National Health Service History
1978 -1987 - Clinical advance and financial crisis
|Winter of discontent||1978|
Alma-Ata declaration: Health for All
Conservative government (1st term)
|1979||Royal Commission on the NHS reported|
Patients first (a priorities document)
|Kennedy’s Reith lectures||1980|
Black Report on inequalities in health
|Humber Bridge opens||1981|
Care in action (a priorities document)
Barbican centre opened in London
Tylenol deaths from cyanide sabotage
|1982||First reported case of AIDS|
Körner Reports on information
Mandatory GP vocational training
NHS restructuring; abolition of areas
Conservative election victory (2nd term)
|1983||NHS management enquiry (Griffiths)|
Mental Health Act
Pay review body established for nurses
Binder Hamlyn report on cash limits for family practitioner services completed, but not published
British Telecom privatisation
Band Aid concert for Ethiopian famine
Data Protection Act
Implementation of general management function
Limited prescribing list for GPs
Stanley Royd salmonellosis outbreak
|Word processors increasingly common||1985|
Enthoven’s review of NHS
Chernobyl nuclear disaster
|1986||BSE identified in cattle|
Primary health care Green Paper
Neighbourhood Nursing: Cumberlege Report
|Conservative election victory (3rd term)|
Black Wednesday on stock market
King’s Cross tube station fire
|1987||Promoting better health (White Paper)|
Achieving a balance (medical manpower)
Health Education Authority
The thirtieth anniversary of the NHS in 1978 brought self-congratulatory noises from the Department of Health and Social Security (DHSS).1 The medical profession took a different view and dissociated itself from celebrations.
In 1948 the NHS may have been an example to the rest of the world, but 30 years later it measures poorly against many alternative methods of providing health care, and its medical and nursing staff are disillusioned and depressed. Yet only ten years ago the same staff were enthusiastic and optimistic. There is nothing wrong with the concept of the NHS . . . What has gone wrong?2
Two experienced commentators, Sir Francis Avery Jones, a clinician, and Professor Rudolf Klein, an academic, thought NHS reorganisation had put too great a distance between administrators and clinicians, breaking up the partnership and trust between those working in and those running the service. Economists, civil servants and administrators with no recent clinical contact had written three major documents of the previous decade, the Report of the Resource Allocation Working Party, the Priorities document (Priorities for health and personal social services), and The way forward. The combination of an administration remote from practical realities and abrasive labour relations had made the NHS vulnerable to financial stresses, when all over the world medical services had been struggling to reconcile economic stagnation with a period of remarkable technical and pharmacological innovation. A major cause of low morale was the dangerous delays in decision-making that NHS reorganisation had produced. An environment free from internal dissension and outside interference was needed.
There was increasing scepticism about the idea of an all-embracing welfare state. Not even prosperous economies (and Britain’s was not that) could slake medicine’s insatiable thirst for resources and skilled staff. ‘There has been a lot of wild talk recently about the NHS being in danger of collapse through lack of funds,’ said David Ennals, Secretary of State. The fact is that current spending in real terms has gone up every year under this government.’3 Staff were not convinced. The managerial response to low morale seemed to be to demand better information systems. The cult of arithmetic waxed. The workforce was counted, cash was limited, budgets were set and indicators of performance were calculated. Less attention seemed to be paid to the organisation and development of clinical services. The direct access between staff and management enjoyed pre-reorganisation was sadly missed.4 Large-scale organisations were increasingly seen as out-of-date monuments to the optimistic belief in rational planning that dominated the 1960s and early 1970s. The reorganisations of 1974 and 1982 epitomised the change. In 1974 the emphasis was on the centralisation of planning and the centre could reasonably claim credit for growth. In 1982 the emphasis was on decentralisation of responsibility; governments were well advised to diffuse the blame for bad news.5
Overshadowing the health service was the financial pressure after the oil crisis. Spending on the NHS had previously grown faster than the economy. In the earlier decades, staff believed that if they did not get the money they wanted one year, they would do so in the next. The reduction of growth in real terms, from 34 per cent in earlier decades to less than 1 per cent, now meant that some dreams would never come true. The Labour government had tried to constrain NHS costs by income policies and cash limits, and to shift more resources to the care of people who were elderly, mentally ill or mentally handicapped. It proved difficult to change spending patterns at a local level. The search for a new national solution began.
Public mood had swung away from unquestioning admiration of science and technology. Ian Kennedy’s Reith Lectures in 1980 were a watershed in public perception of medicine. Kennedy suggested that there should be a new relationship between doctor and patient, with people taking greater responsibility for their lives, challenging the power that doctors exercised.6 Nuclear energy was seen as a threat, the car was evil and jet aircraft were noisy and polluting. Films were concerned with doom, disaster and the paranormal. Much could no longer be taken for granted; violence might be random and meaningless.
On September 29th 1982 12-year-old Mary Kellerman of Elk Grove Village, Illinois, woke up at dawn and went into her parents’ bedroom. She complained of a sore throat and a runny nose. Her parents gave her one Extra-Strength Tylenol capsule. At 7 a.m. they found Mary on the bathroom floor, and immediately taken to the hospital, she was pronounced dead. Doctors initially suspected that Mary died from a stroke. A 27-year-old postal worker was found lying on the floor. His breathing was labored, his blood pressure was dangerously low and his pupils were fixed and dilated. The paramedics rushed him to hospital. He was dead. Firefighters discussing four bizarre deaths noticed that all had taken Tylenol. A hospital doctor wondered about cyanide poisoning. The police retrieved suspect bottles and a day later it was confirmed that capsules, all from one batch, contained 65mgrms cyanide, 10,000 times the lethal dose. There were 7 deaths mainly around Chicago. 31 million bottles of Tylenol were recalled but it seemed that the factory was blameless, bottles on store shelves seemed to have been tampered with. Johnson & Johnson introduced money off coupons and tamperproof packages.7 Public confidence soon returned, but the poisoner was never found. Over the next months there were many copy-cat incidents, some fatal.
Patients and health care were not immune from evil. Tylenol entered the textbooks and became a classic example of industrial – and health care – crisis management. Johnson & Johnson's top management put customer safety first, before they worried about their company’s profit and other financial concerns.
The BMJ felt that there was a flight from science. Increasingly patients were being treated by alternative medicine meditation, acupuncture, ginseng and a galaxy of special diets. Much of the appeal of alternative medicine lay in the setting in which it was given. Practitioners gave their patients time, courtesy, individual attention, and they listened. Healing was not necessarily the same as curing, and a compassionate healer who did nothing to arrest the disease process could relieve symptoms.8 Whatever the merits of alternative medicine, those seeking it were seldom cranks; they were well-informed people seeking a solution to an unresolved long-term problem. They had not lost confidence in conventional medicine. Young doctors showed more interest in the techniques than their seniors.9 Nevertheless, for medicine there was a downside. While the media gave massive publicity to the hazards and side effects of orthodox medicine, the proponents of alternative medicine such as chiropractic did not follow the same standards of proof when it came to assessing their favoured alternatives. The British Medical Association (BMA) Board of Science and Education examined how far it was possible to assess the effectiveness of alternative medicine. Although not totally impossible it was nearly so, partly because with some therapies no two patients were treated alike. While alternative medicine comforted many, and some might be ‘healed’, the responsibility of the medical profession, said the BMA, was to types of care that could be assessed scientifically.10
Television was now deeply involved in health service affairs. Since Your life in their hands was first screened in 1958, ever more programmes had been produced, sometimes sensitive and deserving acclaim, occasionally a travesty of medicine. Ian McColl, Professor of Surgery at Guy’s, advised the BBC on request, and the requests were frequent. Most doctors now accepted that the public needed information to form a view of important but undecided medical issues, and to cooperate in treatment. However, producers did not seem to feel that a balanced approach necessarily mattered.11 When Channel 4 was set up the BMJ urged the new programme makers to increase public awareness about the influence of life styles on health, the limitations of what medicine could do and the need to debate medical priorities.12 In October 1980 BBC’s Panorama broadcast a programme on brain death. It centred on four American patients, said to have been declared brain dead, who subsequently recovered. In none of the cases were the criteria for certifying brain death, set out by the Royal Colleges,13 satisfied even approximately. The Director General of the BBC, Ian Trethowan, was told in advance that damage would be done to the renal transplant programme and patients would die as a result. The BBC edited out the comments of British doctors whom they interviewed. The Secretary of State told Parliament it had been a disturbing broadcast and his department had received torn-up donor cards from people worried by what they had seen. In a single night Panorama virtually destroyed trust between television and the medical profession. Transplantation numbers remained static for two years. While the BBC proposed to return to the topic subsequently, it and the Royal Colleges failed to agree on the arrangements for a reply. The BMA and the Colleges held their own press conference in an attempt to allay public anxiety.14
Rudolf Klein said that it was easy to forget one startling fact. Throughout its history the NHS had enjoyed popular support. The NHS was probably the most popular institution in Britain.15 Its finances might be precarious, its staff on the edge of revolt and its facilities threadbare. Yet whenever pollsters asked the public, four out of five declared themselves satisfied, a figure remarkably steady over the decades. The contrast between public support for the health service and increasing cynicism about other national institutions such as Parliament was striking. However, general satisfaction was combined with specific grievances, such as the organisational routines of hospitals and the personal attitudes of staff. There was also a generational effect. People who grew up in the pre-NHS era had lower expectations. Dissatisfaction was therefore likely to increase.16
The introduction of the NHS had greatly reduced the role of private health care, and what little persisted was essentially in the hospital sector. Following Barbara Castle’s forays, however, health care had moved hesitatingly and haphazardly towards a mixed economy. The assumption that health care policy could be equated with what was happening in the NHS was no longer valid.17 Private care was performing two main functions. First was the elective (non-emergency) treatment of acute self-limiting illness, paid for predominantly by insurance, mostly in the south where the NHS itself was best funded, and undertaken by consultants also working in the NHS. Secondly, there was the long-term care of elderly people in residential and nursing homes, paid for partly by the individuals concerned but increasingly by social security private provision of publicly financed care. There was, according to Rudolf Klein, no clear explanation for the growth; was it ‘overspill’, an excess of demand over supply creating a private sector? Were the attractions of private health care making it the preferred pattern when payment was no great problem? Could the blame be laid at Labour’s door, whose wages policy provided an incentive for employers to offer health insurance, and whose assault on private practice had lessened the commitment of some consultants to the NHS? The General Household Survey in 1982 showed that 7 per cent of both sexes had some form of private insurance. The number of operations performed privately was also rising, to 17 per cent in the Oxford region in the early 1980s.18 Previously, private work was often carried out in the evenings or at weekends. Increasingly it was undertaken during the normal working day, nearly all by consultants working for the NHS, which created an awkward relationship seldom found in the commercial world or the public service, although accepted by Bevan from the beginning.19
Private health care was particularly common in some surgical specialties, such as ophthalmology, heart disease and orthopaedics. Waiting times for an NHS outpatient appointment in these specialties were usually lengthy, and further time was spent waiting for admission. The NHS workload of surgeons who also engaged in private practice varied widely, and the specialties with the longest waiting times were also those with the highest earnings from private practice. Two-thirds of private work was undertaken by 20 per cent of NHS consultants, and doubling their income was comparatively easy in some fields. Many reasons for NHS waiting lists could be quoted. There might be a shortage of consultant staff, although the local surgeons were sometimes loath to see an additional colleague appointed. Shortage of money might mean the curtailment of operating sessions. Often the only way for patients to avoid a long wait was to pay, when the problem disappeared.
Developing countries could not even start to emulate the patterns of health care common in the West. Increasingly they looked to primary health care, the use of semiskilled workers based in the community, and collaboration between different sectors agriculture, water, sanitation and education. In September 1978 the World Health Organization (WHO) and UNICEF called a conference at Alma-Ata in the USSR. The resulting declaration stressed that primary care was the route to Health for all, this was achievable by the year 2000 and could be attained at affordable cost.20 The definition of health was idealistic: health was a state of complete physical, mental and social wellbeing, not simply the absence of disease or infirmity. The Alma-Ata declaration pointed to unacceptable gross inequality of health status, the right of people to participate in the planning and implementation of their health care, and the need to switch expenditure from armaments and conflicts to social and economic development, of which primary health care was an essential part. Primary health care was not primary medical care; it was far broader. It was universal, based on homes and families rather than clinics, provided according to need, culturally acceptable with an accent on health promotion, housing and education, and involving the community in the planning process. It demanded redistribution of resources, between and within nations, radical change in medical priorities and passing power from the professional to the community. The European countries did not immediately recognise the ‘health for all’ movement as relevant to them; they saw it largely as a call to the richer countries to provide greater help to the third world.
The ‘new’ public health, based on these ideas, was in some respects a rediscovery of old traditions. Previously health promotion had been conducted in an earnest and worthy way. Now it became a mass movement with various schools of thought. The nature and style of health promotion broadened from disease prevention by providing information, and programmes with clear objectives and outcomes that could be measured, to community-based intervention based on alliances and pressure for legislative activity. Some argued that, alongside simple intervention such as immunisation, educating public opinion was essential and legislation would then follow. Others felt that legislative action, regulation and changes in taxation could be introduced irrespective of a public demand for them. Most believed that government, health promotion agencies, the media, educational institutions, local authorities, health authorities and industry all had a role to play, together and individually. Money, coordinated action, programme planning, research and evaluation were needed. Changes in life style were needed, particularly in smoking, diet, exercise, alcohol consumption, sexual activity and behaviour on the roads. Nationwide health promotion strategies were called for.21 Sometimes it took a disaster to shift public attitudes. Restrictions were increasingly placed on smoking in public places after the disastrous fire at King’s Cross underground station in 1987, when 31 people died.
The Americans produced Health for the year 2000 shortly afterwards. In 1985 the European office of the WHO published Targets for health for all. In 1986 the Ottawa charter for health promotion, the outcome of a joint conference organised by the European regional office of WHO and the Canadian Public Health Association, set out a broad conceptual policy for the direction that health promotion and ‘the new public health’ might take.22 The WHO launched its ‘Healthy Cities’ project in 1986, which aimed to build up a strong lobby for public health at local and city level. Early participants in Britain were Glasgow, Liverpool and the London Borough of Camden. The ‘Healthy Cities’ project reflected the increasing importance of the green movement, and health promotion was becoming increasingly politicised. Should organisations concerned with health promotion continue to restrict themselves to education or be more active in promoting healthy life styles, arguing for changes in society and the social, economic and legislative environment desirable for healthy living? Should health education encompass the socioeconomic factors relating to health? Richard Wilkinson, a community medicine student at Nottingham, researched the widening social class differences in death rates. This dissertation was published in 1976, picked up by the media and by the New Statesman. It was seen by David Ennals who, in 1977 commissioned the Black Report on inequalities in health, there was a broad consensus that the welfare state was a good thing, even if worryingly expensive. Published three years later, the Report showed that the association of health and socioeconomic status was not trivial; the standardised mortality rate was more than twice as high in social class V as in social class I. The association was universal. Wherever there was social disparity there was disparity in health, and disparity was to be found in a wide range of conditions from obesity to accident rates, arthritis and stroke.23 By the time of publication in 1980 things had changed and the Conservative government issued the report as duplicated copies of the typescript, without a press conference. The report was allowed to mature undisturbed, although it was updated in 1987 by the Health Education Council.23 By then, government had become unhappy with the HEC. The Health Education Authority (HEA) replaced it in 1987. A body less independent of government, it was given the task of health education on AIDS.
Strong though British primary health care was, it had not been particularly successful in the incorporation of health promotion. Social workers were seldom integrated into primary health care teams. Priority was not always given to people with the greatest need, and patient participation was rare. Alma-Ata challenged professionals to be more ‘patient-centred’ and government to give higher priority to primary care.24 Nevertheless, save in public health circles, Alma-Ata was barely mentioned throughout the management changes to come.
Access to services
Relevance to need
International concern with the rising cost of health care, and increasing awareness that not all treatment was helpful, was leading to closer examination of what professionals were doing. Robert Maxwell at the King’s Fund proposed six criteria that defined health care quality.25 Maxwell’s ‘six’ were drawn in part from American sources, for example the work of Donabedian and the US Joint Commission on Hospital Accreditation. They proved influential in Britain because they encompassed population aspects as well as those relating to individuals.
Retrospective review had led to the improvement of some forms of care, for example the confidential enquiry into maternal deaths. In 1979/80 the Association of Anaesthetists undertook a study based on over one million operations in five regions, associated with over 6,000 deaths within six days after surgery. The report by L N Lunn and W W Mushin showed that, although anaesthesia was remarkably safe, mistakes and avoidable deaths did occur.26 Trainee anaesthetists might be left unsupervised, and monitoring instruments might be inadequate or not used. In 1982 the Association of Surgeons and Anaesthetists set up a confidential enquiry into peri-operative deaths (CEPOD) related to operations in the Northern, South Western and North East Thames regions. Immunity from prosecution was obtained from the DHSS and all deaths that occurred within 30 days of any operation were studied. Probably the most vigorous self-appraisal ever undertaken by the profession, it was financed by the King’s Fund and the Nuffield Provincial Hospitals Trust. There were about 4,000 deaths among 555,000 operations. Widely differing standards of care were found and several problems were apparent. Surgeons might be operating outside their field of expertise, or there might be inappropriate surgery on patients known to be dying. Consultants were not always involved in serious decisions their trainees were making about patients, and some trainees were going far beyond their competence. The quality of hospital notes might be poor. Few deaths were reviewed as a routine. Sometimes elderly and sick patients were subjected to long operations when already in a poor medical condition.27 Two regions began a prospective review of neonatal deaths.
Walter Holland, at St Thomas’, followed Rutstein in looking at conditions in which it was generally accepted that appropriate and timely intervention could prevent death, and at the variation in mortality in different districts for ten conditions, including cancer of the cervix, tuberculosis, high blood pressure and asthma. Substantial variations that persisted over time were apparent. In one district it was found that the screening process for cancer of the cervix failed to reach high-risk individuals; in another there was failure to follow up abnormalities.28
In the USA workers examined the process of health care, variations in practice and the number of procedures undertaken. John E Wennberg, a US epidemiologist, showed what is now commonplace but was then a surprise. Medical care varied greatly from place to place in cost, quality and outcomes. Where you live determines how well or badly you are treated, and how much it will cost. From Dartmouth, New Hampshire, he showed that apparently similar groups of people in Vermont and Maine were treated for conditions such as enlargement of the prostate, carotid stenosis and coronary artery disease at widely varying rates, and even when far more operations were done there seemed to be no apparent difference in the outcome for the patient.29 Similar variations were found in the UK by Klim Macpherson. Wennberg believed that the different rates occurred because different decisions were being made about the need for aggressive treatment. Doctors were not equally well informed, and were motivated by factors other than pure science. Patients were seldom given enough information to make a rational choice and their preferences were not always sought. The more doubt there was about the indications for treatment, the wider the variation from clinician to clinician. Wennberg believed that some procedures were of little worth and that if they were abandoned the increasing cost of health care would lessen, and rationing would probably not be required.
To underpin decisions on priorities, measurements of outcome rather than process were required. Systems to assess health status were developed in the USA and in the UK. Questionnaires, sometimes self-administered, took account of pain, disability and emotional factors. They could be used on a regular basis to track the effect of clinical care. An economic perspective led to the development of the ‘quality adjusted life years’ (QALYs), which attempted to measure life expectancy and quality of life. Devised by the US Senate Office of Technology Assessment, QALY was popularised in the UK by Williams and Maynard, economists at the University of York.30 A year of healthy life was taken to be worth one; the value was lower if health was poorer or life expectation shorter. It might be possible to cost treatment that changed the QALY and produce a ‘cost/QALY’. For example, advice to give up smoking was cheap to give and, although comparatively few people took it, enough gave up smoking to generate a substantial benefit. Complex surgery might rate poorly, for the costs were high and life expectancy might not change dramatically. These techniques challenged the clinical freedom to carry out any treatment, however costly and slim the possibility of success.31 QALYs did not solve the problems facing clinicians. How did one value death or the quality of life enjoyed by people with widely disparate conditions needing hip replacement or renal dialysis or suffering from dementia? At a crude national level QALYs might provide a new insight, but to doctors caring for patients it was like comparing apples and oranges.
Robert Brook, Medical Director of the Rand Corporation in the USA, described the appropriateness of clinical practice as ‘the next frontier’ in clinical development.32 The Rand Corporation had long been interested in whether different patterns of health care organisation, or different forms of treatment, improved patients’ health.33 Everyone agreed that new drugs should be tested before their introduction. A similar consensus developed over surgical procedures. The phrases ‘health technology’ and ‘technology assessment’ were coined to cover new types of treatment and their scientific assessment. David Eddy, of Duke University, wrote about the creation of clinical guidelines.34 Paul Ellwood’s consultancy firm, Interstudy, developed questionnaires on patient health status. In his Shattuck Lecture on ‘outcomes management’ in 1988 he brought these ideas together.35 Guidelines, outcome management and evidence-based medicine (as the concept later became known in the UK) were much the same idea. As health costs rose, consumer groups became more powerful and widely varying patterns of practice persisted, could management remain on the sidelines? In the USA audit and quality assurance were generally introduced by management and backed by sanctions. When so much was being spent on care that was of doubtful efficacy, management had an incentive to examine the processes and the outcomes. This approach was not to the liking of the British medical profession, which preferred an educational approach. Government chose to keep out of the professional minefield. In 1948 the profession had been given an assurance that it would be free from outside intervention in clinical work, and British doctors were cautious about medical audit with its implied threat to clinical freedom. If the professionals wanted no outside interference, said the BMJ, would they ensure that patients had no need to be concerned about the quality of care? Jargon obscured the simple idea that doctors should look at their day-to-day work to see if they could improve it.36
Regular clinical review of routine work was not regarded as part of the day-to-day activity of a doctor. Don Berwick, who ran quality assurance at the Harvard Community Health Plan, a health maintenance organisation (HMO)* in Boston, argued that it should be, and that clinicians should be educated and encouraged, not policed.37 In the USA the Agency for Health Care Policy and Research (AHCPR), an agency within the US Public Health Service, was well financed to develop a wide-ranging programme of evaluative research to produce treatment guidelines and stimulate research on the effectiveness of established treatment. Well-established operations, such as transurethral resection of the prostate, might have a complication and re-operation rate far higher than had been thought. Priority was therefore given to major problems common in health services, which involved many people and cost much money, rather than rare conditions at the forefront of medicine.
[*HMOs, a US system of health care delivery first emerging in the second world war but becoming popular in the 1980s, were increasingly seen as an interesting organisational development. They provided an integrated health service for ‘members’, usually on a local basis and financed through capitation payments. Varying in pattern, they might own their own facilities or contract for them. They aimed to offer quality care more cheaply by restricting the choice of doctors, providing secondary care only in selected hospitals, encouraging clinical guidelines and sometimes placing an accent on primary health care. They competed with each other and with fee-for-service medicine. ]
Increasingly, new drugs were produced by techniques that manipulated DNA. The first drug for human use produced by genetic engineering reached the market in 1982, human insulin. New drugs were often designed to act on DNA or intercalate with it. Interferon, initially discovered in 1957 as a protein that interfered with viral infection, was the focus of much research. It proved to be a group of compounds, with several varieties alpha, beta and gamma that were produced in small quantities by recombinant methods. Although they caused regression in some types of tumours, their side effects limited the dose that could be given and interferon never was to cancer what penicillin had been to bacterial infection.38 A new antiviral drug of remarkably low toxicity, acyclovir, was introduced in the early 1980s, active against the herpes simplex virus that causes cold sores and varicella-zoster virus. It was immediately applied to eye infections, cold sores and viral encephalitis.39 The pharmaceutical industry undertook less work on cardiovascular drugs, where there had previously been great activity, to concentrate on cancer chemotherapy.
Diabetic control was improved by the introduction, in the late 1970s, of self-monitoring of blood glucose. It allowed patients to make spot checks before driving, exercising or sleeping, and enabled patients to build up a profile of their blood glucose concentrations to establish the best insulin dose. Combined with continuous subcutaneous infusion or multiple daily injections almost normal levels of blood glucose could be achieved.40 In dermatology the outlook for patients with psoriasis was improved by the introduction of ultraviolet light in combination with a skin sensitiser, and for those with acne by retinoid drugs derived from vitamin A.
The relief of pain had long been part of a doctor’s role. However, patients’ analgesic requirements differed and the dosage had to be adjusted to match individuals. New forms of equipment such as infusion pumps allowed patients to control their own pain and proved to be safe and effective when used for postoperative and obstetric pain, coronary pain and pain in terminal disease. No longer need patients in discomfort have to wait until a doctor or nurse had time to ask the necessary questions and decide if another dose was required.41
The popularity of oral contraceptives peaked in the mid1970s when about 3 million women were using them. Then usage fell a little, as women became aware of clinical studies showing complications and occasional deaths from thrombo-embolism. Lower-dosage pills restored some of their popularity. Increasingly, people turned to sterilisation, in particular vasectomy, as a safe and effective alternative.42
In the 1960s the benzodiazepines had replaced barbiturates in the symptomatic treatment of minor neuroses and anxiety states. The public and the profession embraced them with enthusiasm, and consumption continued to increase during the 1970s. Then it was noticed that some patients tended to ask for them for unduly long periods and they were shown unequivocally to produce pharmacological dependence. It was accepted that they were usually unsuitable for anything more than short-term use and their use began to decline.43
The establishment of the Committee on Safety of Drugs in 1962 had helped to keep unsafe drugs off the market. Sometimes, however, because adverse reactions were uncommon they became apparent only when drugs were in wide use. Opren (benoxaprofen) was an example. There were concerns about its safety from an early date. The manufacturers, however, promoted it as a useful drug in the rheumatic diseases: it suppressed inflammation and was effective in controlling symptoms when given only once a day. In 1982 eight elderly women were reported to have developed jaundice, and six died. At that time over 500,000 people in Britain had taken it. Other reports of adverse reactions followed and the drug was quickly withdrawn. The BBC programme Panorama suggested that the company had made deceptive claims, obscured important information and did not act quickly enough when the drug evidently caused problems; faults in the approval procedure were uncovered.44 The need for post-marketing surveillance was becoming clear. But this was costly and difficult - how did one establish a control group? For which drugs would it be most important perhaps those for disorders that were not life-threatening and for which reasonably safe alternatives were already available?45 Not only might an individual drug have side effects, but there was also a danger of interaction between powerful remedies.46 Two drugs might alter each other’s absorption, metabolism or excretion. Drugs might be additive, and be potentiated by alcohol. So complex were the interactions that wall charts, cardboard sliderules and computer systems were developed to alert the doctor or pharmacist to dangers.
Much of the achievement of high technology radiology was the result of advances in microprocessors and processing power. CT scanning revolutionised investigative practice, improved diagnostic accuracy and rapidly became the method of choice for imaging the brain. A new phenomenon originally identified in 1945, nuclear magnetic resonance, was also applied to imaging. It did not use ionising radiation but strong magnetic fields and radiofrequency pulses. The hydrogen protons of water and fat were imaged, their concentration and settling down behaviour when stimulated determining the contrast of the images. Computing systems, central to the display of images, had already been developed for CT scanners, and magnetic resonance imaging (MRI) could piggyback on the technology. Workers in Nottingham and Aberdeen, aided by EMI, showed its potential and in 1978 a contract was placed for the development of the first serious clinical instrument. It was installed at the Hammersmith Hospital in 1980, at a time when EMI was seeking to leave the field of imaging. Unlike CT scanning, which was immediately successful, there were many teething problems with MRI and a phase of disillusion in the UK, if not in the USA. The resolution of the images was poor, there were problems with contrast so that some tumours could not be seen, and the speed of the scans was in no way comparable with CT scanning. There were even doubts as to its safety, for example in epilepsy. However, in 1981 the first patient studies began and the first series of patients was published from the Hammersmith in 1982. After that, development was rapid. Many workers contributed to the success of MRI and there is no doubt that the British teams were the first to produce good usable pictures. They established the basic principles, which have changed little over the years. In 1983 there were five clinical MRI systems in the world, of which four were in Britain.47 The technique was non-invasive, doing patients no harm although the noise and the isolation in the scanner were found by some people to be frightening. Development of MRI depended largely on improvements in the technology of powerful magnets and was incredibly rapid. Scans were soon at least comparable with the quality of CT images. The new system excelled in the head and spine, distinguishing the brain’s white and grey matter better than any previous system and improving diagnostic accuracy. Varying the pulse sequence enabled blood vessels to be displayed. MRI was clearly destined to be a further ‘quantum leap’.48 In joint disease it seemed likely to replace arthroscopy and arthrography. There was an expectation that CT scanning would be replaced by MRI, but CT scanning itself improved and provided much faster, simple and reliable images all over the body with less error from movement.
Another new approach, positron emission tomography (PET), used radioactive atoms that emitted positrons. These could be introduced into compounds such as the sugars that are metabolised by the body, and injected into the blood stream. The PET scanner could then measure the gamma rays being emitted, and create an image of the tissues and the chemical changes that were taking place. This technique was rapidly applied to the study of brain disorders.
By 1980 the application of computing to digitised images was changing the face of diagnostic imaging. In 1985 Professor David Allison, at the Hammersmith, knowing of experimental work elsewhere, raised the possibility of creating a film-less department of imaging. He began to interest the DHSS, charitable trusts and manufacturers in the idea.
Between 1983 and 1985 the DHSS reviewed the Public Health Laboratory Service (PHLS), an essential part of the country’s protection against infectious disease. The review recommended that the responsibility for the administration and funding of peripheral laboratories be passed to health authorities. The government consulted on the recommendation and accepted the arguments in favour of an integrated laboratory and epidemiological network as a protection for the public health.
The pattern of infectious diseases was changing. Traditional diseases such as diphtheria, poliomyelitis and smallpox were less common or had even disappeared. Brucellosis, dysentery, measles, tetanus and tuberculosis had also declined.49 Others were emerging. Pathogens such as Campylobacter enteritis, Cryptosporidium, enteropathogenic E. coli and Norwalk-like viruses (responsible for winter vomiting disease) had new opportunities. Giardiasis producing diarrhoea and the emergence of typhoid strains showing resistance to antibiotics added to problems.50 A worldwide perspective had to be taken. Even cholera might on occasion reappear in the UK, after an absence of many years. Nowhere was further away than a 36 hour flight, as business and leisure travel increased. Demographic patterns influenced infectious disease, with the rapidly expanding, young urbanising populations in the developing countries, and ageing ones in the West. There were serious public and political concerns about food-borne and waterborne disease. Innovative ways of processing food introduced new hazards. In the past much of a nation’s food had been produced locally; now with an open market in food manufacture, faults in one country could lead to outbreaks throughout Europe. An outbreak of Salmonella poisoning in 1982 was traced to small chocolate bars imported from Italy. After a public warning, 3 million bars were recalled and the outbreak quickly came to an end. Another Salmonella outbreak in 1987 was traced to small sticks of German salami, popular with children.51 The cost of such outbreaks was considerable. Poultry were becoming an increasingly common food, but when reared intensively are readily infected with Salmonella. In the mid1980s a particular strain, Salmonella enteritidis phage type 4, acquired the ability to pass through the hen to infect the developing egg. Human infections with this strain increased rapidly.
In the early 1980s cross-infection in hospital by methicillin-resistant Staphylococcus aureus (MRSA) was becoming increasingly serious. New strains were resistant to many antibiotics and revealed an increased ability to spread within and between hospitals. In August 1984 an outbreak of salmonella food poisoning at Stanley Royd Hospital, a large psychogeriatric hospital in Wakefield, Yorkshire, claimed the lives of 19 patients and led to a public enquiry. Investigations showed the poor quality of hygiene in hospital kitchens, a widespread problem often known to management but sometimes not remedied. New kitchens were expensive, there were other priorities, and the NHS could claim Crown immunity, to the irritation of environmental health inspectors. The Stanley Royd outbreak also revealed management failures and the lack of anyone clearly identified as responsible for the handling of outbreaks.52
In the mid1980s the incidence of meningococcal septicaemia rose in the UK, and, although fluctuating year on year, remained high. Chiefly affecting the young, it had a fatality rate around 10 per cent; there were 1,0002,000 cases annually, of whom 150,200 might die. People no longer expected a healthy child to sicken and die rapidly from an infection and cases attracted national publicity. Legionnaires’ disease became better recognised, the infecting organism was identified, and cases were now regularly reported. One outbreak in 1981, occurring among men working on a power station site, was traced to a water system in a cooling tower. A larger one in April 1985 occurred at the Stafford District General Hospital (DGH). It affected 101 patients, 28 of them dying. Again it was related to the design of the air-conditioning system and shortcomings in maintenance of water-spray cooling systems. In November 1986 a new disease in cattle, bovine spongiform encephalopathy (BSE), was identified by the Central Veterinary Laboratory. The first case was found in the herd of West Sussex farmer Peter Stent, who had contacted vets after he found one of his cows behaving in an abnormal way. It was not clear if it was transmissible. The conclusion was that BSE was a "prion" disease like scrapie and that it could have been caused by infected animal carcasses or offal processed into cattle feed. Epidemiological studies were begun.
In the 1970s mosquitoes were becoming insecticide-resistant and the number of cases of malaria rose substantially. In 1980 there were 1,670 with nine deaths, a number that fell slightly with improving mosquito control in the Indian subcontinent. Usually the disease appeared in travellers within a month of their return to the UK but occasionally the delay would be much longer. The tropical disease hospitals in Liverpool and London saw few cases in the early stages, and GPs, faced by patients with an unexplained fever, were sometimes slow to make the diagnosis, particularly if malarial prophylaxis had been taken.53
The incidence of gonorrhoea fell steadily during the decade and more than halved to about 20,000. The decline in syphilis was even steeper, from more than 2,500 to fewer than 200 cases. Cases of herpes infection, Chlamydia and genital warts increased in numbers and, until the arrival of AIDS, were the major cause for public concern. Genital herpes, in particular, received enormous attention. Emotive articles in the press suggested that herpes sounded the death knell of an individual’s sexlife.54 The increasing size of the problem, the incurable and untreatable nature of the condition, neonatal infection and the association with carcinoma of the cervix were all discussed.
The disease of the decade was acquired immune deficiency syndrome (AIDS).55 It was unusual in that from the outset it was highly politicised, and the policies adopted owed much to the activities of those initially most affected, the gay community, and its network of friendships. An uncommon form of pneumonia in five homosexual men was reported in the USA by the Center for Communicable Disease in 1981, rapidly followed by reports of cases in the UK and an increase a previously rare form of cancer, Kaposi’s sarcoma. As experience was gained, it was appreciated that infection was seldom diagnosed immediately. Many had poor immunological resistance to infection before developing severe illness. AIDS was part of a spectrum of disease and produced a wide range of symptoms, including neurological defects. The gay community in the UK learned rapidly from the experience of friends in the USA, organised itself to obtain government help, spread the message about reducing the number of partners and safer sexual behaviour, and developed systems to support sufferers. In 1982 the Communicable Disease Surveillance Centre (CDSC) began to monitor death certificates. From 1983 other groups were recognised as at risk, recipients of blood transfusion, intravenous drug abusers, people with haemophilia, Haitians and children of infected parents. The cause was not known until 1983 when the human immunodeficiency virus (HIV) was identified in France. BBC TV’s Horizon ran a programme about the problem in New York, but in contrast to the size of the epidemic in the USA there were only 15 cases in the UK in 1983 and 74 in 1984. Lacking effective treatment, public health measures were the only way the spread of infection might be reduced. There was no evidence that the virus was spread by casual or social contact but the abandonment of promiscuity, homosexuality and drug abuse, while it might have been effective, hardly seemed a practical control measure.56
The safety of blood and blood products became an issue and perhaps the worst treatment disaster in the history of the NHS. Initially there was scepticism about the extent of the risk. Many blood products were imported from the USA from commercial organisations that recruited paid donors, some in prison and others drug users, potentially infected populations. People with haemophilia, who had gained greatly from treatment with Factor VIII, were now afraid not only of AIDS but also that withdrawal of treatment could take them back to the early 1960s when the disease produced joint damage and pain, and greatly shortened life expectancy. From 1984 the UK improved its own blood product preparation, heat treatment was used to eliminate transmission from blood products, and from October 1985 transfusion centres routinely screened donors for HIV. By this time, however, thousands of people had been infected, a later report (by Lord Archer) putting the numbers of haemophiliacs infected with Hepatitis C at 4,620 of whom 1,243 also were infected with HIV. Within 20 years almost 2,000 had died. Many campaigned to discover whether Government had been too slow to react, and whether Government though acting in good faith had underestimated what was later seen as a high risk. Other countries, for example Canada and Ireland, had similar problems but instituted compensation fare more rapidly.
The early recognition that people from Haiti were frequently sick was later followed by the realisation that the disease was frequent in the Congo, and that after Belgian withdrawal from that country, technicians from Haiti were often recruited. They, like aid workers, were often young and sexually active.
A test for the virus was developed in 1984. It was discovered that there was a high incidence of AIDS in Central Africa, and people who had been sick in the late 1970s could be identified retrospectively as suffering from AIDS.57 The test was used to screen blood donations in 1985. Not until the middle of that year were heat-treated, and therefore safer, blood products available. In the early 1980s large quantities of cheap heroin arrived in Edinburgh. The police arrested drug dealers and confiscated needles; the result was that drug abusers simply shared needles and by 1985 half the drug abusers tested were HIV positive. An outbreak among adolescents at a school near Edinburgh, in 1984/5, showed how appalling were the consequences for these young patients and the babies a few of them bore. AIDS was a catalyst in refocusing drug abuse policy on minimising harm. The homosexual and the drug-using cultures were different, although some links were formed.
AIDS involved just about every contentious aspect of human behaviour and, given the voyeurism of the press, individuals would be regarded as unimportant compared with the story that they could tell. Merely by contracting the disease, against their own wishes, the early cases might become public figures about whom the press felt people had a right to know. Anxiety, even hysteria, came to surround the disease as sufferers lost their jobs, were evicted from housing, children of patients were expelled from their schools and one with AIDS as a result of treatment for haemophilia became the centre of media attention.58 The press covered cases in which doctors with AIDS continued at work and guidelines were developed by the medical profession and the DHSS to safeguard the public. An injunction was granted against the News of the World, banning it from revealing the identity of two doctors undergoing treatment.59 Much that was learnt about the disease was the result of open discussion with gay men. When these were patients it was essential to maintain confidentiality, even though it meant narrowing the number of professionals with knowledge of individual cases. Confidentiality might be seen not only as a personal issue but also as a public health one: only by safeguarding confidentiality could essential information on the epidemiology of AIDS be obtained.
Between 1981 and 1985 policy was developed from below; little was known about the disease and most of that came from the gay press, gay men and patients. Key people in the UK ensured that the disease had less impact in the UK than in many places, in particular the CMO Donald Acheson, who ate and slept AIDS from 1985 onwards. He was central to the process of listening to the clinical specialties involved and the gay community, developing their ideas and relaying them to ministers, forcing them to take it seriously. By 1984 Acheson was referring to AIDS as the greatest challenge in communicable disease for many decades. He established and oversaw an Expert Advisory Group on AIDS, ensuring that government had the best advice available and could move rapidly when prepared to do so. By 1985/6 AIDS was generally recognised as a major issue and collective fear developed. Nobody knew what would happen next, and what clinical or ethical problems would emerge. Some believed that AIDS should be treated like other grave communicable diseases, for example by notification, a view opposed on the ground that this would prevent sufferers from seeking help. Acheson used TV and the circulation of 20 million leaflets to minimise harm, preaching safe sex rather than no sex. Gay pressure groups painted AIDS as a human rights issue. While doctors regularly tested patients for other diseases without fully discussing all possibilities, patient consent here was necessary and pre-test counselling became almost mandatory. Informing sexual partners of infectivity was left to the patient. Prevalence studies were more difficult to mount, for epidemiology could not be conducted without the human rights issue. Important issues were also raised for the blood transfusion service.
The number of patients, who mostly lived in London, was in no way comparable to those in the USA or Africa. Over the first few years the number of cases doubled every year, but by the end of the decade the numbers were rising less fast. By September 1986 more than 500 cases had been reported in Britain compared with 30,000 in the USA, where many were children, the offspring of drug-abusing parents. The pattern of the epidemic, not just in the UK but worldwide, was determined in part by sexual habits, the numbers of contacts and the prevalence of the disease among particular groups. In Africa it crossed rapidly into the heterosexual population; in the UK it did so to a far smaller extent. A liberal and scientific consensus developed. One early result was a government publicity campaign on ‘safe sex’ in explicit terms that Whitehall would not normally contemplate. In 1986/7 the government, strongly urged by Donald Acheson, Kenneth Stowe (the Permanent Secretary) and Robert Armstrong (Cabinet Secretary), launched a major, sustained and consistent publicity campaign, the TV adverts using a tombstone theme and subsequently an iceberg. The message concentrated on minimising risk, the danger of ignorance and the fact that AIDS could affect everyone. The gay community was not directly targeted, in part to avoid increasing public feeling that AIDS was a ‘gay plague’ and in part because this was the advice of the advertising agency. The following year the campaign concentrated on the danger to drug users of sharing syringes, and was deliberately designed to shock. One poster showed a body in a plastic bag; another a bloodstained syringe. TV companies were encouraged to make their own documentaries, widening the information available to the public and dealing with questions such as needle exchange schemes for drug abusers. The Daily Telegraph asked its readers for indulgence, saying that by its nature the epidemic could only be discussed and countered in terms more explicit than normal.60 HRH The Princess of Wales took a personal interest in people who were dying, and by her presence reduced the fears that normal social contact was risky. The first major breakthrough in treatment came in 1986 when Wellcome introduced zidovudine (Retrovir). Trials showed that it prolonged life, stopped weight loss and increased the wellbeing of patients with AIDS. Drug treatment, like the disease itself, became a political issue.
Knowledge in clinical genetics exploded as it began to be possible to map the fine structure of human genes. How genes controlled the structure of a single protein could be defined in molecular terms. Monoclonal antibodies, discovered in the mid1970s, were specific for one antigen and produced from a pure single-cell culture line. They revolutionised the study of immunity and opened the possibility of many new diagnostic tests, and perhaps even therapy. Genetic disorders accounted for a substantial fraction of human disease. Singlegene defects such as Huntington’s chorea, cystic fibrosis, phenylketonuria, thalassaemia and haemophilia were rare, but severe in their effects. Chromosomal abnormalities such as Down’s syndrome were more common, and there were even more conditions such as spina bifida and congenital heart disease with a genetic component. The first practical application was prenatal diagnosis for congenital and genetic defects. Methods included amniocentesis, visual examination of the fetus by endoscopy, measurement of alphafetoprotein in maternal serum and removal of placental tissue for examination (chorionic villus sampling).61 Diagnoses as early as 810 weeks made it possible to consider the likely outcome when deciding whether a pregnancy should be terminated. There was a tantalising possibility of replacing a missing enzyme or a defective gene, for example by destroying the bone marrow by irradiation and replacing it with health marrow from a compatible relative.62
Technology and pharmacy drove developments in gastroenterology. Video-chip cameras and better endoscopes made the assessment of stomach, duodenal and colonic disease swifter and easier for both doctor and patient. The diagnosis and treatment of benign tumours of the colon that might later become malignant could be carried out on a day-patient basis. There was resistance to the new technology among the older specialists, and sizeable endoscopic units were slower to develop in the UK than in other countries.
From the 1950s onwards, the number of deaths and admissions for gastric and duodenal ulcers had been falling. Changes were taking place in what had been one of the commonest causes of admission to hospital. It was hard to know whether diagnosis was now more accurate, or treatment was better or that changing social conditions and diet were responsible. H2antagonists relieved symptoms so effectively that some people were given them as a ‘diagnostic test’: if a patient’s condition improved after taking an H2 antagonist, it was considered unnecessary for radiology or endoscopy to be done.63 Then workers in Perth suggested that peptic ulcer was an infectious disease caused by bacteria. In 1983 Robin Warren (a pathologist) and Barry Marshall (a physician), reported the presence of bacteria in the stomach wall and suggested that there might be a causal link between them and peptic ulcer, gastric cancer and other bowel diseases. When the theory was presented at a conference in Brussels it was regarded as preposterous, and Marshall gained a dubious notoriety. Scientists set out to prove him wrong, and could not do so. Believing that antibiotics might be capable of curing the infection, Marshall swallowed the bacteria himself, rapidly becoming sick.64
Inflammatory bowel disease, such as chronic Crohn’s disease, could be treated by artificial nutrition, which varied from supplementing the normal diet to intravenous feeding. Improving the general state of health substantially was possible.65
|Benign breast disease||37,100|
|All anal operations||35,160|
|Malignant skin lesion||25,330|
|Amputation of leg||4,250|
Source: BMJ 1983, 66
Since the start of the NHS, surgery had been dividing into evermore subspecialties but in district hospitals ‘general surgery’ remained central to surgical activity. The most commonly performed operations were long established. Roughly 645,000 general surgical operations were performed during 1978 in England and Wales.66 Sometimes, subspecialty expertise offered patients a substantially better outcome. For example, one man in ten would eventually need an operation for benign enlargement of the prostate: 80 per cent were done by general surgeons, who used a major abdominal procedure. There was an alternative method, resection by an instrument passed up the urethra, virtually painless, needing half the time in hospital and with a mortality less than half that of the open techniques. The argument for the specialist urological surgeon was now clear although it was no procedure for the occasional operator. The technique was not easy to learn.67
Day surgery had long been encouraged, to provide good care at less cost. Day wards did not need to be staffed at night and at weekends; shorter time in hospital meant that more patients could be treated if theatres were available; and there were savings on ‘hotel facilities’. The practicability was established and many hospitals had excellent day surgical units. Yet even in hospitals committed to day surgery, the full potential was seldom exploited. In Southampton it was estimated that, excepting cardiac and neurological surgery, every surgical specialty needed day surgical facilities and the proportion of cases suitable lay between 40 and 80 per cent.68
Minimal access surgery (often called colloquially ‘keyhole surgery’) was a major advance applicable to many more common procedures. It was the result of spectacular developments in the technology of operating instruments.69 Operative mortality and morbidity had been accepted as unavoidable for 150 years, but in the early 1980s it became apparent that less invasive methods could reduce complications and risks. Reducing surgical trauma reduced morbidity and mortality. The first laparoscopic cholecystectomy was performed in 1985. Urologists had been in the forefront with transurethral prostatic resection. Between 1979 and 1983 there were radical changes in the treatment of kidney stones. First came their removal through tiny 1 cm tracks from the body surface, per-cutaneous nephrolithotomy.70 Secondly there was shockwave extracorporeal lithotripsy, a completely new form of treatment, developed by the German engineering firm Dornier. Focused shock waves, either sound or electrical, were passed through soft tissue to break the kidney stone into fragments. These then passed along the natural urinary passages to the outside. The first UK machine was installed in London at the Devonshire Hospital lithotripter centre in 1984. In the first 50 patients treated the average length of stay was 3.7 days; within two years 1000 patients had been treated, with a high success rate.71
Endoscopic appendicectomy had been performed in Germany and medical gastroscopists and colonoscopists were rapidly relieving surgeons of the responsibility of treating ulcers and polyps. Vascular surgeons were doing endoscopic endarterectomies, using lasers to treat coronary artery obstruction. Orthopaedic surgeons were undertaking intra-articular operations of the knee and many other joints. Neurosurgeons, ENT surgeons and gynaecologists were also adopting the new techniques. With the development of CT scanning and ultrasound, endoscopes could be passed into the bile ducts making it possible to deal with stones even in elderly and medically sick people. Some types of obstructive jaundice could also be treated.72 By 1987 it seemed possible to predict the elegant and less traumatic way in which surgery would develop in the next decade.73 How dangerous the techniques might be in unskilled hands was not, at first, appreciated.
Microsurgery made possible the successful reattachment of an amputated limb. At first the scope of the technique was limited by the size of the blood vessels that could be joined reliably. Developments in optical technology, micro-instruments, sutures and needles made it possible for surgeons to join small vessels and nerves, so that finger reattachment became practicable. Internal fixation would stabilise bones, joints might need repair, vessels and nerves were joined, and adequate skin cover obtained. Such surgery was extremely demanding of time and practicable only in specialised units. The younger the patient, the better the result.74
Although fitting seat belts to new cars was compulsory, people were under no obligation to use them. The evidence that they would save lives was not seriously questioned, but there were questions of civil liberty. From 1983, however, wearing belts became compulsory. All regions now had major accident plans. The absence of such plans in the early years of the health service had been responsible for confusion at the time of the Harrow and Lewisham crashes. Regular training exercises paid dividends at Manchester airport in 1985: a fire occurred on a Boeing 737 at takeoff, with 137 on board. Toxic smoke inhalation was a major problem; 52 died on the aircraft, 85 escaped. Wythenshawe Hospital was rapidly warned, the consultant in charge was there within minutes, triage began and as patients arrived they were handled systematically.75
The growing need for surgical treatment of fractured neck of the femur and for arthritis of the hip, reaching almost epidemic proportions, overwhelmed the wards allocated to the trauma service and spilled into the beds needed for general surgery and elective orthopaedics. By 1987 total hip replacements for arthritis numbered 35,000 per year, and total knee replacements 10,000. In the 1950s there had been a substantial failure rate with total hip replacement, but by the 1970s it was recognised as one of the outstanding surgical successes of the previous 20 years.76 Charnley’s own cases, now counted in their thousands, showed that less than 1 per cent a year needed revision because of loosening. Acrylic cement used to glue the new head into the shaft of the femur was well accepted. Operative complications - infection and pulmonary embolism were few and patients were discharged in days rather than weeks. Initially most patients were elderly and many had to wait; the first operation lasted them all their lives. Increasingly, however, younger and more energetic patients were operated on, and the revision rate within five years might be as high as 25 per cent. A repeat operation took twice as long and patients required longer in bed afterwards. More than 100 different patterns of hip replacement became available, varying widely in price. Despite the Charnley hip being one of the first to be used in large numbers, after 25 years none of the newer ones had been shown to match it.77 However, the high molecular weight polyethylene used for the Charnley cups wore slowly, at about 0.1 mm per year. Revision operations were necessary and the cement used to fix the components was suspected.78 Other methods of fixation were tried, for example porous metal components into which bone cells might grow, and prostheses coated with bone salts before implantation. Then the possibility was suggested that the particles produced by polyethylene wear might be to blame. Some of McKee’s original metal-on-metal hip replacements were still giving good service and showing little signs of wear after many years. Surgeons began to experiment again with metal components, now excellently engineered.
Arthroscopy became increasingly important in orthopaedics, particularly for disorders of the knee. Minimal access surgery was applied to the treatment of lumbar disc prolapse. Using an operating microscope the disc could be dealt with through a 2 cm incision, and the surgeon could see inside the disc space. The operation could be completed in half an hour, and most patients could leave hospital within two or three days instead of two or three weeks.79
Cardiac ultrasound began to be a useful clinical tool in the mid1970s. The development in the 1980s of cross-sectional echocardiography revolutionised non-invasive diagnosis, particularly for congenital heart disease, and was capable of supplanting cardiac catheterisation for most purposes apart from coronary angiography. It produced good anatomical images, and the introduction of pulsed, continuous wave and colour Doppler flow mapping improved the knowledge of heart function, providing an accurate method of looking at spatial information about the velocity of blood flow within the heart and major vessels.80
It was clear that much heart disease could be traced to smoking. Advances in therapy were merely repairing the effects of a preventable disease. The Royal College of Physicians (RCP) refined estimates of the relationship of diseases to smoking. It was causing 100,000 deaths annually, and a third of deaths in middle age.81 Cigarette smoking fell steadily in the 1970s and early 1980s, especially in men; for example, the proportion of adults who smoked fell from 51 per cent of men and 41 per cent of women in 1974 to 36 and 32 per cent, respectively, in 1984. Thereafter, though, the decline became slower, particularly in younger adults. A clear relationship existed between price and consumption. Passive smoking also appeared to increase the risk of disease. Pressure for the introduction of widespread screening of blood cholesterol levels was, however, resisted by the Standing Medical Advisory Committee. Evidence did not exist to justify the cost of screening in terms of any benefits that might result.
The treatment of angina improved with the introduction of beta-blocking drugs (e.g. propranolol), which increased the capacity for pain-free exercise. An important new class of drugs, calcium channel-blocking agents, were introduced for angina. They reduced the strength of cardiac muscle contraction and the work the heart did, altering heart rhythm and dilating blood vessels. They were soon used for abnormal cardiac rhythms and for high blood pressure as well.82
The ability to resuscitate people suddenly and severely ill, if the breathing and the circulation could be maintained, was behind the creation of a new discipline, the paramedics.83 There was no evidence that doctors were any better at preserving life in these emergencies. The US city of Seattle was early to develop the idea, basing paramedics with the fire service because, by its nature, a fire service has few routine commitments and fire stations are well distributed. The Seattle paramedics received 1,600 hours’ training and could administer any of the 40 drugs they carried. Because roughly a third of the community was also trained in cardiopulmonary resuscitation, the efficacy of the whole service was increased. In Belfast and Brighton coronary ambulances had been introduced and it was shown that, with advanced life support skills, many victims of heart attacks could be saved.84 Hampton, in Nottingham, was critical of services such as that in Belfast where doctors were used. Paradoxically, if a GP had been called, an accurate diagnosis would be made but time would have passed; Hampton thought a mobile unit was unnecessary because the most dangerous moments had passed and the risk of death before being admitted to hospital was low. Progress could not be made on the basis of a few special vehicles. A complete restructuring of the ambulance service was needed, separating the 10 per cent of real emergency work from the 90 per cent that was no more lifesaving than a good taxi or bus service. He believed that all emergency vehicles should carry a defibrillator and be staffed by crews who had received advanced training.85 Some ambulance services, such as those in Nottingham, introduced this for some of their crews, and in 1984 a national training programme for paramedics was adopted on government recommendation.86 Groups of GPs also banded together, equipped themselves properly and worked with the ambulance service to provide early help and resuscitation to road accident victims (BASICS, the British Association of Immediate Care Schemes).
In the early 1960s, pilot schemes had shown that fibrinolytics (clotbusters), though expensive, could be used safely in patients with acute myocardial infarction. A succession of clinical trials suggested that mortality could be reduced by their early administration, immediately on admission to hospital or, if there was going to be a delay, by the GP.87 Oral anticoagulants, popular in the 1950s, had suffered a decline in use because of problems with serious episodes of bleeding and doubts about their efficacy. As methods of controlling the dosage improved, anticoagulants were reassessed to see if there was any benefit from their longterm administration. Exercise regimens were introduced as people recovered from a heart attack.88
Effective drugs had been available for the treatment of high blood pressure since the 1950s. Because of their uncomfortable side effects, though, only the most severe cases were treated until better drugs became available. By the 1970s they were. There was debate about the advantages in treating people with mild hypertension, the level at which treatment should begin and the extent to which pressure should be reduced. With 175 general practices, the MRC set up an experiment to examine the benefits of treating mild hypertension. It was found there was a reduction in the incidence of strokes, with a much smaller effect on heart attacks, from both diuretics and betablockers.89 In the ten years since the trial began there had been further advance in the treatment of raised blood pressure, but the question of whether to treat had now been settled.
If a patient had chronic angina from coronary artery disease that did not respond to drug treatment, and the vessels were anatomically suitable, there was no longer any dispute that surgery, coronary artery bypass, was effective. Coronary artery bypass grafting secured a firm foothold. In 1978 the units in the Thames regions did 1,720 operations and the numbers steadily rose, making exceptionally heavy demands on nursing staff. With elective operation there was a better than 95 per cent chance of surviving the operation, with a 90 per cent chance of improvement; 7080 per cent of patients were cured of their symptoms.90 There was also a place, not clearly determined, for emergency surgery after acute myocardial infarction.91 The number of coronary artery bypass grafts undertaken nationally rose from 2,297 in 1977 to 6,008 five years later.92 Some units operated on few patients and a joint report of the Royal Colleges of Physicians and Surgeons recommended that, to maintain expertise, centres investigating and operating on the heart should have at least three cardiac surgeons each performing not fewer than 200 open heart operations a year.93 Coronary artery bypass grafting was the topic of the first consensus conference in the UK, organised by the King’s Fund. Economic studies of the procedure were presented. Alan Williams, from York, costed the operations and calculated the cost per quality adjusted life year (QALY) gained. Particularly in severe cases of angina it compared well with valve replacement for aortic stenosis and the insertion of pacemakers for heart block. It was probably less costeffective than hip replacement.94 In 1976 another surgical technique was developed, percutaneous transluminal (‘balloon’) angioplasty. The coronary arteries were displayed radiologically (coronary arteriogram) and a fine double-lumen balloon catheter was passed down the coronary artery to the site of the obstruction. The balloon was then inflated and the atheroma squashed, increasing the blood flow to the heart.95 Lasers and high speed revolving cutters could also be introduced into the coronary arteries. These were, however, difficult techniques best performed by the experienced. It might result in acute and abrupt occlusion, when emergency open heart surgery would be needed, at increased risk. In one patient in three there was restenosis, which meant that angioplasty might need to be repeated.
In 1982 the first total artificial heart was implanted in Salt Lake City, Utah with the goal of permanently sustaining life; earlier attempts had been to provide a brief bridge to a heart transplant. The patient, a dentist whose heart was rapidly failing, received an implanted device driven by an external pump and lived for 112 days, before dying of organ failure unrelated to the implant. The technology was sound, though the surgical technique and anticoagulation was untested. It had been shown that an artificial heart could sustain life for a long period.
In 1978 Roy Calne confirmed the potency of cyclosporin A (discovered in 1976 at the Sandoz laboratories) in the prevention of rejection. When it became commercially available in 1983 this largely replaced azathioprine.96 With the improved drug regimens, patients previously with no hope could expect a good chance of restoration to near normality. The capacity to perform transplants was limited both by the size of the units and by the limited supply of organs.
Heart transplants, suspended after the early failures, were resumed in 1979 at Papworth by Terence English, and in 1980 at Harefield by Magdi Yacoub, a brilliant and charismatic surgeon who worked round the clock and inspired great devotion among his staff. Both centres were equipped for advanced cardiac surgery, with sufficient medical, nursing and technical personnel, and support in pathology, immunology and microbiology. There were three reasons for resumption. First the Stanford Medical Center had produced convincing evidence that heart transplantation could be an effective form of treatment. Secondly there had been a change in the public’s attitude towards the concept of brain death, which made heart donation easier. Thirdly there had been improvements in preserving hearts between removal and reimplantation.97 Private donations of £300,000 to both units met part of the costs. An evaluation undertaken in 1984 showed a three year survival of 54 per cent and a cost of about £12,700 for the operation and six months’ postoperative care. The programme expanded, further units being established in Newcastle and Manchester with the ultimate aim of providing this service on a regional rather than a national basis. By 1987 combined heart-lung transplantation, first reported in 1982, was also moving out of the experimental phase.
Liver transplantation, though a great ordeal for a patient who was already sick and often grossly malnourished, became steadily more effective. About 70 per cent of children and 60 per cent of adults would be alive a year later. Bone marrow transplantation was also increasingly successful, though costly. The centres treating patients were few and almost entirely in London. Sir Douglas Black, the DHSS’s chief scientist, recommended further centres in the regions to make the service more widely available. About three patients a week were having a transplant in 1982, most commonly for leukaemia, both myeloid and acute lymphoblastic in type. A few people with aplastic anaemia, or with a liability to infection from a deficient immune system, were also treated.98
Year Kidney Heart Heart/lung Liver
1979 842 3
1980 988 25
1981 905 24
1982 1,033 36 21
1983 1,144 53 1 20
1984 1,443 116 10 51
1985 1,366 137 37 88
1986 1,493 176 51 127
1987 1,485 243 72 172
1988 1,575 274 101 241
total 12,244 1,087 272 720
Source: DHSS. On the state of the public health 1988.99
By the early 1980s young patients with renal failure and no complicating factors had an excellent outlook. Most felt well and many were in fulltime employment. The pattern of treatment that emerged under the restraints of the NHS was strikingly different from that in other countries. The UK strategy was to restrain hospital dialysis, using home dialysis followed by renal transplantation, the single most important therapy in numerical terms from 1977.100 Implicit was the attitude that people incapable of performing independent dialysis or who were unlikely to receive a transplant would be rejected by the units, which were hard-pressed and short of money. Physicians in the selection and referral chain sensed this, so high-risk patients such as elderly people and those with diabetes tended to be excluded. Increasingly, though, it was shown that people in these categories too had reasonable survival rates.101 As the transplantation programmes grew, so did public concern about the criteria for determining death. A conference of the medical Royal Colleges had agreed these, but the Panorama programme on ‘black Monday’ led to a fall for several months in the number of kidneys available from patients diagnosed as ‘brain dead’.102
There were other ethical problems. How could the state keep a controlling hand on public expenditure when it concerned matters of health? How could the profession safeguard the interests of individual patients when, because of restricted resources, one patient’s transplant was another’s hip replacement? Antony Wing showed that, although the acceptance rate for treatment up to the age of 45 was much the same in Britain, France, Germany and Italy, far fewer older patients were accepted in Britain than in the other countries. There was no rule about acceptance; that was just what happened when doctors had to ration scarce resources. A research study revealed that British and American nephrologists had different standards of acceptance for treatment. Were British doctors acting against the interests of patients by rejecting many because of shortage of resources? Or were US doctors motivated in part by financial factors, accepting more patients for treatment and choosing the most profitable form of care regular dialysis in a hospital unit?103 In 1980 the use of continuous ambulatory peritoneal dialysis (CAPD) became widespread. Instead of removing the patient’s blood and passing it through an external dialysis system, dialysis fluid was introduced into the patient’s abdominal cavity, and then removed along with the waste products that, in health, would have been removed by the kidneys. No large capital expenditure was required for this form of therapy, and there was a rapid and radical change in the upper age limit of patients accepted for treatment.104 By the end of the decade twice as many patients were on CAPD than haemodialysis at home. Units increasingly ran an integrated approach, offering patients CAPD, haemodialysis or renal transplantation, as appropriate. In December 1984 the government announced, for the first time, a target for the number of new acceptances annually: 40 new patients per million per year. Britain remained far behind Europe where, because of the existence of insurance-based health care, targets were never required.
Advances in biochemistry, immunology and molecular genetics improved the recognition and understanding of neurological diseases. An increasing number were found to have an autoimmune basis, for example myasthenia gravis, peripheral neuropathies and multiple sclerosis. This suggested possible methods of treatment, by corticosteroids, high dosage human immunoglobulin, plasma exchange and immunosuppressive drugs. CT and MRI scans provided new ways of looking at the nervous system. Not only could tissues could be seen in outline, but their function could be studied as well. During relapses, MRI could demonstrate the appearance and disappearance of plaques of multiple sclerosis, making it possible to monitor treatment. Positron emission tomography (PET) made it possible to determine the rate of oxygen utilisation, and the distribution and utilisation of chemicals responsible for the transmission of nerve impulses. Patients with paralysis from a stroke could be scanned with little discomfort to determine whether haemorrhage or thrombosis was responsible.
Surgery was now firmly established for deafness when the problem was sound conduction by the bones of the middle ear. There was, however, still no medical or surgical help when the problem was damage to the sound receptors of the inner ear, sensorineural deafness. Although there had been dramatic advance in the design of hearing aids, many people suffered from such profound deafness that even the most powerful aids provided little help. However, there were nearly always some surviving fibres in the auditory nerve, even when the sensory hair cells in the inner ear that respond mechanically to sound had disappeared. It now became possible to stimulate the surviving nerve fibres by tiny electrodes inserted into the cochlea. In 1978 a report was submitted to the DHSS on a visit to the only centres worldwide where cochlear implants were being done, Los Angeles, San Francisco and Stanford.105 Roughly 20 implants had been done by that time. The implants became increasingly sophisticated and reliable, and the results were so promising that the technique was extended from adults to children.
Major developments were made in surgery for cancer of the head and neck. Improvements in plastic surgery and reconstruction meant that ENT surgeons could now confidently expect their colleagues to retrieve the situation they had created by wide excision of the tumour.
Corneal grafting had become a well-established operation and many more could have been undertaken had the supply of corneas been plentiful. However, the doctors most often present when patients died suddenly were the house officers, and few thought of eye donations, even when they asked for permission to use kidneys. For a while it was thought unnecessary to tissue type recipients, but this eventually was found to be desirable. In 1986 corneal banks were opened in Bristol and Manchester.
Patients with cancer often required long-term care both in and out of hospital. The hospice movement and the Macmillan and the Marie Curie nurses increasingly linked with nurses in the hospital. Oncology wards might now organise regular meetings with them, community nursing staff and the social services, to discuss the care of individual patients. The best way to treat even common cancers was not always clear. Tom Stamey, a respected American urologist, wrote in 1982 ‘I do not know how to treat carcinoma of the prostate.’ The cancer was common and most men would survive a normal life span without treatment. Some forms of treatment such as radical surgery, though popular, were disabling. A major study showed that hormone treatment, also common, had at best doubtful benefits. The scientific foundation of treatment was insecure.106 In the rarer cancers there was increasing recognition of the importance of specialised centres; the greater the experience the better results. Staff were aware of the complications that could occur, and how to manage them. Testicular cancer, bone cancer in children and neuroblastoma were examples of such conditions.107
New cytotoxic drugs continued to be developed, often related to an existing one, in an attempt to increase efficacy and reduce toxicity. Cisplatin, which acted on DNA strands, was useful though toxic, and analogues were sought.108 By the late 1970s cancer of the testis could be treated, with an 85 per cent cure rate, as CT scanning allowed accurate ‘staging’. Two main types of leukaemia were the result of disorderly growth of the precursors of two sorts of white blood cell. Survival after treatment of acute lymphoblastic leukaemia in childhood improved substantially; the outlook for myelogenous leukaemia was more discouraging.
Radiotherapy departments were now switching from radioactive cobalt machines because radiocobalt slowly decayed, lengthening treatment times and needing replacement every three to four years at considerable cost. Linear accelerators, introduced in the 1950s, were now usually specified when new equipment was required. They might cost more but they could treat more patients.
Breast cancer claimed 12,000 lives a year but there had been few advances in its treatment. There were two approaches to early diagnosis: screening by mammography of an asymptomatic ‘at-risk’ population; and careful instruction of women in breast self-examination, which was highly publicised. Clinical trials in both were established.109 Early results apparently showed a substantial reduction in mortality in screened populations and there was strong public demand for screening. An advisory group, chaired by Sir Patrick Forrest, was established in 1985 and its proposals were accepted. In 1987 a national breast screening service was announced; and in March 1988 each region began inviting women between 50 and 64 years of age for screening every three years.110 Attention was also focused on the early diagnosis of cervical cancer. From 1983 it was decided to replace the national cervical cytology recall system, which dealt largely with women who had already been tested, with a locally based scheme. This would call all women for a smear every five years from the age of 35, and would be based on computerised family practitioner committee records.
During the decade lung cancer decreased for men but increased for women; men were giving up smoking to a greater extent than women. The risk of passive smoking was also now clear; breathing other people’s tobacco smoke was a cause of lung cancer.111
The ninth report of the confidential enquiry, covering 19761978, showed a continuing fall in maternal deaths, and attention increasingly centred on the infant. Abortion was no longer among the leading causes of death but the other causes were the same - pulmonary embolism, inexpert anaesthesia, high blood pressure and haemorrhage, ectopic pregnancy and sepsis. Nearly all births now took place in hospital. High technology was seen as imperative in the interest of mothers and their babies. Ultrasound was now used regularly around the 18th week to scan the fetus for anomalies. With the reduction in home deliveries, emergency flying squad calls were few, and it was hard to provide a good service staffed by professionals accustomed to working under domiciliary conditions. The management of problems became conservative, the accent being on transfer to hospital.112 District midwives were restricted to antenatal care and postnatal visiting, unless they were allowed to manage their own cases in hospital, alongside hospital midwives. Increasingly, GPs were content just to supervise the antenatal and postnatal periods.113
In the 1980s a consumer movement developed, challenging the policy of encouraging all women to give birth in hospital, and the loss of small and sometimes isolated maternity units serving rural communities. Clear differences were emerging between the professional groups, the midwives believing that an increased number of births could take place at home to the satisfaction of mothers, and with safety. Technology and intervention were seen as dehumanising a natural process, childbirth. The movement drew support from the National Childbirth Trust, the feminist movements and some politicians. It criticised the crowding of clinics and the lack of sensitivity sometimes found.114 Labour was increasingly induced, sometimes in as many as 40 per cent of cases. There was wider use of epidural anaesthesia and the caesarean section rate was steadily increasing throughout the developed world. Was it impossible to achieve better results without ever more obstetric operations?115 A Labour MP made parliamentary history by nursing her baby in the House of Commons. Emotions ran high; midwives argued that greater attention should be paid to the wishes and needs of the mother, and home delivery should be available. Obstetricians stressed the risks of giving birth at home, far from the emergency facilities of a consultant unit.
From 1968 Patrick Steptoe in Oldham and Robert Edwards in Cambridge made a series of technical advances that raised the possibility of successful in-vitro fertilisation in the human. These included the demonstration that spermatozoa would penetrate oocytes in vitro, that oocytes could be recovered by laparoscopy, and that embryos could be grown to the early stage of development in vitro. The procedure was refined and the birth of the first ‘test tube’ baby took place in Steptoe’s unit in Oldham General Hospital on 25th July 1978. They then turned to simplification of the procedure, but never by taking dangerous short cuts. Everything was checked and rechecked, within good scientific rules and the strictest possible ethical guidelines.116 Major alterations to the procedure, including the stimulation of ovulation by drugs, increased the success rate and the technique clearly had an important place in the treatment of human infertility. There was debate about ethics, the major concern of opponents being the manipulation and survival of human embryos, the concept of a human person and when a human could be said to exist.117
In 1982 the government decided to set up a wide-ranging inquiry to consider the social, ethical and legal aspects of techniques that modified human fertilisation and embryology. The chair was taken by Mary Warnock, who was asked not to recommend the establishment of any new organisation or authority. The membership encompassed several professions with a concern in such matters, and a variety of religious traditions. The members had to look in many directions of medicine and science, and take into account public opinion that varied from the elegantly argued and cogent to the frankly ludicrous. The report, published in 1984, was timely and thoughtful but did not provide a detailed prescription of what should be done. Although there were three notes of dissent on surrogacy and research on human embryos, it was agreed that some principles should rule, and some barriers should not to be crossed. The logic of their discussions led to the need for a controlling body, and the report proposed a new statutory authority to regulate fertility services, monitor developments and vet individual research projects. It proposed that spare human embryos could be frozen and stored for repeated attempts, with an upper limit for storage. There was a division within the committee on the issue of experimentation with spare embryos.118
In an attempt to reduce the number of unwanted pregnancies, family planning services tried to reach the younger age groups. DHSS guidance, that parental consent could in some circumstances be dispensed with for someone under 16 years of age, was challenged in the courts by Victoria Gillick. The presiding Law Lord considered that the only practicable course was to entrust the doctor with a discretion to act in accordance with his view of what was best in the interests of the young woman who was the patient.119
As the use of cervical cytology increased, more disease was identified and more women required follow-up to exclude carcinoma of the cervix. Colposcopy, magnifying the cervix, made it easier to spot lesions, and to remove them accurately and more safely.120 The new imaging systems found gynaecological applications. Laparoscopic surgery was at first used mainly for diagnostic purposes. However, it was increasingly applied to the treatment of endometriosis, and the polycystic ovary syndrome.
Hormone replacement therapy was introduced for women past the menopause. A reduction in fractures associated with osteoporosis and in coronary artery disease were claimed as its benefits, though there was a possibility of an increase in cancer of the breast in the longer term. It rapidly became a popular form of treatment.
The fight to allow parental access to children in hospital had been won. Some facilities were provided for resident parents, but although modern wards had mother and child cubicles, the increasing numbers of parents meant that many would be sleeping on mattresses on the floor beside the child, and in the morning the ward kitchen might be full of parents trying to prepare their child’s favourite breakfast.121 The pattern of childhood disease continued to change; accidents were by far the most frequent cause of death after the first year, and sudden unexpected death was increasingly seen as a problem.
Developments in the medical specialties had a ripple effect on paediatrics. Increasingly, paediatrics divided into subspecialty areas mainly in regional referral centres: paediatric oncology, cardiology, immunology, genetics and haematology.122 The care of mothers and their babies was the subject of a Social Services Committee report in 1980. Concerned at the peri-natal death rate, further concentration on large maternity units and the phasing out of home delivery were key recommendations. The safety of mother and baby was paramount, and the labour ward should be regarded an intensive care area with better access to neonatal intensive care.123 Neonatal units could now use cerebral ultrasonography to image the brain, and the accent changed from respiratory distress to the prevention and treatment of intracranial damage from delivery.
The 1980s saw two major improvements in the treatment of thalassaemia. Initially although one could determine by amniocentesis whether a baby was likely to be affected, this was only possible late on. The introduction of chorionic villus sampling made it possible to determine whether a fetus was affected as early as the 11th week of pregnancy, allowing the mother to be offered selective abortion. Second, in 1983/4 Guido Lucarelli in Pesaro, who had many patients with the disease, started a large programme of bone marrow transplantation, with substantial success. Bone marrow transplantation was also offered selectively to patients with severe sickle-cell disease, but the initial results were not so good, because patients were ill and supportive care of the highest order was required. Prophylactic treatment with penicillin by mouth was found to reduce the death rate substantially, and became routine treatment.12
Human growth hormone (HGH) had been used since 1959 to treat children with short stature who were deficient in it. There were probably 100150 children each year for whom it was indicated and those started early on treatment made good progress. Supplies were short, because HGH was derived from pituitaries specially removed during post-mortem examinations.125 Some children died of a recurrence of the condition that had led to their treatment in the first place, for example intracranial tumours, but it was reported that three patients in their 20s and 30s had died of an illness resembling Creutzfeldt-Jakob disease (CJD), a progressive and fatal brain disease probably caused by a ‘slow’ virus present in the preparation. Human growth hormone was withdrawn from use in 1985. Subsequently a further 14 died from CJD, out of a total of about 1,900 receiving HGH between 1959 and 1985.126 Within about a year, synthetic hormone was available.
Increasingly the patients in general hospital wards were in the upper age groups. Nearly all district hospitals now had a geriatric service and a day hospital. Of growing concern was the problem of psychiatric problems among the elderly. Between half a million and a million old people suffered from some degree of dementia, the commonest mental disorder in that age group. Special psychiatric services for elderly people were developed, and about half the geriatric services had such a facility. The Health Advisory Service made psychogeriatric services a special interest, and published a report, The rising tide, bringing together hard won experience on how such services could be established.127
Demand for hospital beds and the need to reduce the length of stay emphasised the importance of rehabilitation and support from social services. It became common for geriatricians to undertake domiciliary consultations to reduce inappropriate admission; perhaps one in three admissions could be avoided in this way. With the development of rapid assessment, effective treatment and early discharge came questioning of how far the NHS should be responsible for long-term provision when medical conditions had been treated as far as possible. Enlightened local authorities had developed personalised systems of care management. Some NHS chronic wards still existed, and the quantity of local authority residential accommodation was falling. There were, however, huge increases in the provision of private residential and nursing homes that more than matched the reduction of NHS and local authority places. Commercial companies entered the field, in retirement areas the homes competed with each other and the quality of care available improved. Day care had increased, but domiciliary services such as home helps and health visitor visits to elderly people barely kept pace with the growing elderly population. Joint finance, a system by which part of a health authority’s allocation was earmarked for cooperative ventures with the local authorities, might be used to encourage the transfer of patients from the NHS to local authority provision. The NHS was ceasing to see, as part of its function, the provision of accommodation for frail elderly people.
The development of mental health services was now government’s top health priority. The number of beds continued to fall. This should have freed resources for community-based services, but regions and districts sometimes subverted the money for acute care. However, in the early 1980s there was increasing government pressure on regions to dispose of underused or surplus property. The old mental hospitals stood on large sites. Financial incentives, and a booming property market, made them marketable. Local authorities were seeking land for housing, and property developers were seeking sites for hypermarkets and shopping centres. It became easier to find the capital to fund new and local facilities.
Fewer beds in the old asylums, coupled with the adoption of open wards, increased the problem of managing patients with dangerous, violent or criminal propensities. It remained difficult to transfer patients from secure hospitals into NHS provision when the time was right. Unions such as COHSE often took a tough line, and the courts sometimes found that no place could be found for a criminal who seemed more in need of health care than of a prison regime. Lack of staffed beds, the patient’s characteristics and refusal by staff to admit a person were the reasons commonly advanced.128 Difficulties remained in the establishment of the regional secure units, the longer term solution to the problem. Even the regions keen to do so experienced opposition from staff, unions and local communities. Some regions, not having a forensic psychiatrist available to help, moved ahead but experienced problems with the siting and design of the buildings, which needed to form links with the probation service, prisons and the district psychiatric services. Some regions established a single unit; others a more complicated pattern of central and satellite provision.129
Twenty-five years after the Mental Health Act 1959, which marked a new era of enlightened mental health provision, a further liberalising Act increased the rights of patients on 28day observation orders to appeal, discouraging the use of emergency orders. The Mental Health Act 1983 restored formal legal safeguards to a central place in mental health legislation.130 It was successful in its aims; more patients appealed, but the number discharged by tribunals remained small.131 Few of the large mental illness hospitals had as yet closed; comprehensive community health and mental handicap services were uncommon. Few community mental health teams existed. Those attempting to orchestrate change faced obstacles from lack of money and lack of will to make the change come about, from professionals and the community itself.132 There was increasing criticism of the mental health services. Had such deinstitutionalisation as there had been, gone too far? The House of Commons instituted a large-scale inquiry on the community care of the mentally ill and handicapped, reporting that the pace of removal of facilities for mental illness had far outrun their replacement in the community, and that it had been blithely overoptimistic to believe that modern treatment would lead to a massive reduction in the need for long-term care.133
Following the GPs’ charter in 1965 the standard of general practice continued to improve, but patchily. Reorganisation in 1974 and restructuring in 1982 changed little for the GPs, although family practitioner committees (FPCs) were promised greater independence. Bousanquet in York showed that practices differed in their philosophy, young doctors investing highly in their practices often at a cost to their personal income, while older ones were often being more ‘traditional’ in their approach though showing a greater willingness to undertake home visiting.134 According to the 1981 morbidity survey, GPs were doing more preventive work. More time was being spent on psychiatric disorder, ten patients consulting GPs for every one attending a psychiatric outpatient department. Depression, potential suicide and marital problems were brought to the surgery. An increasing number of doctors not only undertook counselling themselves but also employed counsellors to whom they could refer their patients, raising questions about its effectiveness and the training and qualifications of the counsellors’ themselves.135 Increasing access to sophisticated investigations began to move general medicine out of the hospital; not every difficult case had to be referred. Increasingly it was the norm for GPs to use peak flow meters, to assess the severity of asthma, and electrocardiographs. Well woman clinics and blood pressure screening were no longer the sign of a fanatic. The literature of general practice not only expanded rapidly but also yielded several classics. A significant change in the vision of general practice was taking place.
One potential of the British primary health care system was little explored; GPs were too busy dealing with illness to worry much about health.136 Health promotion was the subject of a series of special reports published by the Royal College of General Practitioners (RCGP).137 Godfrey Fowler, an academic GP in Oxford, looked at the evidence for its effectiveness. Cardiovascular disease, heart disease and stroke seemed to be promising, although GPs would have to become more active in education on change in life style.138 Elaine Fullard, who had a background in health visiting and worked with Fowler, believed that many GPs would practise preventive medicine if they were helped to organise their practices to make it easier. A ‘facilitator’ was provided, a trained nurse experienced in general practice to help interested practices to set up programmes that included advice on smoking and diet, and checking blood pressure.139 The idea became popular; increasingly, health promotion became a task for practice nurses and health visitors.
The management of chronic diseases - diabetes, high blood pressure and asthma were also areas in which nurses could work effectively. Julian Tudor Hart thought the GPs’ charter (1965) had provided immense opportunities.140 GPs were capable of much of the care of chronic disease currently carried out by the hospitals, if they would only do so. They were in the right place and had the right training. GPs should anticipate future deterioration in health and act early with the weapons now to hand. With office and nursing staff available, a good records system, and making use of direct access to the hospital laboratory, imaging departments and postgraduate centre, GPs could undertake much of the work currently done in medical outpatients. Tudor Hart saw the way ahead as the salaried community GP, accountable to patients and local democratic organisations in which patients participated. He influenced the policies of both the Labour Party and the Medical Practitioners’ Union (MPU). His view on the transfer of care from the hospital to the community was accepted by the Conservatives for financial and professional reasons. Some forward-looking local medical committees (LMCs) such as the Northumberland LMC also developed visionary proposals for future general practice.141
The number of GPs and the proportion working in groups continued to rise. List sizes fell and teamwork was more common although the nurse’s role in the surgery was mainly limited to treatment room work. General practice now attracted more than its share of the best medical students. Vocational training that had existed on a voluntary basis for many years became mandatory in 1982. Young doctors entered a threeyear course, one year in general practice with a suitably experienced trainer and two years in appropriate hospital posts. Training schemes were popular because they provided stability in one area, good posts and a passport to general practice if that later seemed the best option. Premises also improved; about 17 per cent of doctors now worked in health centres, fewer, though, in the conurbations. However, health centre running costs were escalating and maintenance was poor. In 1979 the DHSS told regions that they no longer had to allocate specific amounts of capital to health centre building and the programme slowed. GPs were encouraged to improve their facilities by their own endeavours, often with money from the General Practice Finance Corporation. The Royal Commission on the NHS in 1979 saw the advantages of health centres but thought it would be foolish and unprofitable to try to force general practice into one mould.142 Some matters continued to rankle, in particular the commitment to issue certificates for short-term sickness. Year after year the issue was raised at GP conferences until at length, in 1982, self-certification for the first seven days of incapacity was introduced.
It had long been believed that general practice in inner cities, and London in particular, was not as good as elsewhere. The central problem was its varying quality. London’s difficulties were found elsewhere, but London seemed unique in its failure to resolve them. Its size encouraged isolation, lack of awareness of good practice elsewhere and a feeling of impotence. The mobile young, a multitude of ethnic groups, an intelligentsia, users of drugs and alcohol - they all congregated in London. With a few exceptions, academic general practice developed late in London. London had fewer innovative GPs, and incentives offered nationally were not readily taken up. Modern premises were largely nonexistent. Compared with the rest of the country, team working was poor with fewer practice nurses and attachment schemes. Without reasonable accommodation it was hard to develop teams. The combination of high land values, unsavoury locations and planning problems made it almost impossible to find a good site in the right place. Recruiting young doctors of high quality was a perennial problem. The archetypal inner city doctor faced a high morbidity and a dismissive attitude on the part of the nearby teaching hospitals, which were slow to provide access to laboratory and X-ray facilities, and were not greatly interested in vocational training and postgraduate centres. Inner city GPs were thought to send too many people to hospital, if only because that was what the patients expected and demanded. They were, on average, older. More were single-handed and had trained overseas. Fewer had purpose-built premises and staff attached to the practice. Young doctors seldom wished to enter such practices, and when single-handed vacancies became available energetic young GPs often lost to those with experience rather than expertise. ‘Better’ doctors went to greener pastures. Because they were further from specialised services, they themselves provided a wider range of care and the task of developing a good practice was intrinsically easier. Such practices seldom had problems recruiting the colleagues they wanted. David Morrell, based at St Thomas’, toured his inner city area to see what might be done. Most of the premises were totally inadequate and many GPs saw no way of improving matters. There was an impression that the doctors had been lulled into accepting second best, and were not inclined to rise up and demand something better.143 One innovation in London was a new community care centre in Lambeth, opened by HRH The Princess of Wales, to help those who needed medical and nursing help of a non-specialist nature, but who for lack of suitable home circumstances might end in a specialist unit not designed for their needs.144
If the domination of London’s health services by acute hospital-based medicine was to be reduced, primary health care had to play its part, as it did elsewhere. A study group was therefore established by the London Health Planning Consortium as part of its work on rationalising London’s health services. The choice of chairman was difficult, for most eminent people would appear biased to one or another of the interest groups whose cooperation was essential. The choice fell on Donald Acheson, then Dean of the Southampton Medical School. Acheson’s report provided a clear analysis of the problems.145 It made 115 recommendations, some directed towards government. Kenneth Clarke said they were a maze and a minefield, difficult to handle.146 Among those providing evidence was Professor Brian Jarman, of St Mary’s Hospital Medical School. He had developed a measure of the social characteristics that in London GPs’ opinion most increased their workload or the pressure on their services. His index used eight census variables and correlated with other indices that attempted to measure deprivation or the levels of illness in different areas. The index was subsequently accepted by the BMA and used by the DHSS as part of the payment system, to compensate inner city doctors for the additional work in deprived areas.147
Indicators of deprivation in the Jarman index148
Pensioners living alone
Children under five
By the early 1980s a few GPs were beginning to install practice-based microcomputers, smaller, more powerful, faster and cheaper though lacking in tailor-made software.148 There were perhaps 100 practices using computers seriously although the market was unstable and firms tended to merge or go bankrupt. 1982 was Information Technology year. After discussion with the profession, practices were invited to volunteer for a trial, ‘Micros for GPs’, in which 150 practices would be helped to buy microcomputers with £2.5 million from the Department of Industry. Almost 2,000 applied, the practices were selected and an evaluation was set in hand. The main benefits seemed to lie in the ability to aggregate and analyse information, so that practices could assess what they were doing, plan, review their activities and introduce change. From then on computerisation proceeded apace. By 1985 more commercial systems designed for GPs were available and these were also assessed.149
The DHSS had traditionally done nothing to alter the framework of general practice without the full agreement of the profession. To the doctors’ puzzlement it ceased to be quite so supine. In 1984, after TV programmes about the quality of deputising services, Kenneth Clarke, the Minister, proposed regulations to control their use. No longer could a doctor pass the practice over to a service every night and every weekend, as some did, providing no out-of-hours cover personally. FPCs were given a role in the supervision of the quality of deputising services. GPs, 45 per cent of whom used them, thought the imposition of a limit on their use unacceptable. The General Medical Services Committee (GMSC) said that the draft circular from the DHSS
"would destroy most deputising services and stretch or damage those remaining. It employed an Orwellian way to monitor deputising doctors, and was a threatening document based on misinformation and ignorance. It had produced a reaction from the profession not seen since the 1960s".150
John Ball, the GMSC Chairman, and Kenneth Clarke respected each other and could do business. Both sides backed off and an agreement was negotiated to tighten up the conduct of deputising services in a way acceptable to most GPs. Barely had the dust settled than there was a more serious confrontation.
Since the earliest years of the health service there had been concern over the large and growing sums spent on medicines. Educational material such as Prescribers’ Notes and bar-charts showing the costs had been sent to GPs. Regular statements analysed their prescribing. DHSS regional medical officers visited GPs whose prescribing substantially exceeded local costs, after which their costs usually fell spectacularly. Nevertheless, expenditure continued to rise. Different companies marketed the same drug under different names for different costs. Less expensive but effective alternatives often existed. Some GPs had introduced practice formularies and audited their prescription costs. In the view of the DHSS, safe and effective prescribing was often economical prescribing as well. In November 1984, with little of warning, Norman Fowler, the Secretary of State, announced that certain groups of medicines would no longer be available for prescription on the NHS.151 The groups had been carefully chosen and were generally those for minor and self-limiting ailments including tonics, antacids, mild pain relievers, cold cures and laxatives.
The reaction from the profession to the ‘limited list’ was immediate, intense and critical.152 Both the RCGP and the GMSC rejected the proposals. Doctors should decide on prescribing, not the DHSS; it was the thin end of a rather thick wedge. Patients would have to take medicines that were unpalatable and less acceptable or pay the price. The drug industry launched an advertising campaign showing a happy pensioner who could afford her drugs and a sad one who could not; Roche sent GPs pre-printed letters of complaint to sign and forward to their MPs. The pharmaceutical industry believed, according to Kenneth Clarke, that its contribution to Conservative funds entitled it to special consideration. At a meeting with Margaret Thatcher they were disabused of this notion. Publically their argument was that patients would suffer to save the government £100 million, and the new mandate was an encroachment on clinical freedom to prescribe whatever particular preparation the GP deemed most appropriate. Kenneth Clarke’s views were clear: there were better ways of spending the £100 million that would be saved by more prudent prescribing. There was no passion in Parliament against the limited list. Raymond Hoffenberg, President of the RCP, said that the profession had chosen a weak issue on which to defend its rights.153 Many hospitals had long operated hospital formularies that imposed some kind of restriction on prescribing. There were educational and financial advantages in examining the drugs to be used. Doctors were fighting the issue as a matter of principle, rather than because they had scientific reasons for their choices. An expert advisory group was established to oversee the list. Within a year or so, substantial sums were being saved and few believed that patients’ health care was the worse.
Overall development of general practice backed by greater investment
Improved undergraduate, vocational and postgraduate education
Average list sizes to be reduced to 1700 by early 1990s
Identification of payment for normal working hours, work-sensitive payments for out-of-hours, and ‘continuity’ payments for chronic disorders
Incentives to increase the number of young doctors in the inner cities and the establishment of supernumerary doctors in rural areas
Profession should take responsibility for audit and clinical standards
There was a ferment of ideas about the improvement of primary health care. From 1977 to 1979 a working group of the GMSC, concerned at the much smaller increase in spending on general practice than on other parts of the health service, assembled proposals for a ‘New Charter’. From the GPs’ angle, pay was a major consideration: it should be comparable with that in Europe and reflect widening responsibilities in the continuing care of all age groups, including preventive and curative medicine and health education.154 Out-of-hours payments were a central issue. A salaried service was considered but the group thought a single contract, rather than several options, was the best approach. The MPU proposed an alternative leftwing solution. Community GPs, with extra training in epidemiology and research, should be salaried and work from neighbourhood health units, usually health centres, with the support of a deputising service. They should help to define local health needs and implement national programmes to reduce heart and arterial disease, cancer and other illnesses that might in some degree be preventable. The GPs should relate more closely to local authorities and the community to which they were accountable. Medical education should change substantially. The community itself should be directly involved in the selection of medical students to ensure that selection was non-racist, non-sexist and non-class biased.155 At the other political extreme, Michael Goldsmith’s Harrow Health Centre sought to provide good primary health care and to do so at a reasonable cost outside the NHS.
In the RCGP and academic circles there was also radical thinking about the future of general practice. Thinking was based on assessment of changes in society, demography and medical specialisation, and in medical problems themselves including chronic disease management and health promotion.156 Issues of quality appeared on the RCGP agenda. What was quality, and how could it be encouraged and measured? In 1983 Donald Irvine, Chairman of Council of the RCGP, argued that variation in quality was the outstanding problem in general practice. He said that each GP should be able to describe his current work and the services the practice provided for patients, should define specific objectives for patient care and monitor the extent to which they were met. The RCGP ‘Quality Initiative’ was an attempt to give leadership to the increasing number of doctors concerned with their performance.157 What sort of doctor? analysed the nature of good practice and listed four fundamental attributes of the good GP professional values, accessibility, clinical competence and ability to communicate.158 Avedis Donabedian was invited to visit the College and comment on activities that stemmed from the College’s initiative. Doctors, particularly those involved in vocational training, were visiting each other and entire practices became willing to expose themselves to outside professional scrutiny. In 1985 the RCGP published a radical document setting out its strategy for maintaining and raising quality.159 It proposed that GPs should have passed the RCGP membership examination before becoming principals. It stressed the need for continuing medical education and argued for protected time for this. Computerisation should be universal, and the GP contract should be altered so that unacceptable levels of performance were reflected in a GP’s pay. With a wide variation of GP performance, general practice had to reform itself or be reformed. The Times welcomed the RCGP policy to lobby for payment by results as a welcome sign of modern economic reality in one part of the medical profession. Perhaps the RCGP would use local muscle in local pay bargaining.160 The GMSC, whose task it was represent all NHS GPs, was not amused, and invited the College to take its guns off the GMSC’s lawn.
The two main challenges to the status quo were the wide diversity in the quality of care with little incentive other than professional pride to strive for the highest standards, and secondly the general acceptance that the NHS must prove that society was receiving value for money. Alan Maynard, an economist, thought that general practice was difficult to define, highly variable and anticompetitive in its delivery, hard for patients to assess and was resulting in ever-increasing bills for the taxpayer.161 Conservative think tanks, such as the Centre for Policy Studies (CPS), founded by Keith Joseph and Margaret Thatcher, were increasingly interested in NHS reform in general, and primary health care in particular. From government’s perspective, spending on the family practitioner services was growing fast. It was hard to forecast accurately what would be spent on a service that was not cash limited, and to control that spending. In 1982 the DHSS commissioned accountants, Binder Hamlyn, to look at increased financial accountability. A year later their report was on the verge of being published when there was a political decision not to do so. Its contents never became public. But embedded in the Binder Hamlyn report were the suggestions that if all payments to GPs were payments per patient, a cap on spending on prescribing was possible; and if capitation was 100 per cent, controlling spending would be easier.
In April 1984 Norman Fowler announced plans to review primary health care. The review was a way out of having to do anything precipitate about the proposals in the Acheson report on inner city general practice, the unpublished Binder Hamlyn report, the ability of GPs to continue to practise into their 80s if they wished, and so on. John Ball, Chairman of the GMSC, believed the process would take several years and resigned to ensure that there was continuity of professional leadership. Michael Wilson, not a man to whom compromise came easily, replaced him. Kenneth Clarke, as Minister of Health, took a personal interest, and a small and junior departmental team was created, outside the normal hierarchy and unmarked by yesterday’s thinking, to distil emerging ideas. The new GMSC Chairman described the idea that the future of general practice might be determined by this young team as a rather bad joke.
The confidential ministry proposals went through many revisions, while Kenneth Clarke moved to another Department. Downing Street suggested that GP-hospital links were important, and the best arrangement might be to allow GPs to select services for their patients from hospitals of their choice and for the district health authority’s funds to follow. GPs might also be given a fixed drugs budget. While the BMA equated quality of care with small GP lists, there was little evidence that smallest GPs provided a better service. The suggestion that GPs might be given a budget to purchase hospital services for their patients, and a section about American HMOs, appeared in drafts but were removed by older and wiser hands. A Green Paper, Primary health care an agenda for discussion, was published for consultation in April 1986.162 The profession initially welcomed the commitment by government to comprehensive primary health care and its willingness to negotiate on the development of services to patients.163 Naively, ministers thought they might have a happy tour round the country, presenting their ideas before entering into genuine consultation with the profession. Believing that an informed professional debate would be helpful, a DHSS officer quietly suggested to Marshall Marinker, Alan Maynard and Denis Pereira Gray that articles might be written for the BMJ, to appear immediately after the publication of the Green Paper, outlining the pros and cons of different types of incentive systems and contracts.164 GPs, content with the existing contract, ignored them. The authors were later accused of putting ideas in the government’s mind, and the profession, by ignoring them, of getting its just deserts.165 The BMA, seeing an election over the horizon, thought it could kick the ball into touch, that the profession had a veto and that the government was weak.
Central was the government belief that primary health care mattered and that financial incentives could be used to get it right. The proposals aimed to improve services, to make them more responsive to the public and to centre them increasingly on health promotion. Managerially, clearer priorities would be set for the family health services in relation to the rest of the NHS. The consultative document echoed much RCGP thinking and its Secretary innocently told a medical newspaper that opening the package ‘was just like Christmas’. The more the GMSC examined the proposals, the less it liked them. The Minister, when meeting the GMSC, said he was more interested in hearing its views on improving primary health care than in answering detailed questions.166 Ten ministerial ‘road shows’ took soundings on various aspects of the Green Paper.
A good practice allowance was proposed to reward GPs giving the highest standards of care and to provide an incentive to others.167 Direct linkage of pay with quality would have broken new ground. There were inevitably questions about how assessments could be fair and, as in 1966, the profession rejected them. Who should judge, how could rigidity in assessment and interference in clinical freedom be avoided? Those aspects of health care most easily measured might not be those of most importance, or ones that mattered to patients. GPs felt that it would be impossible to devise a scheme that would be fair to practices with a greater than average number of problems, for example those in areas of social deprivation. The good practice allowance was seen as a merit award, given by management to doctors who did as they were told and awarded on foggy criteria possibly in the teeth of natural justice. It clearly was not going to fly. In December 1986 Michael Wilson and the GMSC sent the profession’s response to the Secretary of State. Most of the government’s ideas were rejected; instead the GPs wanted to discuss their own proposals.168
New payments to encourage preventive medicine and greater efficiency
Set clearer priorities for family practitioner services
Increase competition and give public greater choice
Compulsory retirement at 70 and abolition of ‘24 hour retirement’
Cash limits on funds for direct reimbursement for ancillary staff and premises, but an extended scheme
General Practice Finance Corporation to be privatised
Incentives for inner city practice
Nurses given limited powers to prescribe
Pharmacists given financial incentives to widen their services
Officials looked at other ways of achieving the same objectives, and in November 1987 a White Paper outlining government proposals was published, Promoting better health.169 It presented the profession with a package that left room for negotiation only at the margins. Instead of the good practice allowance, financial incentives would be used to encourage specific services such as immunisation, cervical cytology, comprehensive care for elderly people, postgraduate education and practice in the inner cities. Other proposals included freedom of GPs to advertise their services, practice information sheets, greater emphasis on training, retirement at 70 years, help for inner city doctors and an increase in the proportion of GP pay related to list size (then 45 per cent) to ‘provide a greater incentive to doctors to practice in ways that will encourage patients to join their lists’. The devil with the GPs’ contract was in the details. These were left to be worked out in discussion. Some incentives, including those for postgraduate education, had hardly been considered. The 1965 GPs’ charter had linked seniority awards to postgraduate medical education but Barbara Castle had let this go, at the request of the profession. Additional money for the doctors might be available, but that depended on the progress of negotiations. Initially some GPs saw advantages in some proposals: the accent on primary health care and health promotion, the delegation to nurses and increased staff. However, there would be more work and a risk that the new dispensation would again improve the better but not the poorer practices.170 Before long the profession’s attitudes hardened. Julian Tudor Hart dubbed leading GPs who had supported the need for change as ‘the gang of four’ (Dennis Pereira Gray, Donald Irvine, Marshall Marinker and Colin Waine), though his own ideas had been as influential as anybody’s. The stage was set for a battle royal out of which few emerged unscathed.
In parallel with the Green Paper a review of community nursing was taking place. The Health Visitors’ Association wanted one because of uncertainties about their role but Kenneth Clarke, decided that all three nursing professions should be included, and set the terms of reference. Julia Cumberlege, then Chairman of Brighton District Health Authority (DHA), was asked to chair the review, with a small team and a sixmonth deadline. This irritated the nursing organisations, which considered the timescale unrealistic.
By the early 1980s it had become clear that hospitals should be concentrating their resources on curative medicine. Patients whose needs were for long-term care would increasingly receive this at home. The review team wanted to make this easier, give a new impetus to nursing in the community, create better links with social services and explore the role of nurse practitioners. The subliminal feminist agenda, appealing to nurses, was of nurse prescribing, nurses managing their own services and nurses negotiating with GPs as equals within primary health care teams. The trend to organisation on a neighbourhood basis had developed in local authorities. Many had been organising services such as housing from a locally based unit rather than a distant and centralised office. Local centres were more accessible and put problems right more quickly and sensitively. Similar patterns of care were developing for the mentally ill and handicapped. GPs had, themselves, always worked within and for a local population. The Cumberlege Report, published at the same time as the Green Paper on primary health care, proposed the organisation of community nursing on a neighbourhood basis.
The report called for a switch of resources from hospital into the community. It supported nurse prescribing, the nurse practitioner approach (undefined) and common core training with substantial community experience for all nurses. Crucially it recommended that neighbourhood nursing services, covering 10,00025,000 people, should be established in each district, locally managed and near to the consumer. It maintained that nurses were at their most effective when they and GPs worked together in an active primary health care team, but found that close working relationships were often lacking. To improve this, the Cumberlege team suggested formal agreements between GPs and community nurses. The team did not approve of the ‘fragmented nursing’ in the community, and the way in which GPs employed practice nurses while districts ran more broadly based community nursing, midwifery and health visiting. All should be brought together within the neighbourhood nursing context. Brian Jarman, Professor of Primary Health Care at St Mary’s, and Julia Cumberlege wrote a joint article pointing out the advantages to everyone if the best traditions of all disciplines were combined and professionals worked together, preferably from one building, to provide the full range of medical, nursing and social services to an area of 10,000 - 25,000.171 Their carefully drafted appeal to sweet reason, from a socialist GP and a conservative authority chairman, fell on deaf ears. It had little appeal to extremists on either side.
GPs vigorously opposed the report, feeling that, while it paid tribute to the idea of primary health care teams, in reality it was dismissive of practice nurses, apparently because they worked alongside doctors. GPs had had experience of the intrusion of nurse managers into the relationship of doctor, nurse and patient, and were wholly opposed to any plan to zone GPs to fit in with a tidy system of neighbourhood services. Nursing organisations, on the other hand, gave an almost unqualified welcome to the proposals. There appeared to be a surprising inability of doctors and nurses to understand each other’s position.172 While the proposals were never formally implemented, they influenced the organisation of services in many districts and later some community trusts were based on neighbourhood nursing units.
The Bonham-Carter Report of 1969 had recommended bigger hospitals serving a population of 200,000 - 300,000.173 Although never formally accepted by the DHSS, this idea had taken root and many hospitals on the drawing board or under construction exceeded 1,000 beds. The disadvantages of these hospitals were now becoming apparent. There might be impersonality and problems of staffing and management, and of accessibility to the community. Were larger hospitals needed when shorter length of stay in hospital would lead to fewer beds in total?
The quadrupling of oil prices by 1978 effectively finished the ambitious programme of hospital building. Sir Francis Avery Jones suggested that existing hospitals should be surveyed, and capital money should be spent on refitting older ones, especially those built before 1914, which were well built and generously proportioned.174 Dr Gerard Vaughan, then the Minister of Health, issued a consultation document in 1980 suggesting less emphasis on centralising services and more on retaining a wider range of facilities in small hospitals, which were more accessible, popular and conducive to high staff morale.175 DGHs should not normally have more than 600 beds, and some beds in acute specialties should be provided outside the main DGH. More of the geriatric and psychiatric beds than originally envisaged should be sited away from the main hospital because there would be no room within it. Gerard Vaughan reviewed plans for new hospitals against these criteria, although the BMA and the Joint Consultants Committee severely criticised them. They thought his proposals were woolly on questions of safety in small acute hospitals, and that relegation of geriatric and psychiatric patients to peripheral hospitals was undesirable. The proposals were seen as an ill-disguised attempt to justify the status quo; in many places groups of hospitals had not been brought together on one site as had been the intention of the Hospital Plan, large asylums had not been shut, single specialty hospitals continued, and staff still worked in inefficient and decrepit surroundings.176 As a result, no formal guidance was ever issued. Staff had been willing to put up with substandard and ill-maintained buildings with the promise of a replacement on the horizon. Now they had less hope of any improvement. The proposed policies were, however, realistic. The shortage of money meant that the country would be relying for years on existing buildings, and planning had to allow for this. In future there would need to be more careful appraisal of all options, including the option to do nothing.
If there would be less new building, better estate management and refurbishment were called for. Avery Jones’ suggestion was taken up by the King’s Fund Jubilee project, which showed what could be done to upgrade older hospitals. There was an alternative, the ‘Nucleus’ hospital introduced in 1974 as a result of the oil crisis, and the culmination of all the work on standardisation since the 1950s. The doctors’ reaction towards Nucleus was one of resignation; it was often that or nothing. At least it improved the facilities for the vital new technology now being introduced. Before long there were 50 Nucleus projects on the drawing board some totally new, others expansions of an existing hospital. For example in north east London there was the Homerton Hospital (1986) and Newham.
The work on clinical budgeting undertaken by Iden Wickings at the Westminster was slowly taking root. Merely giving doctors financial information did not alter their behaviour, but when clinicians controlled the expenditure, for example the replacement of equipment, they might make savings that could be used for better purposes. Management budgeting focused on the use of money at unit level, involving clinicians in management.177 Virtually nothing was known about the expense of individual clinical procedures, although research projects had attempted to find out how much some, such as hip replacement, cost. In 1979 the Financial Information Project was established to examine the need for financial information for health planning, and for clinicians in the management and organisation of their units. The project concluded that costing at the level of the individual patient would be needed, but would probably be prohibitively expensive. Doctors did not like the phrase ‘clinical budgeting’ so ‘resource management’ was substituted. Four schemes were set up in demonstration districts in 1985 in Basingstoke, Ealing, North Tees and Southmead. Shortly after, the programme was expanded as the ‘Resource Management Initiative’, in six hospitals and six community sites. Their aim was to help clinicians and other managers to make better informed judgements about how the resources they controlled could be used to maximum effect. It was an ambitious programme of management change, following on Cogwheel. The programme was steadily expanded to more than 100 sites, the single biggest coordinated investment in computing in the NHS. The £300 million programme was rushed forward but came to be seen as ill conceived, often based on poor quality data. Only a minority of the case mix management systems worked, and even when they did they seldom proved much help to the staff.178
In the hope that managers would compare the performance of their units with similar ones, the DHSS and the NHS developed a series of performance indicators. They initially covered clinical activity and finance. Often, however, the information was not available to answer the interesting questions that arose precisely why were lengths of hospital stay continuing to fall, and why were there substantial differences between regions? Statistics did not deal with the problem of readmission; patients discharged rapidly who were sent back to the same or a different hospital were counted twice, making it hard to assess the effectiveness of care. There was almost no research to show which admission policy yielded the greatest benefits as to health outcome though if a patient were discharged quickly hospital costs rose, for another would immediately be admitted in his place.179 In 1984, in response to a severe financial crisis, Guy’s decided to adopt a method of management pioneered at Johns Hopkins Hospital in Baltimore, which was a more sophisticated version of Cogwheel.180 The medical staff, together with the nurses, took over much of the management responsibility for running the hospital. Sixteen clinical directorates were established, each headed by a senior clinician, who together formed a hospital management board. Each clinical director held a budget and delegated responsibility for a wide range of activities, including waiting lists and outpatient management.181
The 1974 reorganisation, with the introduction of the planning system, highlighted the paucity of NHS information, its availability, relevance, quality and timeliness. A new information system to replace hospital activity analysis (HAA) seemed essential. In 1980 a steering group was established, chaired by Mrs Edith Körner, an ex-vice-chairman of the South Western RHA, to agree, implement and keep under review the principles to guide future developments, and to propose changes. The working group ignored ‘the siren calls of enthusiasts inviting it to run before those who would have to implement the proposals were able to walk, or who suggested collecting the uncollectible’.182 It ignored Accounting for health and the SCICON Report.183 The group issued a series of reports that set out a common spine of information, a minimum data set to which other items could be added. A major problem was that the finance subcommittee consisted only of finance officers; the addition of people able to link money and clinical activity was rejected. The system was implemented in 1987. From the outset there were criticisms, for Körner’s work was strongly directed towards supporting management, and the functions of the district general manager in particular.184 The minimum data set contained no information required solely for the care of individual patients. The emphasis was on aggregated data, cost and numbers. Information needed by health professionals to evaluate the results of their care and information about the occurrence of disease or the health needs of populations were excluded. Partly on the grounds of confidentiality, the need for access to information about patients’ identities, doctors’ identities, diagnoses and major components of treatment (which HAA had provided) was denied. There was inadequate recognition of the need to compile and maintain registers to schedule, control and evaluate primary and secondary health care. As the costs of the NHS are largely incurred by the treatment of individual people for specific problems, the basic data necessary for the intelligent management or the professional assessment of health services were missing. There was also little emphasis on the use and feedback of information. Körner was implemented at substantial cost and produced little benefit.
The attempt by Albertine Winner’s London Coordinating Committee in the mid1970s, to coordinate the planning of the metropolitan regional boards, had been clinically based. In several specialties there were too many units too small in size for the best performance. Now London’s hospital service was increasingly affected by RAWP (1976)185 and the economic problems after the oil crisis. Health authorities had less growth money and a wider range of responsibilities. London was losing to the north, to shire counties such as Essex and Sussex who were demanding fair play, and money also had to be transferred from acute services into the care of people who were elderly, mentally ill or mentally handicapped. Faced with financial crisis there was an attempt
to remould the capital’s health services to ensure high quality and accessible services for the population; and
to provide appropriate support for the medical schools’ clinical and research activities
Re-examination began under Labour. Although the offices of three of the four Thames regions were in the same building in Eastbourne Terrace, intercommunication was almost nonexistent. Ministers believed that London’s health services could be reshaped only if they were brought together within a single strategic framework. This they were unlikely to organise for themselves. The London Health Planning Consortium (LHPC) was therefore established in 1977 as an officer group of the four regions, the postgraduate hospitals, the University of London, the University Grants Committee (UGC) and the DHSS itself.186 It was not an executive body, and decisions continued to lie with the statutory health and academic bodies, and where necessary with the Minister. It was, however, excellently serviced and chaired by John Smith, a DHSS officer of great drive who had also chaired the Resource Allocation Working Party, which gave him an excellent background. It was continued under the Conservative administration.
Methodology for projecting bed needs (1978)
Profile of acute hospital services in London (1979)
Towards a balance (1980)
Reports on specialties (1979 - 1980):
cardiology and cardiothoracic surgery
neurology and neurosurgery
radiotherapy and oncology
otology and laryngology
Primary health care in inner London (Acheson Report) 1981
The level of acute services likely to be available in the future was examined, starting with the demographic change predicted over ten years. London’s population had fallen from 8.5 million during the second world war to 6.9 million in 1977 and was likely to fall to 6.3 million by 1988. Inner London had fallen from 4.8 million in 1931 to 2.7 million in 1977 and would be 2.3 million in 1988. Account was taken of the changing age structure, level of hospital utilisation, the differences in turnover and length of stay compared with other parts of the country, the need to compensate for social deprivation, and the shortcomings of London’s non-acute services. The study undermined the myth that the extra beds were mainly used by people from outside London; comparatively few were. It showed how the progressive outward movement of the population from central London had led to a marked inequality of access to acute services and to an over-concentration in central London.187 The Report concluded that there might need to be reductions of 2025 per cent in the number of acute beds in inner London. If the reductions were not made, resources would not be available to improve the standards of geriatric, mental illness and mental handicap care. The Consortium commissioned the Acheson Report on primary health care.
Calculating the number of acute hospital beds likely to be available was an essential preliminary to an examination of the clinical facilities for undergraduate medical education and the intake of the London medical schools. If the number of beds fell, the medical schools would need to rethink the way they provided clinical experience. All the schools were visited and the problem was analysed in Towards a balance.188 It was proposed that teaching hospitals, each of which lay at the apex of a wedge radiating outwards from inner London, should relate to major hospitals further out, as in the wartime emergency hospital service. Such an arrangement could provide a good clinical service and a sound basis for teaching. This structure left four teaching hospitals in the centre without many people around them; the movement into them of some postgraduate hospitals and their institutes was suggested. There was close cooperation with a university working party, chaired by Lord Flowers, considering the use of university resources for medical and dental education. The Flowers Report, published on the same day as Towards a Balance, proposed a series of amalgamations for the same reasons that had led to the Todd pairings in 1968.189 The plan was no better received, and students from the Westminster Hospital paraded with coffins outside Senate House.
Everyone agreed that there were too many units providing services such as radiotherapy and heart surgery. There was no consensus on which should close. Existing provision and the likely needs over the next decade were examined by groups with an independent chairman. Specialists in the field under examination came from outside the Thames regions to avoid special pleading. The reports recommended substantial rationalisation of units that were often too small to be viable and provide the best opportunities for service, teaching and research.190
Faced with proposals that offended almost every powerful lobby in sight, Patrick Jenkin took refuge in an advisory body.191 In May 1980 he asked Sir John Habakkuk, Principal of Jesus College Oxford, to chair a London Advisory Group and act as an honest broker. Habakkuk agreed that a reduction of 15 per cent in the number of acute beds in London was correct and that services should be concentrated on major hospitals rather than maintaining an acute service role for many more. This would free resources for the elderly, the mentally ill and mentally handicapped, and for primary health care.192 The LHPC work was planning at its best logical, intellectually appealing, backed by analyses and the facts to win the argument, and taking on board as far as possible all stakeholders. When the work was complete, the DHSS dismantled the team that by then had great expertise. Implementation was left to the regions, the opponents of change breathed a sigh of relief and little was done. The Flowers proposals for a smaller, leaner but well-organised pattern for London medical education had been talked to death. There had been little consensus and no single body had both the will and the power to act. Later some London teaching hospitals had cause to regret their intransigence and inability to see where their long-term interests lay.
Who, asked the BMJ, would have the courage to bell the cat?193 Rationalisation began during the 1982 restructuring of the NHS, spurred by financial pressure that demanded major mergers across existing authority boundaries. Amalgamation was a time-honoured way of reducing the number of hospitals, and the medical schools of UCH and the Middlesex Hospital had for some time been working with each other. Patrick Jenkin took the decision to unite two districts as Bloomsbury, encouraging the University of London to merge the medical schools of UCH and the Middlesex. The schools at Guy’s and St Thomas’ also merged as the United Medical and Dental Schools. The process of change continued. In 1984 the medical schools of Charing Cross and Westminster hospitals united, and in the following year the districts in which they were situated were merged into one authority, Riverside, with plans to rebuild and reduce the number of hospitals to two. Brent and Paddington were also considering merger; ‘we’re huddling together for strength and warmth,’ said the district manager.194
London, unlike the rest of the country, had single-specialty hospitals with associated academic institutes. They varied from large ones such as Great Ormond Street and the Royal Marsden, to small ones such as St John’s Hospital for Diseases of the Skin. Many were in need of redevelopment and some of their institutes were academically dubious. They had survived the logic of the Hospital Plan (1962) and Sir George Pickering’s examination. They had survived the 1974 reorganisation and remained outwith the regional structure, directly responsible to the DHSS. The civil servants had a soft spot for them and their devotion to clinical medicine. A Labour proposal to bring them into a single postgraduate group for management purposes was vetoed by Patrick Jenkin in 1979 when the Conservatives took office.195 An alternative was sought and the London Advisory Group distinguished between six where either the hospitals needed rebuilding or the future of the matching university institute was in question, and six larger ones that could rationally continue in their current form for the foreseeable future. The first group were amalgamated with general medical schools and managed by DHAs. Department officers visited teaching hospitals such as St Thomas', the Westminster and the Middlesex, trying to find an appropriate and willing partner. The advantages of taking on a unit of prestige - and its budget - were not lost on some hospitals, and St Thomas' was a willing host for the skin hospitals. Others, such as the Westminster, felt they were in need of neither advice, nor help, nor a new unit. The second group of larger hospitals were managed by new special health authorities (SHAs), replacing the existing boards of governors. The Hammersmith Hospital was also to be managed by a SHA. 196
As economic problems began to bite it was easy to run the argument that there were too many acute beds in London but long-stay services were often sadly lacking.197 Some areas took draconian measures whereas others used creative accounting to postpone ward closures, but the longer the delay, the deeper the cuts had to be. Capital was converted to revenue; bills were left for payment in the next financial year. Staff represented 70 per cent of the NHS budget, so reduction in numbers through natural wastage and redeployment was inevitable. Patrick Jenkin, as Secretary of State, insisted that authorities should live with their cash limits but Lambeth, Southwark and Lewisham Area Health Authority (AHA) refused to make cuts of £3.5 million to balance the books. Mr Jenkin appointed five commissioners to take over management.
Closing single wards did not solve problems for the infrastructure costs still had to be borne. Even the closure of an entire hospital, such as the Connaught, did not help greatly as facilities at hospitals nearby were used more intensively, and the savings fell short of those predicted. The most efficient districts were the hardest hit for they had the least fat. High technology specialties had, in recent years, often outpaced growth in more ordinary ones and were candidates for cutbacks. Faced with the unpalatable decision of whether to cut local acute or regional services, most authorities settled for cuts to both. Hospital closure was vociferously opposed. It was the smaller institutions such as the Poplar, the Metropolitan and the South London Hospital for Women that were selected. Although these were often housed in buildings with a huge backlog of maintenance work they provided services that were greatly valued locally. Closures began under Labour whose ministers were in a cleft stick. They could not simultaneously impose RAWP and deny regions the right to balance the books. Each was delayed for months while the community health council had its say. Closures continued under the Conservatives, although the Elizabeth Garrett Anderson Hospital had astutely obtained a written statement of support from Mrs Thatcher, while in opposition. Because the Thames regions planned in different ways, after the demise of the London Health Planning Consortium the chairmen of the twelve teaching districts jointly examined what was happening. They found it impossible to say with any confidence what London medicine might look like in a few years.198
The oil crisis also hit the medical schools. In 1981 the University Grants Committee wrote to the universities to say that it would no longer be able to offer to clinical medicine the protection it had previously enjoyed. The total grant to universities fell 17 per cent between 1980/1 and 1983/4.199 How, asked the University of London, were their schools going to spend the money they were not going to have? Medical education had grown fast as new medical schools had opened and the numbers of students and medical academics had risen in line with the recommendations of the Todd Report. Faced with a cutback, medical schools were loath to reduce student numbers. Instead vacant posts were left unfilled, redundancies were considered and departments were at risk of closure. If the attempt was made to preserve those of highest quality, how was excellence measured? Could charitable moneys be raised? One option was to try to get districts to fund more of the service work carried out by university employees. In many medical schools research projects culminated in the introduction of new investigations at the cutting edge of medicine and university laboratories would find themselves providing a diagnostic service. Since the NHS began there had been a ‘knock for knock’ arrangement, NHS employees doing some of the teaching and academic ones providing a measure of service. The partnership was under threat.
It had taken several years, under Labour, to negotiate a new consultant contract. Once it was agreed it had to be priced under the Income Policy. The additional money was minimal and after the Conservatives took office in 1979 the proposals were abandoned, It was quickly decided to increase the income of part-time consultants roughly 10 per cent and to allow whole timers to earn an additional 10 per cent from private practice. The two groups of consultants had previously fought each other; their interests were now much closer.
Further attempts were made to forecast the future demand for medical staff. Over the first 30 years of the NHS the number of hospital doctors had more than doubled at a growth rate more than 3 per cent a year; the number of GPs had increased by only a third. Although changes in health policy influenced the numbers required, for example Better services for the mentally ill (1975), the increase had broadly paralleled the growth in the money available to the NHS. Perhaps the key factors were the number of doctors trained and that the NHS could afford to employ, rather than an abstract view of what was ‘needed’. In 1978 the UK health departments published a 20 year prediction of the requirement for doctors, and Maynard and Walker made a ‘best guess’.200 The estimates for the number of doctors required in 2000 AD ranged from 72,000 to 100,000, and both groups said they lacked data and research was needed. The Royal College of Surgeons said that previous forecasts, Willink (1957) and the Royal Commission on Medical Education (1968), had not met with conspicuous success. The most important lesson was that the future was unpredictable. The BMJ believed that such exercises showed how insubstantial was the work of even reputable groups studying manpower and that the health service could not survive another 30 years of ad hoc policies.201 In October 1981 the House of Commons Social Services Committee, chaired by Mrs Renée Short, reported on medical staffing, recommending an increase in the number of consultants and a freeze on junior posts. (4th Report 1980-81) That had been policy for 12 years, during which time the numbers of juniors had increased by 62 per cent while consultant posts had risen by only 29 per cent.202 By 1983 the profession, though arguing for consultant expansion, was again coming to believe that too many students might be entering medicine. By the year 2000 there might be 25,000 - 30,000 extra doctors, and without enormous capital investment they would be unable to find employment.203 The Advisory Committee on Medical Manpower Planning, despite intensive statistical work, was unable to reach any conclusion about whether the country would need more or fewer doctors over the next 30 years but concluded that existing policies would maintain a reasonable balance. Doctors would grow in numbers by about 1.1 per cent a year.204 Members of the BMA Council were not reassured: Anthony Grabham said that the provision of as many doctors as the government wanted, and a few more, would make the profession’s negotiating position weaker; John Marks declared that nothing would suit the Secretary of State more than 2,000 hungry doctors.205
Although the geographical distribution of doctors was more even, there were still major variations between regions, and between teaching hospitals and the others. There was a mismatch between training and career posts, and between UK doctors and those from overseas. The opportunity to balance the senior and junior staffing of hospitals had been lost time and again.206 In 1981 the DHSS tried once more to improve the hospital career structure by proposals to double the number of consultants and halve the number of senior house officers over the next 15 years, changing the pattern of consultant work, and reversing the ratio of consultants to juniors from 1 : 1.8 to 1.8 : 1 (ratios expressed in the Department's response to the Short Report). Addressing the consultants, Sir Henry Yellowlees, the CMO, said he did not think that consultants need necessarily be resident, nor did he favour shift medicine, but he refused to guarantee that consultants would never be required to sleep in the hospital.207 There was a tart response from the consultants who said that the Department’s calculations were flawed and proposals were being put forward that had not been discussed, let alone agreed, with the profession. A service led by consultants was one thing; a consultant provided service quite another.208
Mrs Renée Short’s committee looked at staffing again in 1985; Kenneth Clarke told the committee that the Royal Colleges and he were in total agreement in support for consultant expansion, but the Colleges tended to believe that the reduction of junior posts was a difficult problem that might be deferred. Consultants found it hard to accept that they should share in the simpler work, with fewer juniors and more in their own grade. They resisted the proposals in their locality, and making changes proceeded with the ease of extracting teeth from a non-anaesthetised animal.209
Increase the number of consultant posts
Restrict the number of training posts
Introduce a new career staff grade for doctors who do not wish, or are unable, to progress to the consultant grade
In 1986 a joint group of the profession, the NHS and the DHSS was established, and a further and detailed examination of staffing issues began. The group’s report, published as Achieving a Balance, was a carefully crafted and politically sensitive compromise; each group both achieved something and conceded something.210 Juniors would work a few years more than was absolutely necessary to achieve specialist status, and longer hours than was necessary for their training; consultants would do a little more oncall than they would have liked; there would be some consultant expansion; and there would be a new intermediate service grade with little prospects of a consultant post. After long and acrimonious debate the juniors accepted it. The following year Achieving a balance: a plan for action was published, a ten-year programme.211 There would be more consultant posts, consultants would be appointed at an earlier age, there would be fewer registrars and the new staff grade would be introduced. It also introduced the idea of career registrars and visiting registrars; career registrars expected a career in the UK but the visiting ones would return home after training. Virtually every review of medical staffing and training had called for an increase in the number of consultants of about 4 per cent a year; the rate achieved was nearer an average of 2 per cent. Achieving a balance: a plan for action proposed a more realistic increase of at least 2 per cent annually over ten years.212 Arguments rumbled on; for example, there were many training posts in the academic hierarchy, the lecturers and senior lecturers who combined research and teaching with their service activities and yet expected in time to become NHS consultants. Earlier proposals had foundered in the objections of the regional consultants; now it was the academics, and particularly the academic physicians, who delayed the implementation of the proposals.
In 1948 junior doctors had largely been male, unmarried and had lived in the hospital. Now many had family responsibilities and wished to live out. Rota systems were invariable, but 36 hour shifts were common. There were causes célèbres in which patients’ deaths were associated with tired juniors. The BMA wanted hours reduced, and in 1979 the MPU, now a section of Clive Jenkins’ ASTMS, took up the cause. Not only their patients but their families, too, suffered. It was reported that when a surgical registrar came home early one evening his two year old daughter ran terrified to her mother crying ‘Mummy there’s a man here’. Shorter hours, however, meant more juniors (not sensible from the point of view of the career structure), or more intense work at night if one junior covered several jobs, or more involvement of the consultants who were unenthusiastic about night shifts.213 In 1982 the DHSS asked health authorities to eliminate rotas more onerous than one night in two on duty.
|Total in training (3 years)||90,000|
|Wastage of qualified staff/year||30,000|
Total qualified staff
|Total unqualified staff||120,000|
|Adapted from Price Waterhouse (1987).214|
Nursing and midwifery staff (including those in training) represented nearly half the NHS workforce, accounting for a third of NHS revenue and nearly 3 per cent of public expenditure. Even allowing for the reduction in working week in 1980, down to 37.5 hours from 48 hours in 1948, the number employed was rising after the 1974 Halsbury pay award. Yet in the priority specialties, mental illness and geriatrics, staffing was often unacceptably low and there were also critical shortages in dialysis units, paediatric intensive care and leukaemia units.215 In 1987, 40 years after the Wood Report on the recruitment and training of nurses (1947), nursing remained a high recruitment but high wastage profession, massively dependent on new student intakes. Nursing was the largest single recruiter of women school leavers with between five ‘O’ and two ‘A’ levels, taking 17,000 out of a total of 70,000, a number that demography was likely to reduce. Student wastage was much greater than in higher education, where it was nearer 10 per cent. Over the decade the number of inpatients, day cases and outpatients all increased. Earlier discharge, medical advance, potent drugs, monitoring equipment and intravenous treatment added to the nursing burden.216 The situation reached desperate proportions with shortages of 20-25 per cent. Untrained staff were increasingly employed. Straight eight-hour shifts and part-time working had been introduced to reflect the needs of married and non-resident nurses, and with more married nurses came greater use of statutory maternity leave. Unit meetings, time off for study and union meetings added to the demands on nurses without necessarily improving patient care. Health authorities were instructed in 1983 to put domestic, catering and laundry services out to tender and money was saved, but this meant fewer staff employed for fewer hours for the same workload. Sometimes nurses had to fill the gaps, washing, cleaning and apologising as meals and laundry failed to materialise.217 The morale of the nurses fell and by 1987 both qualified and student nurses were leaving in droves. As money became tighter, nursing budgets were often cut, both in hospital and in the community, to deal with overspending in other parts of the service. Obtaining firm staffing figures was difficult, and determining the numbers to be employed was more an art than a science.218 Several nurse-patient dependency systems had been developed after early work by Barr in Oxford. One of the simplest was to allocate a set number of nursing hours per patient per day to each ward. Some systems worked top down, trying to relate numbers to measures of output or activity. Others worked bottom up, planning from ward level. All gave different results and none achieved widespread acceptance. This resulted in wide differences between the numbers employed. The DHSS felt nursing staffing was primarily a local responsibility that required local knowledge.
Nurses complained of being unable to get on with their job and not gaining the respect they felt they should enjoy. Students thought they were being used as ‘pairs of hands’, that there was a gap between theory and practice and that they were thrown in at the deep end.219 More rapid patient discharge and more time off for nurses meant that students could not get to know patients and their background properly. Changes in the syllabus meant rapid rotation between specialties, without time to learn each thoroughly, or to revise their knowledge.220 In the search for solutions, education became the focal point. There was conviction that the time for tinkering was over and this was nursing’s last chance. Nurse education was a vast and complicated patchwork of provision with 200 nurse training schools and little linkage with other educational systems
The UK was one of the last major English-speaking countries to conduct its basic nursing education within hospitals on an apprenticeship basis. One reason for suggesting that nurses should be prepared through higher education, rather than in hospital schools, was the hope that this would reduce wastage. The Royal College of Nursing (RCN) established a commission, chaired by Dr Henry Judge, Director of the Department of Educational Studies at Oxford, who had written extensively on the professions that, like nursing and teaching, were largely staffed by women. He believed that the NHS still relied on the ‘easy come, easy go’ system that Revans had described in the 1950s, and recommended the transfer of nurses’ education into the higher education system, uncoupling education and service. There should be a foundation course followed by suitable supervised clinical practice and a staff development programme.221 Student bursaries would be needed, and the cost would fall on the Treasury. The qualification gained should be a diploma.
The United Kingdom Central Council (UKCC) was established in 1982 after the Nurses, Midwives and Health Visitors Act 1979, replacing the many autonomous statutory bodies, several of which had been active in practice development. The national boards, such as the English National Board (ENB) were then created, after further disputes about reserved seats for ‘minorities’ midwives, health visitors and psychiatric nurses in which the nursing unions played a part. The UKCC and the ENB examined the problem of basic nurse education simultaneously. There was friction between them. The UKCC’s proposals were formulated by its Education Policy Committee, not by a group specially established. The Committee consisted in part of nurses in management or educational positions, with four ‘outsiders’, also educationalists. There were no practising nurses or doctors. The proposals were driven by Celia Davies, the project officer, a sociologist by training, and a forceful person with a deep commitment to women’s issues.222 Leadership was passing from clinical nurses, who were inevitably involved in medical development, to a group more in tune with educational theory, sociology and community issues.
A threefold division of labour:
a single level of registered nurse (the ‘second level nurse’ to be phased out)
a more advanced specialist grade, e.g. health visiting and district nursing
a support worker
The registered nurse to be a ‘knowledgeable doer’
A common foundation programme of 18 months followed by a second 18 months in a ‘branch programme’ (adult, child, mentally ill or mentally handicapped)
Reorientation from acute towards community care
Schools of nursing to link with higher education
Supernumerary status for 80 per cent of the time
Students to receive training grants
Academic recognition of professional qualifications
In May 1986 the UKCC published proposals for reform: Project 2000 a new preparation for practice. The key proposal, advocated by every review of nursing education since the 1940s, was to end the dependence of hospitals on student labour. June Clark, later President of the RCN, said that education would be much broader, more community orientated, and based on a health-orientated nursing model instead of the disease-orientated medical model.223 When submitted to the DHSS, Project 2000 contained no costings; it was returned for these to be incorporated. The timing was good, for nurses were arguing for change in the run-up to the 1987 general election, at a time when there was a substantial shortage of nurses and when they were yet again angry about pay, barracking ministers at their College conference.224 It was a moment at which it would have been foolish of MPs to show indifference. Professional status was involved but the case for a new system was argued on educational and service grounds. There were too many schools, some of doubtful quality. Students’ studies suffered from their ward work, so they should be supernumerary to ward establishments. Educating nurses alongside other students would increase the academic content of their education and their experience of the outside world, and might decrease wastage, then 7-20 per cent with a further 15-20 per cent failing exams. On service grounds it was said that the needs of the NHS were changing, that a high proportion of nurses worked in the community, or in mental illness and mental handicap, and the current training was inappropriately hospital-based. It was said to be difficult to manage a flow of learners and that wards suffered from ‘constant replacement’ as groups moved on. Sometimes it seemed to ward staff as if the students, allocated by tutors for educational reasons, were more trouble than they were worth. Project 2000 appeared to regard the case for the abolition of pupil nurse training and the State Enrolled Nurse as self-evident, although it would create difficulties in the less popular aspects of care where SENs made a vital contribution. Phasing them out was likely to increase reliance on nursing auxiliaries with even less training.225 Consultation took place. There was widespread concern about the cost and staffing implications of the proposals, the care of an ageing population and a shortage of recruits. In May 1988 John Moore, then Secretary of State, announced, to the cheers of the nurses, that the government had accepted the broad thrust of the proposals. There were two conditions to acceptance - further work on widening entry into nursing, and concrete proposals for the new support worker and the framework of training.226
Nursing was affected by the rapid discharge of patients, which made it impossible to plan work on the ward days ahead. The increasing numbers of specialists made it harder for a ward sister to discuss patient care with the medical staff. Sisters were younger, frequently less experienced. Sometimes there was more than one. They were not nearly so often on duty, less pre-eminent on the ward and less able to censure junior medical staff when it was warranted.227 In 1953, the Nuffield work study report had suggested that team nursing might be better than task allocation, in which all the nurses worked together and tasks were allocated to individual nurses, a medicine round, meals, the doctor’s round, and bed making. Team nursing was increasingly used, the nurses being divided into groups, each responsible for particular patients, perhaps in four to six bed bays. Nursing academics pressed for a further stage- the introduction of primary nursing, the delivery of nursing care by an individual nurse assigned to an individual patient. Such a nurse was responsible for the overall assessment of need, planning action and evaluating the effectiveness of the plan made for the patient. Others would carry out the programme and report their observations and any changes made in her absence.228
Nurses undertook a wide variety of activities, which made it difficult to define nursing. Academics sought a unifying philosophy, and one result was the nursing process. Winging its way across the Atlantic, it was seized on as a solution to problems both in education and in practice. It drew on decision-making theory, and simplified it. Larry Weed, Professor of Medicine in Vermont, was arguing for medical records that were structured differently, around the patient’s medical problems; and a systematic approach to the history, its analysis and the consequent treatment. Social workers were developing ‘client care’ plans. Using these ideas, it was suggested that nursing was a ‘process’ that should relate to a patient’s ‘problem’. Nursing was offered a new starting point.229 Introduced to the UK by the Department of Nursing, University of Manchester, the nursing process adopted Henderson’s promotion of self-care as the basic aim of nursing. It proposed a systematic approach to individual patients, collecting information by taking a nursing history, identifying patients’ nursing needs, planning the nursing methods to use and assessing the results. Midwives, who were far clearer about what they were trying to do, rapidly found the new approach unproductive. Systematic methods of problem solving were neither new nor unique to nursing, being the same logical approach to decision-making used by managers, or anyone faced by a personal decision such as the purchase of a car.230 The nursing process was based on the assumption that a nursing diagnosis and care plan could be independent of the medical diagnosis; that individual nurses could be accountable for carrying out and reviewing care plans and evaluating their outcomes; and that the patients had an active part to play. It implied that nursing was a distinct activity not subordinate to medicine and challenged inter-occupational relationships in hospitals.231 Patient-orientated care had long been an aim and the nursing process aimed to supplant task assignment. Properly undertaken, it needed time not always available in a busy ward; if applied by rote the results were of little value. It had not evolved upwards from ward nursing and patients’ needs, but descended from schools of nursing often forced on unwilling or uncomprehending staff by enthusiastic nurse managers, who saw it as a way of giving nurses autonomy and freeing them from medical constraints.
The nursing process was followed by ‘nursing models’ that provided a theoretical basis for how individual nurses and groups of nurses perceived and organised nursing, and were part of the call for nurses to assert themselves. Some British nursing models, for example those patterned on the activities of daily living, were straightforward and were used to structure basic textbooks on nursing. Others verged on alternative medicine. The development of an additional ‘model’ appeared to be an initiative test for a new department of nursing. Nursing models were sharply differentiated from the medical model that was somehow bad, seldom defined and always rejected. In nurses’ eyes medicine was disease orientated rather than holistic; analytical rather than integrational; scientific rather than orientated in a psychosocial way; and autocratic rather than an activity in which the patient was a partner. Nurses criticised ‘the overwhelming dominance of medicine and the “medical model” of illness.’232 Doctors were unaware of the existence of a medical model, and when it was explained to them did not recognise it. The accusation that they were interested only in diseases and not in people seemed wrong and offensive. Doctors preferred traditional formulations of the medical role, for example that attributed to Ambroise Paré, ‘to cure sometimes, to relieve often and to comfort always’.233 Professor Mitchell, Professor of Medicine in Nottingham, thought the nursing process was based on a false dichotomy between the cause, treatment and clinical course of the disease, and the resultant problems of daily living. Some nursing texts placed an impenetrable barrier of educational, sociological and psychological jargon between themselves and their readers. He thought that the nursing process was complex and encouraged the completion of time-consuming checklists that were often inappropriate and sometimes bizarre.234 In reply a nurse, herself responsible for one of the more common models adopted in the UK, wrote that many nurses were concerned with people who did not have a disease, for example midwives, health visitors and those caring for the mentally, physically and visually handicapped. Many people were not receiving medical treatment but did require help. Nurses did not reject the relevance of medical diagnosis and treatment to nursing; instead the nursing process encouraged them to place an emphasis on health, normality and individuality.235
A feminist and political agenda became more apparent. Several groups of nurses emerged who described themselves as ‘radical’: radical midwives, radical health visitors and radical nurses. The groups had informal contacts and joint conferences. All wanted sweeping changes in health care, linking its improvement to improvement in the nurses’ lot.236 For the midwives ‘radical’ meant returning to their roots as independent practitioners. Did nurses act as the patient’s advocate? In the case of hospital scandals many had remained silent out of fear, or loyalty to the hospital. Were nurses educated to fit a preconceived pattern, or to develop particular skills? Did they receive a fit training, or were they trained to fit? Textbooks on holistic nursing appeared, some with a ‘new age’ flavour, broad in scope and with their ideas packaged in verbal cotton wool. The RCN published a booklet, Towards standards, suggesting that the nurses’ responsibility should be extended further, their accountability should be independent of cover by medical staff, that doctors’ and nurses’ goals for a patient might differ or even conflict and a patient might need a nurse as advocate against the doctor.237 Some in both professions believed that the divergence had extended too far and lasted too long.238 The difficulty of believing simultaneously in a holistic approach to patients’ problems and in professional autonomy with independence from medicine was largely ignored. Nurses reduced their contact with the medical profession at just the time when they would have benefited from a powerful professional ally in the fight to maintain standards and establishments.
In the community, matters were different. District nurses were now almost invariably part of a primary health care team, working closely with GPs who increasingly were employing practice nurses to handle the work within the surgery. Relationships within the practices became closer as nurses and doctors came to understand each others’ pattern of work. Health visitors were also part of the teams. In the 1960s they had been encouraged to regard themselves as ‘family’ visitors, and had worked increasingly with elderly people. In the wake of several well publicised cases of child abuse they pulled back, to concentrate on child protection.
Nursing development units emerged, in which patient care was a nursing, rather than a medical/nursing, responsibility. In 1981 a small group of nurses working in Burford, an Oxfordshire village with a GP staffed cottage hospital, explored a new method of organising nursing care. They adopted primary nursing and tried to work with patients in partnership in a ‘patient-centred’ way. Nursing was seen as therapy, caring for people whose prime need was rehabilitation, and doing so without consultant cover. Two groups of patients who needed rehabilitation after a fractured neck of the femur had been pinned were compared, one remaining in the acute hospital, the others transferring to Burford. A second experiment began in 1985 in Beeson ward, at the Radcliffe Infirmary, Oxford, funded by the Sainsbury Trusts. The patients admitted were sicker and medically less stable. The ward routine was informal and individualised, managed by the nurses. An attempt was made to compare the results of traditional medical with nursing supervision but the randomisation was faulty. The nurses were in charge, as at Burford, and summoned help only when they believed that medical care was required. The junior doctors, however, reported that there might be a delay when medical care was urgently required, as for a patient with hypoglycaemia. They threatened to withdraw cover as it was not clear who was ultimately responsible. The health authority was alarmed and ended the experiment, which had by then attracted considerable interest in the nursing profession.239
The tasks at one end of the spectrum of nursing’s responsibilities are medical and technical, covering work sometimes undertaken by doctors. For example, as day surgery developed, the main clinical decisions were taken in the outpatient department, and when the patient arrived for operation it might be a nurse, not a house officer, who ‘clerked’ the patients and was responsible for much of the subsequent care. At the other end the responsibilities shaded off into domestic work.240
As with many other nursing innovations, nurse-practitioners originated in the USA, where nursing expanded into the grey area between the two professions. In 1971 Kaiser-Permanente, a large HMO in California, pioneered the establishment of a nurse practitioner training programme. Originally a means of meeting a shortage of doctors, it was soon realised that effective and satisfactory primary care for patients could be provided by carefully selected nurses trained to perform expanded roles in physician-nurse teams. Kaiser-Permanente hoped that the additional career opportunity would encourage some of the best nurses to remain involved with patient care. Programmes were developed in paediatrics, medicine, and obstetrics and gynaecology.241 Encouraged by medical staff, nurses went to college for 12 years to train in their new field, learning to take a history, make a diagnosis and prescribe. Then they worked as part of a clinical team headed by doctors, often being the first point of contact. Nurse practitioners often proved better than doctors at continuing supervision of patients with longstanding conditions, and at working in a consistent and empathetic way.
The role proved appealing to a few British nurses. Barbara Stilwell began work in a north Birmingham practice connected to the university medical school in 1982. Strongly supported by her medical colleagues, she felt her work to be a natural extension of nursing and health visiting, and was awarded a bursary to study in the USA. The conditions she handled fell into all categories, although many were related to preventive medicine and health education. Barbara Burke-Masters, in London’s East End, worked with homeless and destitute patients who had difficulty in obtaining normal care. With the support of a local GP she diagnosed and prescribed, and referred patients to specialists when necessary. As in the USA, British nurse-practitioners received little support from the medical or nursing establishment, but more help was forthcoming from medicine than nursing. Both had to organise their own training, because courses, though widely available in the USA, were nonexistent in the UK. Both showed that it was possible to extend substantially the role of a nurse in primary health care, and they provided role models for many practice nurses who had traditionally acted as treatment room nurses rather than as points of first contact.242 Julian Tudor Hart believed that nurse practitioners and practice nurses were the key to effective anticipatory primary health care; the need was for in-service training and credible teachers who had themselves tackled the job. Higher up the nursing hierarchy, he wrote, there seemed to be many botanists but few gardeners.243
In 1946 the Wood Working Party had been asked what was the proper task of the nurse. Now nurses were increasingly interested in what was their proper image. ‘We’re not angels, we’re workers’ declared a nurse at a pay protest meeting. The public had an image of nursing, perhaps dating back to its religious roots, and, in the views of some, to masculine stereotypes of women generally. In Mills & Boon romances nurses were docile, compliant, tender, dedicated, the doctors’ devoted handmaidens whose virtue was rewarded by marriage. There was increasing resentment at this stereotype, and at the others the naughty nurse in the Sun, the battleaxe matron or the limp-wristed gay. Sir Roy Griffiths was said to have described them as ‘doe eyed and dangerous’. Trades unions created their own stereotypes, sometimes militant and black. Nurses might collude in the process. Just who were the nurses?244
The restructuring of 1982, with the concept of strong locally based management able to take decisions, provided an opportunity to eliminate the many tiers of nurse management that made it difficult to take decisions.245 In many forms of patient care, including midwifery, mental illness and mental handicap, and the care of elderly people, effective local management could have been advantageous. However, there was a desire to fit as many middle management nurses as possible into the new structure, which remained top heavy.
Financially 1978 was a turning point. Inflation was rampant, government was attempting to control pay awards with an incomes policy and industrial unrest was widespread. As strikes in the NHS became more frequent, David Ennals, the Secretary of State, agreed procedures with the unions that would reduce unnecessary industrial action. These were published in October 1978. The rules covered issues that would previously have been determined by management without any kind of negotiation, such as the parking of bicycles. Management, in advance, had conceded arbitration on such matters, greatly weakening itself in the process.246 In January 1979 the Secretary of COHSE, Britain’s biggest health union, was angered that government had treated doctors, but not nurses, as a special pay case. In a telegram to the Prime Minister he demanded the resignation of David Ennals. Porters, cleaners and laundry workers were demanding a rise. The nurses sought 18 per cent to restore them to their 1974 post-Halsbury award earnings. ‘Pay not Peanuts’ was their slogan at a mass meeting on January 18 when, despite a rail strike, 2,000 angry nurses heckled politicians at an emotionally charged meeting. Although nurses would stop short of all-out strike action, some worked to rule.
Over the next two months there was anarchy in the NHS. Ambulancemen went on strike and military ambulances, the ‘green goddesses’, were brought into service. Faced with substantial disruption by intermittent and variable action throughout the country, the government encouraged a low profile approach by management in an attempt to maintain a semblance of service. Unions sometimes made the continuation of emergency services dependent on the cancellation of other admissions; doctors resented their intrusion into clinical matters, and in Northampton three operating theatres were blacked and surgeons could operate on emergencies only by bringing in supplies themselves. At times the question emerged ‘who is responsible for taking decisions to ensure that urgent treatment of patients takes place?’ Hospitals that were running normally might confirm union claims that they had brought the health service to a standstill. To avoid making matters worse, union members were frequently paid even when they had withdrawn their labour. A firm local stand received no support higher up the hierarchy. The unions drew up a code of practice to try to ensure that cardiac, dialysis, intensive care, accident and emergency, and cancer patients were treated; deaths that could be laid directly at their door would not have helped them. Nevertheless, patients in general suffered, and in large numbers.247
Most staff returned to work in early March after accepting a 9 per cent increase in pay and the offer of a comparability study, the Clegg reports published in 1980. Roger Dyson wrote that the unions could feel pleased. They were faced with a pay limit of 5 per cent, achieved 9 per cent and defeated the government at little cost to themselves. Few members suffered much loss of earnings. But the NHS had seen a rapid growth in waiting lists. Dyson criticised the inconsistency of the government’s approach that damaged the morale of local management. There should be standard rules about withdrawing pay from staff refusing to work as directed. If the overriding aim was to maintain patient services in the short term irrespective of longer term consequences, the NHS was doomed to future industrial strife.248
The victory of Mrs Thatcher and the Conservatives was a watershed. ‘At some blearyeyed hour during Friday morning’s election marathon,’ wrote a contributor to the BMJ, ‘I was awakened by one expert’s comments about the new administration’s likely spending plans. There would be no cut in the NHS budget. One advantage, I hope, will be a drop in the quantity of legislation affecting health care, leaving doctors and other health care workers with a little more time to treat patients.’249
Before he became Secretary of State, Patrick Jenkin had been enthusiastic about insurance to raise additional money for the NHS. The idea was quietly shelved; it would require a new bureaucracy to administer it, and how did one ensure that those genuinely unable to pay still received the treatment needed?250 Speaking to the BMA, Mr Jenkin said that the main thrust of policy must be to make the NHS more of a local service. Doctors were trained to take professional decisions off their own bat and did not need the torrent of advice that had poured out of the DHSS. The voice of the doctor should not be drowned by the clamour of competing interests in local management. People came to the health service to be treated by doctors and nurses, and other professions and disciplines needed to be reminded of that.251 The Conservatives rapidly came to an agreement on the consultants’ contract. The phasing out of private beds would cease and the Health Services Board would be abolished. Six principles governing private practice in NHS hospitals were agreed with the profession. Labour, now in opposition, saw them as a private patients’ charter and a first step on the road towards a two-tier health service.252 Nor were the doctors enthusiastic. The new moves might undermine the private facilities that had blossomed under Labour, and that were perhaps the best assurance of the safety of private practice.253 For a while Conservative health policy was virtually the same as Labour’s. Priding themselves on the ability to manage the economy better, the Conservatives would have more money available for the health service. It was, however, with some surprise that it was discovered that Patrick Jenkin did not seem to believe in the planning that had dominated the previous decade.
In July 1979 the Royal Commission reported.254 It had been appointed by Labour against a background of a good deal of emotion, worry about lack of finance, pay beds, industrial action and the 1974 reorganisation. It provided a careful and well-documented account of patient services and the problems of the staff providing them. It made 117 recommendations, many of which were simple and sensible and were implemented in the years to come. Like Guillebaud, the report gave the NHS a reasonably clean bill of health. The NHS was not suffering from a mortal disease susceptible only to heroic surgery. There was no crisis but neither were there dramatic solutions. Improvement was possible but it would be a long slog. As to value for money and patient satisfaction the NHS was doing well. There was no evidence that other or radically new schemes of financing would do better. In terms of staff morale and renewal of buildings the NHS was not doing so well and the latter could be solved only by more money. The 1974 reorganisation, though it might have been correct in principle, had led to a byzantine system of administration in need of simplification, and the service lacked leadership at all levels.
The Conservatives judged the report good in parts. A major recommendation, that RHAs should be accountable to Parliament for matters within their competence, was rejected as inconsistent with the responsibility of the Secretary of State to Parliament. The incoming Ministers, Patrick Jenkin and Gerard Vaughan, had done much homework while in opposition. The government decided to tidy things up and iron out the obvious problems, rather than reorganise yet again. Recommendations about the improvement and simplification of the management and organisational structure of the NHS were welcome and within months Patrick Jenkin (with the Welsh Office) produced a consultative paper, Patients First.255 "Our approach" he wrote, "stems from a profound believe that the needs of patients must be paramount". Summarising the Commission’s report as showing that the problems were too many tiers, too many administrators, a failure to take quick decisions and a waste of money, the remedies suggested were
Strengthening local management with greater delegation.
Simplification of the structure by removing the area tier.
Simplification of professional advisory machinery.
Simplification of the planning system.
14 regional health authorities (RHAs)
192 district health authorities (DHAs) replaced 90 area health authorities
7 special health authorities (SHAs) replaced the boards of governors of postgraduate teaching hospitals
90 family practitioner committees (FPCs)
Patients First attracted many comments, largely favourable. The BMJ thought Mr Jenkin was determined to fulfil his pledge that decisions should be taken as close to the patient as possible.256 In August 1980 ministers announced their plans, the key one being abolition of AHAs. To replace them 192 district health authorities (DHAs) were established, usually on the basis of the previous districts and organised like the old single-district areas. If 1974 had been a triumph for co-terminosity between health authorities and local government, the restructuring of April 1982, outlined in health circular HC(80)8, restored the district as the functional and key tier.257 The circular read:
Districts should be established for the smallest geographical areas within which it is possible to carry out the integrated planning, provision and development of primary care and other community health services, together with those services normally associated with a district general hospital, including those for the elderly, mentally ill and mentally handicapped. The new authorities should not necessarily be self-sufficient in all these services. They should as far as possible comprise natural communities.
The determination of boundaries was particularly difficult in central London where the wish for co-terminosity had to be balanced against organisational requirements and managerial practicabilities. Considerable flexibility was allowed for regions to determine the district pattern, and the districts their administrative structure. Although the process had to be complete by April 1982, regions could set their own pace. A major shift of power was taking place: issues previously settled centrally would now be handled at local level, and most people were broadly content.258 Districts would be responsible for the planning, development and management of services. They would have management teams of six, including two clinicians (a consultant and a GP) and a community physician. They would continue to operate by consensus, but a new feature was introduced by HC(80)8 the primacy of the district administrator.
There must be clear arrangements for administrative coordination which are understood and accepted by all. This will be the responsibility of the district administrator. This does not give him any managerial authority over other chief officers, but it does impose on him a responsibility to see that an account is provided to the authority on how its policies and priorities are being implemented.
Their first task would be to organise the services into units of management, each with its administrator, director of nursing services and a senior doctor. There were hospital units and community units, concerned with nursing services, welfare clinics, health promotion, chiropody and the like. The government wanted units to have their own budgets.259 Area health authorities had never been interested in FPCs, which were now to gain independence on condition they were more active in planning and developing primary health care. In 1974 there had been turmoil and pain as staff had to find new jobs, and the process was repeated in 1982. Once more there was a night of long knives, but with fewer jobs to go round. Early retirements were necessary and among the big losses were area medical officers, some of them the best of the ex-medical officers of health. Far more left than anyone had predicted, at a cost of £54 million to a disgruntled Treasury. Consultants were anxious that their contracts should be held by the RHA, and not locally, and that doctors’ role as advisers to health authorities should not be lost. After discussion with the profession, details of how this might work at district level were sent out, but the arrangements at region were never agreed.260
With the new region/district structure in place, the planning system needed modification. An attempt was made to simplify it and to make it more flexible.261 How much money would be available in the future was uncertain, so planning would not simply be a method of allocating growth money. Zero-based planning was introduced; existing services would have to be scrutinised. When Mr Jenkin’s priorities document, Care in action, appeared its priorities were general aspirations.262 Policy objectives were no longer linked with specific financial targets. As there could be no certainty that money would be available, and much would have to be financed from efficiency savings, this was just as well. In times of economic recession the new document was realistic, rational and fitted the policy of devolving power to local level.263
The NHS was labour intensive, with 827,000 employees. Numbers had risen 80 per cent in 20 years and staffing targets were given to the regions in an attempt to control the trend. In January 1982 Norman Fowler, the next Secretary of State, announced new arrangements to ensure better accountability to Parliament. Ministers would lead annual departmental reviews of the RHAs’ long-term plans, objectives and effectiveness with each regional chairman and the chief officers. Regions saw matters differently; one regional officer produced a list of over 40 departmental priorities, only a few of which would have consumed all spare money. It was viewed as another instance of central interference with local autonomy and not quite the thing to be expected of a Conservative administration.264
1982 was to produce the longest industrial dispute the NHS had yet seen. Thirteen health service unions, which were seeking a uniform rise of 12 per cent, rejected a pay award that would have given a 6.4 per cent rise to the nurses and 4 per cent to other workers. Five thousand angry nurses rallied outside the RCN headquarters, and were told by June Clark (a senior official) that they might have to reconsider their position on industrial action. The dispute was overshadowed in the early days by the Falklands crisis, but once that was over the unions embarked on selective one day stoppages that increased in length and intensity. Throughout the dispute the nurses stuck to their longstanding policy that they would not strike. Consultants were advised by the BMA to do nothing that might inflame the dispute, but held that the decision about what was and what was not an emergency should be entirely for the doctor. The disruption grew. Boilermen left hospitals without hot water; the police had to provide emergency ambulance services. The suffering of patients was clearly shown on the media. The government remained firm, Norman Fowler, the Secretary of State saying ‘we simply do not have that kind of money available. It could only be provided by cutting services to patients.’ A higher offer, of 7.5 per cent, was made to the nurses to try to split the unions. It was one thing to be the hammer of hospital porters; to be harsh to nurses was quite another. Some saw the RCN as lambs loose in a world populated by wolves.265 The RCN press office was not so naive; its staff said that 1982 showed that the College could hold its own with Arthur Scargill and the mineworkers when it came to newsworthiness. The press was favourably disposed to the RCN, which was adept at locating ‘a nice nurse, young and attractive’ for the media.266 The tactics of the unions of getting nurses on to the picket lines muddied their image as dedicated servants of the sick, making them seem a bit too much like other people seeking more pay.
Mrs Thatcher said that the unions were damaging patient care and she did not believe that was what trades unionism was for. The dispute dragged on and in September 60,000 people took to London’s streets, and most pits and ports stopped working. Enough is enough, said the BMJ.267 Patients had suffered, waiting lists had become much longer, personal relationships had been damaged and the NHS was in danger of being politicised by outside unions. The NHS, now 40 years old, was saddled with some of the less attractive features of Britain’s industries: outdated plant, poor management, and too many workers who believed that they were guaranteed a job for life. Should it not be more vigorous in the pursuit of efficiency, finding out where ‘privatisation’ of laundry, maintenance and catering would save money? Should it ignore such promising developments as Health Maintenance Organisations, an increasingly popular method of delivering health care in the USA with built in incentives for efficiency? The union tactics had turned the press and public, and drove a wedge between them and the RCN. The government held firm and in December the unions settled for a lower offer over two years. The nurses got their reward for moderation, their own independent pay review body, announced in July 1983. Its establishment recognised their special position within the NHS, and in particular the fact that most of the staff had not engaged in industrial action. The government reserved the right to exclude from the scope of the review body any groups that did resort to industrial action.268
The NHS could not cope with everything that was being thrown at it. There was a continuous increase in demand, fanned partly by political encouragement to deliver ever higher standards and partly by the rising costs of medical advance. From 1982 onwards cash limits bit, nearly all improvements had to come from greater efficiency, and financial allocations included an assumption that authorities would save 0.51.0 per cent of their cash limit each year. It was not enough. In the 1983 election the issue of the NHS suddenly surfaced, with accusations from Labour that if the Tories got their way the NHS would cease to be a national service and would be more concerned with money than health. There was a good old slanging match, Mrs Thatcher saying she had no more intention of dismantling the NHS than of Britain’s defences.269 Once she had won the election it was decided to cut £1 billion from public sector spending, and regional workforce targets were imposed, a reduction of 0.751.0 per cent in directly employed staff, including doctors and nurses.
For 15 years successive ministers had pursued the vision of stretching scarce resources by improving the quality of management.270 The 1968 Green Paper had proposed area authorities with four or five directors under a chief administrative officer. The 1974 reorganisation had been managerial in nature. The 1982 restructuring had aimed to flatten the hierarchy and devolve powers.
The 1983 Griffiths review was the direct outcome of the chaos of industrial action. Thirteen unions (including the BMA and the RCN) were involved. While the main issue was pay, the unions also felt that the current system was no way to run a health service. Kenneth Clarke, as Minister to Norman Fowler's Secretary of State, was concerned that the steady growth of non medical manpower was adding an extra burden to the NHS. Little progress was made over many meetings. As well as the main negotiations with the 13 unions, there were less formal contacts with the TUC and COHSEE, and with the RCN. Ministers wished to get the nurses on side and having been told that there was a possibility of a pay review body specifically for them, the College's opposition became more muted. The other unions began to sense defeat and welcomed the ides of a management review as a component of the final offer.
The Permanent Secretary, Sir Kenneth Stowe, was asked to establish the review and used contacts in the Bank of England to find a good private sector manager who could consider the application of effective management principles to the NHS. Sir Roy Sainsbury identified Roy Griffiths as a fine manager in a customer based service. Sir Kenneth had a difficult 45 minute interview with Griffiths who was poker faced until he smiled and accepted. While Kenneth Clarke had wanted the review to be more about manpower than management, Griffiths insisted that manpower was the secondary issue. A team of four was selected, including a personnel director from BT, a finance director from United Biscuits and a regional administrator; the terms of reference were left somewhat vague, to advise on the effective use and management of manpower and related resources in the NHS.271
Roy Griffiths had relations who were doctors and was already aware of some of the issues. The team neither invited detailed written evidence nor engaged in consultation. Instead they organised visits and met representatives of organisations, they commissioned studies of management in five hospitals and contracted consultancy firms to develop new approaches to management budgets. While preparing his report Griffiths met many people and regularly dined with senior staff at St Thomas’ on whom he tried out his ideas. Nevertheless, coming from business, it was hard for him to avoid the criticism that he was unused to the idea of professional responsibility, and that his definition of management excluded the informal systems that existed in the NHS. It is probably true that the NHS did not, at the time, devote enough of its resources to proper and disciplined management, but it would have been surprising if Griffiths had not immediately identified the absence of general management as the main difference between the NHS and the business world. In a memorable sentence he said, ‘if Florence Nightingale was carrying her lamp through the corridors of the NHS today, she would almost certainly be searching for the people in charge’. It was not the first time a chief executive had been proposed; Council hospitals operated that way before the NHS began and Bradbeer had suggested it for hospital management committees. Griffiths said privately that he wished to encourage doctors into positions of managerial leadership, an attitude favoured by the BMA. In the event, the Institute of Health Service Administrators rebranded itself as the Institute of Health Service Managers, and professionals not only found themselves in a back seat, but later were sometimes actively discouraged by the BMA from playing a managerial game. The Report was published as a letter to Norman Fowler written by Roy Griffiths as something of a polemic.
A small, strong general management board should exist at the centre, to ensure that power was pushed as far down the line as possible
All day-to-day decisions should be taken in the main hospitals and other units
Clinicians should be involved more closely in management decisions, should have a fully developed management budget and the necessary administrative support. This should prompt some measurement of output in terms of patient care. Service objectives and workload would relate to staffing and financial allocations
There should be an accountability review system starting centrally and establishing a chain right through to unit managers
A general manager should be identified (regardless of discipline) at each level and authorities should have greater freedom to organise the management structure suited to their needs (in contrast with the dirigiste approach of 1974)
There should be a reduction in the number and levels of staff involved in decision-making and implementation
The role of the regions should be strengthened (while ensuring that districts and hospitals were liberated to get on and manage the service)
Whether or not general management is appropriate in health services, where much of the talent is professional and on the shop floor, Griffiths believed that the lack in the NHS (and indeed in the DHSS) of a clearly defined general management function was responsible for many of its problems. Early on the team felt that the development of management budgets was vital, and commissioned demonstration projects in four districts. Griffiths wanted doctors to play a much bigger part in management; one of the big disappointments of the review was that this did not happen. Indeed the BMA actively discouraged this.
The government rapidly accepted the general thrust of the report. The BMJ was, at first, guardedly welcoming.272 The recommendations were not based on an analysis from which they could be logically deduced. Perhaps the more that was known of the reasons for them, the easier they would be to criticise and the less likely it would be that any action would be taken. Klein described the change as moving from a system based on the mobilisation of consent, to one based on the management of conflict. Like all newcomers to the health service, Griffiths was dismissive of the differences between the NHS and private industry. Private industry was about competition in conditions of surplus, while the NHS was all about rationing scarce resources on criteria of needs, as defined by professionals, rather than demands, as expressed by consumers.273 The NHS did not have a single pyramidal structure, with Parliament, a Minister or the district management team at the apex. Clinical freedom created a political dimension outside any normal managerial framework. As quickly as efficient management reduced long-established queues, medical science opened new ones. Clinical freedom allowed consultants to make decisions affecting resources, and consultants had to be persuaded if they were to make their clinical demands more modest. A long and divisive conflict was in prospect if management was to going to be autocratic, challenge clinical decisions and overturn the 1948 agreement between Bevan and the consultants about clinical freedom.274
Opposition to general management was not long in coming. If there were to be executive managers who took decisions in isolation that were harmful to patients, consultants would not feel bound to cooperate with them. Community physicians were also opposed to the concept. They had seen themselves as having a key role, determining the needs of the area, setting priorities, leading the planning process and giving the service direction. It had been a flawed strategy because they seldom carried the prestige to deal with the senior and often brilliant consultants in the acute sector.275 In contrast there was no doubt from the gleeful shouts of triumph from administrators that they thought they had entered the promised land.276 The RCN attacked ‘the exclusion of nurses from any meaningful management role’ and spent £250,000 on advertising and publicity. The matter was raised in the Lords. Matrons were being transformed into the ghastly hybrid post of ‘quality assurance manager’. Would not Florence Nightingale turn in her grave at that? Ministers were surprised at the nurses’ reaction, but unprepared to intervene in local management structures, believing that the nurses were after their own management hierarchy incompatible with Griffiths and that management arrangements would sooner or later include all professional groups.277 Nurses had fought for involvement in policy formation since 1946 and were incensed by the initial failure to give the DHSS’s Chief Nursing Officer (CNO) a place at the top table. Their campaign was emotional but soundly based. Although many senior nurses had proved ineffective in management, their demotion from managers to advisers was detrimental to the quality of patient service. Nurses lost a guaranteed path of access, through nursing line management, to the employing authority. In theory a chief executive was in charge of everything; in practice nobody would now control the quality of nursing care.278 After Griffiths the CNO was replaced by a district nursing adviser to the newly created district general manager.279 Clinical units, often headed by a doctor, were established. Senior nurses found posts within this structure, sometimes in quality assurance or as a unit business manager, but not as part of a single hospital-wide nursing workforce. Florence Nightingale had fought for the control of nurses by a nursing head; Griffiths had brought this to an end. Clinical leadership in nursing was in decline, nationally, regionally and at ward level.
It took a year for the DHSS to change its own structure and recruit a suitable chief executive. The job was not widely sought after. The first person to chair the NHS Management Board was Victor Paige who soon left, in June 1986, because he could not carry through the changes he wished in the face of Ministerial opposition. Shortly before his resignation there was a proposal to ‘rationalise hospital accommodation’; the process was begun, but vetoed because it would have meant selling nurses’ homes, a proposal that was clearly not a vote winner. The members of the central Supervisory Board, having little health service background, needed educating and their influence was hardly perceptible. Changes at regional level were more important and there were sitting tenants with a claim to the new post of regional general manager (RGM) the administrator, medical officer, nurse and treasurer. There was wry amusement as some regional administrators, who had raised the inability to take decisions to an art form, were appointed. One doctor, one nurse and one treasurer got RGM appointments; otherwise administrators got the job, the power and the money. Was it satisfactory that the chairmen of the regions reported to the Secretary of State who had appointed them, while the RGMs reported to the Chief Executive? Would the quality of the service be improved by downgrading the status of professional officers? Some RGMs did not want professionals at management board level. As the general management function was implemented, first at region and then at district and hospital level, protests grew. The Griffiths changes were introduced before the 1982 restructuring had shaken down; they were set to a political timetable that was managerially unrealistic. Neither were general management skills widely available; a management development programme was needed.280 The implementation of the general management function, however, opened a door to further changes.
The Management Review is sometimes seen naively as a pivotal moment when the NHS became aware of the need for measurement, evaluation of the effectiveness and efficiency of its arrangements and an active approach to leadership. Rather it was one of a number of stepping stones in the development of the service. Some stepping stones are more shaky than others.
There were other small but significant management changes. In 1983 government announced that, to improve the use of resources, health authorities would have to develop systems of competitive tendering for services such as laundry, cleaning and catering. The policy of contracting-out was established, ensuring that private contractors could compete on equal terms with in-house services, possibly an attempt to reduce the power of the unions.281 The preparation of contracts and tenders was a new field for health service management and the Nuffield Provincial Hospitals Trust helped to define the necessary procedures.282 The principle was established that the NHS did not have to provide all hospital services by a salaried direct-labour force. Hospitals could also seek income from new sources; for example, income-generation schemes led to the rapid development of shopping arcades in unused areas of hospitals.283
Year by year the cost of providing services was increasing. In the mid 1970s Barbara Castle had argued in Cabinet that the changing age structure of the population, with more old people, meant that an extra 1 per cent was required every year just to provide the same level of service, and that a further 1 per cent was required to cover the costs of the new technology that was continually being introduced. In spite of the pain, the policy of reallocation was pursued and ten years later (1977-1987) the gap between the richest and the poorest regions had narrowed from 26 percentage points to 11 points - the most overprovided being 7 per cent above target and the most underprovided 4 per cent below.284 In absolute terms the NHS was getting better year by year, but staff saw deterioration in what was offered compared with what was possible. In Health care and its costs the DHSS produced statistics showing a rising number of doctors, nurses and admissions, and more money being spent on the NHS in real terms.285 Professionals, however, looked at the NHS in a different way, asking about the quality of care received by individual patients and how the potentials of modern diagnosis and treatment could be mobilised. Crude totals of service activity did not provide a picture of how the service was changing, and its accessibility in different parts of the country. The figures showed what was being done, not what was not done in a health service increasingly dominated by the problems of people over 65. Tension between politicians and professionals was built into the structure of the NHS.286 Labour had capitalised on the future of the NHS during the 1983 election campaign it was the one issue it got right. Some student nurse intakes were cut to save money, and in September 1983 the RCN launched a ‘Nurse Alert’ campaign, holding a press conference in front of a backcloth emblazoned ‘Stop killing the NHS’.287 Doctors were frustrated at having to explain to patients why services could not be provided. Morale was said to be dropping; it was hard to identify whether it was RAWP, government cuts, reorganisation, technical advances or changes in management that were causing problems. 288 The presidents of the Royal Colleges wrote to The Times on 21 March 1984 expressing dismay. No relief was in sight.
The BMA, the Institute of Health Services Management and the RCN began statistical analyses of the trends and the likely medium and long-term prospects for the health service. They launched a report prepared for them by Bosanquet, from the Centre for Health Economics at York.289 It called for a commitment to maintain the minimum annual rate of growth for hospital and community services at 2 per cent, to fund pay awards fully and to give health authorities greater freedom to plan their spending over time. Ministers pointed to rising amount of money going in to the health service, and the fall in acute sector costs as a result of greater efficiency that allowed more patients to be treated. The organisations were unconvinced, and continued to hammer home the message that the NHS was seriously underfunded.290
Twelve consultants, representing all the London teaching hospitals, also wrote in protest to The Times in 1986.
We are consultants working in the health districts of inner London and have been monitoring the deterioration of the hospital services in our area . . . during the last five years over £35 million has been cut from our district budgets and . . . has caused the closure of 20 hospitals and more than 2,500 acute beds . . . It is no exaggeration to say that the care of the sick and the proper training of tomorrow’s doctors are now being jeopardised in our hospitals . . . The inner London population is no longer receiving an adequate acute medical service. The future of hospital medical services in London looks grim.291
The 12 had formed a small group and the letter was followed by a press conference in the House of Lords chaired by Lord Ennals. There was a subsequent meeting between some consultants and Norman Fowler, Secretary of State, and additional funding to ‘ease transitional problems from regions receiving the lowest increases under RAWP’ was announced, North East Thames RHA receiving £4.6 million.292 In the House of Lords the medical peers hijacked a debate to discuss standards of clinical care. Lord Smith said he felt that the NHS provided less and less for patients year by year. In 1948 a patient with angina would have been given medicine costing a few shillings; now there would be invasive tests and probably cardiac surgery costing thousands of pounds. Lord Porritt said governments could face up to the health bill only by cutting standards or raising taxation; he favoured a mixture of state, private enterprise, insurance, charity and even lotteries to finance medical care. It had become a dire necessity to practice selective medicine and the selection was made by the wrong people, politicians for financial reasons instead of doctors for medical ones.293
Health authorities had used stratagems to cope with the growing squeeze on their budgets. They had closed beds towards the end of the financial year and delayed paying their suppliers. Creative accounting kept them in balance but their debts slowly mounted. In 1987, as another election approached, it was made clear to authorities that bed closures were out. The ‘good news’ about the NHS proclaimed by Norman Fowler began to jar with the public perception of problems. Frank Dobson, Labour’s health spokesman, said that over the last year there had been a new epidemic an epidemic of hospitals short of beds, an epidemic of doctors hunting for beds, an epidemic of patients turned away.294 June 1987 brought John Moore to the DHSS in Norman Fowler’s place. Moore did not appreciate the dire financial situation of the NHS and failed to extract extra money from the Treasury. Communications failed and the message from the health service did not get through to ministers. Then the unpaid bills were presented and by September 1987 health authorities, realising that no more money was forthcoming, began to close beds by the score. Closures in January had been common enough, but not in October and November. A string of unrelated problems hit the NHS. Proposals for a new pay structure brought the nurses out on strike, and as nurses marched, doctors petitioned Downing Street. Blood transfusion staff took action. In October 1987 a hurricane ripped roofs off the hospitals, symbolising everything happening to the NHS.295 Medicine and the NHS were caught between the need to concentrate on what was effective and essential, and the temptation to embark on exciting developments that were costly, marginal in their benefit but of great interest to the media. A shortage of intensive care beds was blamed for the death of a baby whose heart operation had been cancelled five times in six weeks.
The NHS was becoming a political, statistical and managerial battleground.296 Norman Fowler spoke of ‘seven years’ progress’ with rising numbers of nurses, doctors and dentists, more cases being treated, and more outpatient attendances. Why, asked the BMJ, were the professions not impressed by this rosy scene? The answer lay in the complexity of the NHS, the largest organisation in Europe outside the Red Army. This unwieldy organisation was responsible for one of the few growth areas in the British economy, and one that would keep growing. The reality was that there would never be sufficient money and someone, somewhere, would be short of treatment they might reasonably expect. Much of the additional money had gone to absorb the large Clegg pay award inherited by Mrs Thatcher. More was absorbed by the reduction in the working hours of nurses. Demographic growth and technical developments required extra money merely to maintain the status quo. The rate of inflation of health service costs (pay, equipment and costs) was higher than the increase in the retail price index more generally. Closing beds, not because they were unnecessary but to save money, produced a ripple effect. Expectations had risen. More was demanded than was provided. More could be done than resources permitted. This message was percolating through to the public; the Conservative government was not winning the argument about the successes of the NHS.
Neither NHS reorganisation in 1974 nor restructuring in 1982 had altered the basic structure of the NHS. Society, however, had changed. A command economy can accomplish much, but it may not do it in a timely and sensitive way. People who increasingly expected attentive help in other fields could hardly fail to notice the absence of ‘customer-led’ services in the NHS. In the 1980s the Conservative government explicitly repudiated consensus and partnership with the professions in policy making. The public interest was no longer seen as achievable in this way and the professions were increasingly regarded as just another lobby, rather than carrying a special imprimatur derived from the nature of its expertise and values.297 The broadly bipartisan approach to the NHS ended after the Conservative victory in 1987. It was said that, if there was a third term, Mrs Thatcher’s motto would be ‘the customer comes first’.298 John Peet, a journalist and a member of a right wing thinktank, thought there was a simple and quick way of increasing efficiency built on competition.299 Among the political beliefs underpinning the coming changes were: the paramount importance of a sound economy and strong currency, without which public services could not be funded; the view that there was little the public sector could do that the private sector could not do better; and that managerial inefficiency was rife throughout the public sector, whether in the utilities, the schools or the health service.300 The changing approach in the NHS was only part of a wider ideological battle about society, industry and public services, although many in the NHS did not appreciate this. Maurice Shock later said that professionals failed to read social and political signs and were slow to press for the changes needed to adapt the NHS to rapidly altering circumstances. The once dominant Coop had been virtually obliterated by stores such as Marks & Spencer, and a vacuum had been left in the direction of one of the largest and most expensive organisations in Europe.301 The profession was thrown into confusion when it was struck by the blitzkrieg from the right, which believed that efficiency would be driven only by a market or some modification of one. The left believed that the market had many benefits but could not do certain things - prevent pollution or exploitation, nor generate the economic security of social harmony. Julian Tudor Hart thought there was a fundamental misunderstanding of health care and consultations. Health care was not something that patients consumed; patients and health professions produced it jointly. Patients participating in their own care by managing their diabetes or high blood pressure, for example made for better, more rational and cost-effective decisions. But they needed to be given professional time, something not encouraged by a marketplace.302
Health service reform had been on the Conservative agenda for a while but other issues had priority. In 1982 the Cabinet had been presented with a paper prepared by the Central Policy Review Staff, proposing the replacement of the NHS with a system of private insurance as one way to cut public expenditure. Leaked to The Economist, there was an immediate outcry.303 The proposals were killed by Mrs Thatcher as electoral suicide but left fears that there was a hidden agenda.304 John Redwood and David Willetts at the Centre for Policy Studies had been considering how a market might work within a national health service. Willetts, later a member of the No. 10 Downing Street thinktank on health, argued that the government was getting the worst of all possible worlds. No credit was being given for the everincreasing sums spent on the NHS. There was anxiety that the NHS was heading for the worst features of American medicine, with care provided only if your credit card was good. There could be advantages in radical but public proposals that did not threaten free patient care yet were consistent with the radical Thatcherite philosophy. If an insurance-based system was ruled out, because of the additional overheads, reform had to be on the supply side. GP budgets had already been considered in the context of the review of primary health care. Redwood and Willetts lunched at the Nuffield Provincial Hospitals Trust with Alain Enthoven, a leading expert on the economics of health care, who was on a preliminary visit to Britain before holding a fellowship funded by the Trust. The thinking of the Centre for Policy Studies was discussed, but all the main ideas that later appeared in Enthoven’s Reflections on the management of the NHS were current in radical-right circles.305
Enthoven was involved in the reshaping of US health care organisations, in particular HMOs. His public statement of the ideas was useful to the Centre for Policy Studies. He noted that ‘bureaucratic forces in the NHS drove for uniformity’. Variation was equated with inequality and injustice. The idea of a district trying something distinctly new and different, other than in response to orders from the DHSS, was perceived as a threat to the Minister. Enthoven believed there would be increasing problems for a service without incentives to provide either better quality care or services at a lower cost. There seemed little indication of a desire for radical reform, even though the service was approaching gridlock. He was particularly concerned that teaching hospitals were not getting adequate recompense for the work that they did. One approach, he thought, would be to create an internal market as a way forward, with each district receiving a RAWP-based per-capita revenue and capital allocation from which it would pay for and provide health services for its own residents and for others at negotiated prices. Each district would resemble a nationalised company that would buy and sell services from other districts and trade with the private sector. A more radical alternative, which Enthoven preferred, would be competitive HMOs, an idea also favoured by the Adam Smith Institute.306 The BMJ thought that, although North America was a fertile source of flying critics of the NHS, Enthoven was knowledgeable and constructive. His analysis was sharp and his solutions radical. That the NHS was approaching gridlock was in tune with professional thinking; the NHS did seem held in a grip of interlocked forces making real change difficult. It would be a tragedy, said the BMJ, if his ideas were not taken seriously, weighed in the balance and tested in the small pilot schemes he advocated.307
Alongside a political belief about how services were best provided there was continual evidence that, pressed as it was, the health service could not continue on its current basis. Sir Bryan Thwaites, a mathematician and Chairman of the Wessex RHA, believed that the public was sophisticated enough to recognise that the NHS could not do everything medically possible and that bounds had to be set.308 Applying hard science to soft data, he calculated that expectations were rising at 5 per cent a year, because of public awareness of what could be provided, the absence of any charge at the point of delivery, lowered tolerance of discomfort, doctors’ attitudes and expectations, advances in medical treatment, more research, more GPs leading to more treatment and more consultants leading to more research. Government might be proud of a 2.5 per cent growth rate, but the public was disenchanted that it was not getting what it wanted. The health service needed rethinking; perhaps some services should be outside its range of provision, and more consideration had to be given to costs and outcomes. He gave examples of what the NHS might and might not cover. Safely within his vision of NHS services would be the average man with arthritis, and a young wife expecting her first baby; just outside was the married woman wanting in vitro fertilisation; well outside the NHS was the fiancé with a voluptuous nude tattoo impeding his latest courtship, and an elderly and unlikely survivor of heroic surgery. The Economist thought that choice, competition and cost-effectiveness would settle the matter; managers and clinical staff required incentives. Sir Bryan Thwaites disagreed; each step forward in efficiency was frustrated by two steps backwards in the face of the onrush of expectation.309 Bounds and limits were needed. He did not, however, explain who would make the choices, and how. The problems experienced in the front line were presented graphically in an article about the King’s College Hospital accident and emergency department. If Mrs Thatcher was to retire to her home in Dulwich, that was where a sudden illness would bring her. The conditions were third-world. Nurses rather than domestic staff cleaned up the vomit and blood. ‘If you don’t get it while it’s wet it’s twice as hard to clean up afterwards and if anybody slips over then it’s you who answers for it.’ Patients bled onto the floor; lumps of plaster fell from the ceiling. The picture was Hogarth. How long were people prepared to stick it?310
At the Conservative Party conference in October 1987, John Moore, the Secretary of State, pledged reform of the NHS. A slaughter of sacred cows was promised, which seemed to involve better economic policies to generate wealth, an extension of competitive tendering and more cooperation with the private sector. During the winter of 1987/8 the media began producing horror stories about the NHS on a daily basis.311 In December 1987 the presidents of three Royal Colleges, Physicians, Surgeons, and Obstetricians and Gynaecologists issued a terse statement. Giving a press conference on the steps of the DHSS, their message was clear. An immediate overall review of acute hospital services was mandatory and additional alternative funding must be found. Something had to be done to save the health service, once the envy of the world.312 The view took hold on the Conservative back benches that health care was too important to be left to the DHSS. The pressure to provide more money for the NHS was almost irresistible. Critics argued that the real growth in the NHS budget was not enough to match growing demand from demographic change and the introduction of new costly medical techniques and planned improvements in services. The government believed that a system reflecting a command economy was never going to deal adequately with the demand within the resources available. The next managerial drama, and the greatest since 1946, was about to begin.
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