually per million and Britain continued to lag behind the rest of Europe in the numbers under care.¹¹³ Antony Wing argued for more units and better accessibility, for easy geographic access affected whether patients received the care that they needed. Nurse-practitioners played a key role in home supervision of the patients, who were increasingly elderly. The introduction of the Tenkhoff catheter made CAPD easier because, with careful technique, it allowed CAPD to be continued for several years. About a quarter of patients receiving renal dialysis continued to feel unwell because of anaemia caused by deficiency of erythropoietin, a hormone controlling red blood cell formation. A successful transplant solved the problem because the new kidney would produce this hormone, but not all patients could receive a transplant. Recombinant human erythropoietin became available but a year's treatment cost ,5,000 - yet another call on health service funds that might be better spent on basic treatment, more transplants and patients undergoing dialysis.¹¹⁴

Neurology seemed to have more than its share of genetically determined disease, for example Friedreich's ataxia and Huntington's chorea. Advances in genetics stimulated a better understanding of the mechanisms of neurological disease. In the rare diseases in which there was (muscular) weakness because of the failure of transmission of nerve impulses to muscles, many of which were related to the immune system, the exact site of the problem could often be determined and the biochemical mechanism understood. Gene mapping made it possible to identify missing genes in muscular dystrophy, opening up the possibility of antenatal diagnosis and selective abortion of those males affected, and the assessment of embryos before implantation. Such expertise was available in only a few places, large units with good laboratory facilities.

New imaging techniques improved the understanding of metabolic processes in health and sickness, in brain tumours, stroke and Alzheimer's disease. Positron emission tomography, in which glucose labelled with radioactive tracers was injected, made it possible to study biochemical activity in the brain. The introduction of virtual reality techniques improved the accuracy of brain surgery. New drugs such as GABA antagonists (e.g. lamotrigine) were a major advance in the management of epilepsy. Interferon-beta was used in an attempt to modify the immune process in multiple sclerosis, and to reduce the frequency of relapse. The management of chronic pain steadily improved, and the intensive care of patients with head injury was better. Imaging techniques and interventional radiology radically altered the treatment of cerebral aneurysms. New forms of drug therapy helped patients with incontinence and sexual dysfunction. Improved rehabilitation techniques underlined the fact that, although many neurological diseases were incurable, none was untreatable. Specialist teams of nurses, physiotherapists and social workers improved the care of people disabled by neurological disease, in hospital and in the community. Patient support groups and charities concerned with diseases such as motor neurone disease and multiple sclerosis provided physical and emotional support to patients, raised money for research and put pressure on government to improve public accessibility for people with physical disabilities.

The treatment of sensory deafness continued to improve as better multi-channel cochlear implants, commercially produced on a worldwide basis, became available. The earliest implants in the UK were funded by charities but in March 1989 Graham Fraser, of University College Hospital, took one of his patients to meet MPs at the House of Commons. So impressed were they that David Mellor, then Minister for Health, obtained ,3 million to establish six cochlear implant centres. By 1996, 800 adults and 600 children had been implanted in a continuing programme.

Sophisticated imaging and fibreoptic instruments, initially introduced in Austria and Germany, transformed the diagnosis of nasal and sinus disease that could now be assessed, and sometimes treated, in the outpatient department. Like other forms of minimal access surgery, the technique suddenly became popular, but the potential for damage to surrounding structures, the optic nerve and the brain, was high.

The use of lasers of different types was increasing. Treatment with them was quick, relatively painless and some techniques could only be performed by laser. Photocoagulation was used for treating proliferative retinopathy (in which there was abnormal development of retinal blood vessels), diabetic retinal disease, macular degeneration (where there was damage to the area of the retina providing the most detailed images), retinal holes and chronic open-angle glaucoma.¹¹⁵ A new method of treating short sight was introduced into the UK in 1989, modifying the refractive power of the cornea by reshaping the central area with excimer laser keratectomy.

Cataract surgery was ideally suited to day care, 90 per cent of patients being treated in this way. Improved techniques and equipment continued to reduce the period of visual rehabilitation after cataract surgery to about a week. The new methods involved the use of costly equipment, such as the phaecoemulsifier which is used to break up the now opaque lens before its removal and replacement. The use of self-sealing, sutureless wounds and foldable intraocular lens implants that could be introduced through a smaller incision made for an easier postoperative period.¹¹⁶

The ageing population was inevitably leading to an increase in the number of people developing cancer. A major problem was undetected spread at the time of first treatment, such that the aim was often cancer control rather than cancer cure.¹¹⁷ The hope was that molecular genetics would help to identify those at risk, assist early diagnosis and provide new forms of treatment. Cancer of the lung remained the commonest form, with 40,000 new cases in the UK each year. Whereas survival rates for several forms of cancer had improved over the previous 20 years, the advances had been modest because the great improvements had occurred in rarer cancers, accounting for less than 10 per cent of the total. In surgery the trend was towards operations that were less extensive and destructive. Radiotherapy remained a major form of treatment, used for about half the 200,000 people developing cancer each year.¹¹⁸ It could be delivered ever more accurately using the new scanning techniques, having a potentially curative role for about two-thirds of patients and a palliative role in the remainder. Chemotherapy was increasingly used, opening the possibility that new drugs might in time become first-line treatment in common cancers. The appropriate balance of chemotherapy, surgery and radiotherapy was the centre of clinical trials. Newer drug regimens were expensive; intravenous immunoglobulin for chronic lymphatic leukaemia was perhaps most costly in terms of life saved. Several new anti-cancer agents were promising, including taxol (shown to extend life by an average of a year in patients with ov