Public Health Reports

A mind-numbing series of reports appeared.  They were lengthy, repetitive and because of the compromises necessary to avoid trenching on private liberty, were more radical than some wished, and less prescriptive than others would have them.

The Acheson Inquiry (1998)
Saving Lives - our healthier nation (1999)
Tackling Health Inequalities - A programme for action (2003)
Wanless - Securing Good Health for the Whole Population (2004)
Choosing Health (2004)

Acheson Inquiry

Labour commissioned an inquiry into inequalities in health, conducted by Sir Donald Acheson, an unusual choice as he had been CMO at the time when The Health of the Nation was prepared under the previous administration. The inquiry team, composed of scientists but no economist, based their recommendations on published evidence.  Because of evidence that the poor generally lived shorter unhealthy lives, the key recommendations involved a wholesale redistribution of wealth. The difference between the mortality rates of Social classes IV and I for stroke, heart disease, accidents and suicide were, if anything, widening.  Unlike the recommendations of the Black Report (1980), Acheson’s 1998 wide ranging recommendations were not costed.  Sir Donald wanted to see the package implemented as a whole. ‘The inquiry had not looked at cost effectiveness’, he said, ‘affordability is not a matter for scientists but politicians…’  Some recommendations were vague, for example the need to take ‘measures to prevent suicide among young people’ or ‘policies to reduce fear of crime and violence’.  Sir Donald had asked an evaluation group to look at the quality of the evidence it used to reach its conclusions, and support its recommendations. For most of these there proved to be no high quality controlled studies showing that the recommendations  would improve health - there were few randomised-controlled trials available – but hard evidence of effectiveness has seldom underpinned changes in health policy.  Indeed the widely held view that the extent of inequality of income in a society correlated with the health of the population was undermined by more recent studies, for at least in the US education was a powerful predictor of mortality, far more than income inequality (BMJ 2002;324: 1-2)

Saving Lives - our healthier nation

This was a review of 1992 Health of the Nation initiative that found that its strategy had failed to change spending priorities and had made no significant impact on health authorities, trusts or GPs.  In 1999 Labour published a revised programme as a Green Paper, Our Healthier Nation, then a White Paper, Saving Lives - our healthier nation. This aimed to improve the health of everyone, particularly the worst off, taking into account the social, economic and environmental factors affecting health.  It reduced the number of health improvement targets to four and re-iterated the contributions to health both of social, economic and environmental factors, and the individual decisions taken by individuals and their families.  The document expressed aspirations, and tended to say what government could do - and not what it would do.  The role of the Health Visitors would be strengthened, and educational programmes would be introduced, for examine sessions at school to help children to avoid accidents. The new policy was not substantially different from the old one, though  the goal was now to improve the health of the worst off in particular.

Tackling Health Inequalties

In July 2003 Tackling Health Inequalities - A Programme for Action  set  out a three-year plan on health inequalities. It aimed to meet the 2010 national health inequalities target on life expectancy (by geographical area) and infant mortality (by social class) and was organised around four themes, supporting families, mothers and children to break the inter-generational cycle of health, engaging communities and individuals, to ensure relevance, responsiveness and sustainability, preventing illness and providing effective treatment and care and dealing with the long term underlying causes of health inequalities.

Wanless

In his first report to the Treasury, largely concerned with financial matters, Derek Wanless had provided 3 different scenarios based on different levels of involvement of the public in relation to their health.  In April 2003 he was asked to provide an update on the challenges involved, focusing on prevention and the wider determinants of health. Two issues emerged again, regulation versus patient education, and local versus national projects. He issued a report on population health trends in December 2003 and his final document, Securing Good Health for the Whole Population, appeared in February 2004.  It provided little assistance in policy making, while criticizing policy, service frameworks and targets in smoking and obesity. Wanless thought the costs of the health service would be massively less if  there was "full engagement" - i.e. energetic and effective action by all concerned, including individual members of the population.  Wanless drew attention to the problems of smoking, lack of activity and obesity, while failing to make clear what the costs would be incurred if individuals avoided life-style induced illnesses, and died later of something else instead.  Key points included

•    Individuals are primarily responsible for their own health and lifestyles, but lack of information and the social context in which they live, may lead to people failing to achieve the substantial improvement in health possible. These failures must in part be addressed by government

•   There has been much written, often covering similar ground and apparently sound, but rigorous implementation of identified solutions had often been lacking.

•    There is generally little evidence about the cost effectiveness of public health policies in part caused in part by lack of research funding.

•    This has led to the introduction of a wide range of initiatives, often with unclear objectives and little quantification of outcomes 

•    Report summary - recommendations

Shortly after the report appeared the Secretary of State opened consultation in the run up to a further White Paper on the health of the nation, asking what individuals and organisations thought would be most effective in changing behaviour, health inequalities and organisational responses to improve people's health.  Increasingly the role of the individual was emphasized in the making of healthy lifestyle choices.

Choosing Health

Published in November 2004, the principles were said to be informed choice (with the protection of those too young to choose, and ways of ensuring that one person's choice did not harm others), tailoring proposals to the reality of individual lives, and working together.  Among a myriad of actions to make the NHS a health promoting organisation, Choosing Health proposed

• action to increase the number of smoke-free workplaces

• Curbs on the promotion of unhealthy foods to children

• Clear, unambiguous labelling of the nutritional content of food

• better provision of information to the public, e.g. a Health Direct

• NHS Health Trainers to provide advice to individuals on how to improve their lifestyle

There would be a ban on smoking in most public places such as pubs and restaurants, restriction of  TV advertising before 9 p.m. of high calorie junk foods and provision within primary care health of education on lifestyle.  The plan was criticized because of many of the proposals were already being pursued - there was little new about patient education -  the timescales were long and reliance was sometimes placed on self-regulation by industry.  PCTs in the more deprived areas would, however, receive extra money to pilot such initiatives as health trainers, local people advising others on healthy living.

Infectious Disease and its surveillance

Following 9/11 and the use of anthrax through the mail in 2001 in the USA (with many cases of skin infection and several deaths from pulmonary anthrax), the possibility of similar attacks in the UK, led the government to issue guidance to GPs and responsible bodies throughout the country. The NHS and the emergency services were primed to plan and organise for bioterrorist emergences.  For anthrax, the brunt of the problem fell on the CDC in Atlanta, Georgia that was deeply involved in examining the outbreaks, and learning more about the epidemiology of a previously rare condition. The US government placed a major contract for ciprofloxacin an appropriate antibiotic.  Concern that smallpox might be used by terrorists led by US and the UK government to order supplies of vaccine and to issue contingency plans for on the containment of local outbreaks, and mass vaccination.

The Communicable Disease Surveillance Centre and its successor the Health Protection Agency continued to survey the hazards of infectious disease and European health ministers planned to strengthen and extend the EU's communicable diseases network so that it could be used in the event of bioterrorist attacks as well as the threat posed to health by world-wide mobility of people, food and products. 

Citing the global threat of infectious diseases to health, prosperity and national security, the Chief Medical Officer of the Department of Health proposed in January 2002 a strategy he considered would improve the current system of preventing, investigation and controlling the threat of infectious diseases threats, and health protection more widely -  Getting ahead of the curve.  A new Health Protection Agency (HPA) would combine the existing functions of the Public Health Laboratory Service and three other national bodies (the National Radiological Protection Board, the Centre for Applied Microbiology and Research, and the National Focus for Chemical Incidents) to integrate the approach to protecting the public against infectious diseases as well as chemical and radiological hazards.  There would be a national expert panel to assess the threat from new and emerging infectious diseases. Local PHLS laboratories would be taken over by the NHS, the Agency having local health protection services, working with the NHS and local authorities, to prevent, investigate and control infectious diseases as well as chemical and radiological hazards. The PHLS board believed that the proposals would break up a managed national system, leading to fragmentation.

The national networks had long linked together number of surveillance institutes.  The London based CDSC, for example, acts as the hub of the operation to track developments linked to legionellosis and salmonellosis infection with Escherichia coli O157, and the Institut de Veille Sanitaire in Paris is performing the same role for tuberculosis and HIV and AIDS.

DNA fingerprinting is a powerful tool for identifying people.  Such advances were now applied fingerprint germs, to show their family relationships; to look at their evolution; to track the spread of germs and identify where they came from; or to fingerprint them to prove that a particular strain of the germ was the culprit of a particular outbreak. (Other techniques, e.g. phage typing, had been in use since the 1950s).

Infectious diseases

Tuberculosis remained a global health problem. The breakdown in health services, the spread of HIV infection, and the emergence of multi-drug resistant tuberculosis in many parts of the world contributed to the worsening impact of the disease. Annual notifications in England were steady at roughly 6,000 although the number in London was rising steadily. Around seven out of every ten people with TB came from an ethnic minority group, and two-thirds of people with TB were born abroad. 6% were multi-drug resistant. In 2001 an outbreak in a Leicester school, though contained, demonstrated the need to maintain an effective tuberculosis services, and to be aware of the global problems presented by the disease.  A campaign was launched in 2004 to target high risk groups and mobile radiography units were brought back into use.

In February 2003 an unusual form of pneumonia was recognised. The severe acute respiratory syndrome (SARS) was responsible for the first pandemic of the 21st century.  Initially of unknown origin, it was soon found to be due to a new coronavirus.  Within months after its emergence in Guangdong Province in mainland China, it had affected more than 8000 patients and caused 774 deaths in 26 countries on five continents. It illustrated the potential of air travel and globalization for the dissemination of a new infectious disease and the need for a coordinated global response to contain such disease threats.

Food born infection continued to cause of concern. A survey of 70 general practices produced an estimate of 9 million cases annually, most of which were never seen by a GP. Campylobacter was the most common bacterial isolate, but in the majority of cases, none of the main food poisoning organisms was identified. Milk born coliform infection in Cumbria received national attention.  In 2002 a substantial outbreak of Legionnaire's disease occurred also in Cumbria (Barrow-in-Furness), and Norwalk-like virus gastroenteritis affected a number of large cruise ships.

AIDS and sexually transmitted diseases

Internationally AIDS deaths were set to reach record levels. In the west, the introduction of highly active antiretroviral therapy transformed the prognosis of HIV disease, dramatically reducing infections and mortality.  However in the USA while infections contracted homosexually had been stable from 1992-1996, and the death rate was falling, the rate of new infections doubled over the next four years.  As a result of drug therapy more people were healthy and on the street, and people were less scared of unprotected sex.

Estimated Number of Adults Infected with HIV, According to Region, 1980 through 2003. NEJM 2004 351:115-117  adapted from the World Health Organization

A tendency to complacency in the western world contrasted with the tragedies elsewhere.  Of roughly 40 million cases, two thirds were in Africa, one fifth in Asia and China increasingly figured. China.  In Thailand AIDS first affected homosexuals, then in turn drug users, prostitutes, their clients, the wives and girlfriends of the clients, and then the children of those women.

In 1999, it became policy in England to offer HIV testing to all pregnant women. It was in the inner cities, with their multi-racial populations, that the incidence of maternal infection was at its highest. In 2000 heterosexual sex became, in England, the leading cause of new infections. Since the epidemic began in the early 1980s in the UK about 15,000 deaths were known to have occurred. In 2002 approximately 41,200 people were living with HIV in the UK, about 31% of whom were undiagnosed.  The number of people living with diagnosed HIV rose each year due to increased numbers of new diagnoses and decreasing deaths due to antiretroviral therapies. Most in the UK who acquired infection heterosexually were not infected in this country. More than three quarters were recorded as having acquired infection abroad with almost two thirds of the total in Africa, the majority in East Africa though the impact of the HIV epidemics in southern and western Africa was growing.  Sixty percent of new cases were in London, and a fifth of these were in Lambeth, Southwark and Lewisham, more than half of these in ethnic minority populations.  The patients might be on student visas, seeking asylum, or less commonly treatment not available in their own countries.  Increasingly HIV was drug resistant, 27% of new cases in 2000, compared with 14% in 1994. In 2003 there were 7,000 new cases of HIV, up 20% in a year.  70% were in heterosexual African migrants and 1% of the population were black Africans; this group constituted 32% of all HIV cases in the UK.  Now it became important to act, political correctness aside.  While most of these infections had probably been contracted abroad, it had to be treated as a health problem, not an immigration one. 

There were only two approaches to the epidemic, preventing new HIV infections and anti-retroviral treatment to those needing it. The consensus view was that in the treatment of established HIV infection initial therapy should include a combination of three potent anti-viral drugs; there might prove to be a case for four. Two new classes of anti-HIV drugs - entry inhibitors and integrase inhibitors - and a second generation of non-nucleoside reverse transcriptase inhibitors (NNRTIs) seemed in vitro and in early clinical trials to be effective against HIV strains that were resistant to currently available drugs.  For the third world, new low cost drug regimes, administering zidovudine in pregnancy, offered a chance of reducing the infection of the foetus by the mother by some 80%; more intensive treatment from 28 weeks of pregnancy was even more successful.  But though drug companies might offer special deals, funds were hard to find in the third world and "dismal" was a charitable way of describing the treatment-coverage rates in many countries. The problem was compounded by the unwillingness of some fundamentalist churches to talk about condom use.

The development of a better method of identification of infection in its earlier stages, by tonsil biopsy, opened the possibility of population screening to determine the incidence of infection. A study of 12,500 specimens of tonsils and appendix removed at operation showed 3 cases of the prion responsible for vCJD, suggesting that perhaps three thousand people carried the infection. New guidelines in January 2001suggested that disposable surgical instruments should be used in operations such as appendicectomy and tonsillectomy in spite of the cost.  Shortly after operative difficulties, and possibly deaths, followed their use and they were withdrawn. 

Compensation became available to people who had been infected with Hepatitis C from blood transfusions, developing liver cirrhosis,  after the hazard was recognised, but before the introduction of routine screening in April 1991 -  lump sum payments of £20,000.   John Reid extended this to cover a wider range of people infected as a result of being given blood products by the NHS.  In October 2001 compensation was also offered to victims of vCJD and their families.

Screening

The National Screening Committee, established in 1996, was one of the bodies attempting to introduced evidence into medical protocols.  In its first report in 1998 it identified almost 300 screening programmes, many at a research stage and nearly 100 in practice. Only four met stringent criteria for both quality and evidence of effectiveness, breast and cervical screening, and neonatal blood spot screening for phenyl-ketonuria and hypothyroidism. Earlier considered harmless, there was a growing body of evidence that screening could harm people, particularly because of false-positive and false-negative results. To Wilson’s earlier criteria (see From Cradle to Grave) was added a new one, that there should be evidence from high quality randomised controlled trials that programmes were effective in reducing mortality or morbidity.  In 2003 it was agreed to work towards a national screening programme for bowel cancer, the second most common cancer in men and women and this would be introduced with the testing of stools for blood in the over sixties in 2006.  Further trials would be undertaken for an alternative method common in the USA, flexible sigmoidoscopy.

"Multi-phasic screening" as a form of health check, had been popularized in the USA in the sixties.  Now a new form of "screening" emerged there, with the introduction of whole body spiral CAT and MRI scanning.  Mobile units might offer cardiac, thoracic or abdominal scans.  Other organisations provided Doppler ultrasound investigations to the worried well.  There were, of course, some positive findings - for example young men with an operable but clinically silent cancer. Such procedures might take only a few minutes and cost $200 each, not an impracticable sum.

Alternative medicine

Complementary, or alternative, medicine remained in public demand.  The main common factor seemed to be the time and patience of practitioners of alternative medicine, commodities in short supply in the NHS.  

The Prince of Wales, like many of the Royal family, was a longstanding advocate for these therapies, or at least for research into their effectiveness.  In November 2000 a sub-committee of the House of Lords Select Committee on Science and Technology, chaired by Lord Walton, reported that there was scant evidence that alternative remedies worked.  Yet the public spent £1.6 billion annually and 50,000 practitioners were treating some 5 million patients.  Only osteopathy, chiropractic and  acupuncture were backed by scientific evidence.   The evidence for herbal medicine was mixed, and that for homeopathy was anecdotal.  The subcommittee was particularly concerned about dangerous and inaccurate information that appeared in some media articles, and on internet.  Better regulation of practitioners, and control of misleading product labelling, were needed.  In December 2001 the Department of Health expressed a willingness to consider the provision of some forms of complementary medicine within the NHS, subject to evidence of its effectiveness. Almost certainly such evidence would be a long time coming.  How, in any case, could one regulate and examine people in an ever changing and expanding number of alleged disciplines, most of which had the scientific background of snake-oil salesmen.

Clinical specialties

Emergency medicine

Medical genetics

Increasingly genetic medicine was showing the potential to identify people at risk of serious disease, for example some forms of breast and bowel cancer.  Genetic blueprints of individuals could show the risks that they might run in later life.  Academic centres had evolved into regional centres serving populations of 2 - 6 million.  Clinical and laboratory services worked closely together, and developed "hub and spoke" systems with clinics in district hospitals.  They provided access to the latest developments, clinical diagnosis, laboratory (DNA and chromosomal) diagnosis, genetic counselling and the care of extended families long term.  In 2001 Alan Milburn invested £30 million in genetic services and to create a national policy on clinical genetics, the government announced a forthcoming paper on genetics.  In June 2003 the White Paper Our inheritance, our future - realising the potential of genetics in the NHS was published. It painted a vision of a future health service offering personalised care based upon a person's genetic profile. It promised increased spending on research, on the development of clinical services in primary care and the hospitals, and more education and training programmes.

• investment in upgrading genetics laboratories, and a boost to the genetics workforce, counsellors, consultants and laboratory scientists

• £7 million on new initiatives to introduce genetics-based healthcare into mainstream NHS services

• A new Genetics Education and Development Centre for education and training in genetics

• New research programmes in pharmacogenetics, gene therapy and health services research

Research proposals were sought and funded to examine how information about a patient's genes might be used to tailor treatment to individual need, perhaps reducing the incidence of adverse drug reactions, or targeting patients most likely to respond well.

The Human Genetics Commission (HGC) was created in 1999 to provide the Government with strategic advice on human genetics. Ministers asked the Commission to look at the wider social and ethical issues involved in the use of genetic data in insurance.  The Commission was concerned that the results of genetic tests might be used by insurance companies to the detriment of the population were examined by the Department of Health's Genetics and Insurance Committee (GAIC).  In October 2000 the committee agreed that to allow insurers in the UK to use genetic test results for assessing the risk of Huntingdon's disease.  The Gene Therapy Advisory Committee (GTAC) was also established to advise on the ethical acceptability of proposals for gene therapy research on humans taking account of the scientific merits and the potential benefits and risks, and to advise on developments in gene therapy research.

The lengthy hunt for the structure of the human genome accelerated as commercial interests united  with the international programme led by the American National Institutes of Health. A draft structure for the entire genome was announced in June 2000 and the virtually complete mapping of the human genome was completed in April 2003, two years ahead of schedule.  Breakthroughs in basic science sometimes feed through to major advances in clinical medicine as did microbiology at the end of the 19th century,  and later imaging and immunology.  Genetics is fundamentally concerned with the cause of disease. Some diseases are wholly genetic in origin, for example cystic fibrosis. Others are largely environmental, for example asbestosis. But many common conditions are a combination, for example coronary heart disease and asthma. Knowledge of the human genome seemed likely to underpin a further advance in clinical care. 

The development of pre-implantation genetic diagnosis (PGD) offered the possibility of ensuring that a new born child was not a carrier of some genetically determined diseases.  In 2004, the Human Fertilisation and Embryology Authority (HFEA) that regulates the storage of eggs, sperm and embryos and reviews new developments in treatment and research, agreed to the use of PGD for assessing the risk of familial adenomatous polyposis. Testing for retinoblastoma and BRCA 1 & 2 (breast cancer) was also on the horizon. Genetics offered the possibility of early identification of those people likely to become ill because some disorders of adult life are preceded by a prolonged presymptomatic period, for example vascular disease and diabetes, even though environmental and dietetic factors may play a larger role.  This opened the possibility of predicting and preventing disease, instead of diagnosing and treating it at a later stage. Genetics also provided an insight into the cause of many diseases at a molecular level, making the transition from merely describing a disease to understanding its mechanism.  Diseases previously thought of as one, could be separated into categories with a different origin - and therefore treatment. For example a computer algorithm designed to seek out those breast tumours that had the most similar genetic profiles, and cluster them together, revealed that 98 cancers fell into two main groups that could be recognised on the basis of the activity of 70 genes. A woman who possessed a “poor” 70-gene signature would be 15 times more likely to suffer a recurrence within five years than a woman who had a “good” genetic signature and the second group might possibly be spared aggressive chemotherapy with all its side effects.  The possibility also existed of developing drugs with an appropriate therapeutic action. Genetics provided the pharmaceutical industry with a wealth of new targets against which to design drugs; suddenly the industry went from famine to feast’.

In primary care as much as in the hospital service, an increasing number of conditions could now be seen in a genetic context.

^{The drug treatment of disease}

The examination in the UK of drugs for safety and efficacy had a long history, going back to the thalidomide disaster in the 1960s. Within the European context the European Medicines Evaluation Agency was established to bring together the resources of Community members, and was based in London.  The Medicines Control Agency (MCA) was merged with the Medical Devices Agency (MDA) on 1 April 2003 as the Medicines and Healthcare products Regulatory Agency, (MHRA)  The pharmaceutical industry was having an ever-increasing impact on health services. Increasingly health services were concerned with chronic diseases rather than the accent on acute illness of previous decades.  Particularly in the USA ‘disease management programmes’, in which health services sometimes contracted the management of some chronic diseases to pharmaceutical companies, were adopted.   In theory systematic, integrated evidence-based and long-term care of chronic high cost diseases such as asthma, rheumatoid arthritis and diabetes might be more effective. However, the management of specific diseases by a separate organisation risked the fragmentation of care, as patients with multiple unrelated pathology might be directed to specialised units.  

Ask your doctor about...

A substantial number of patients, however, consulted their doctors as a result of advertisements that they had seen on TV or in the papers. In 1997 the US Food and Drug Administration (FDA) further relaxed the controls on Direct-to-Consumer Advertising  (DTCA) advertisement of prescription drugs. DTCA was a powerful tool, designed to create demand and maximise profits by encouraging patient demand. Bob Dole, the former US vice-president appeared in the US on a TV commercial for erectile dysfunction - paid for by Pfizer. Some drugs now became household names, Viagra, Prozac for depression, Claritin for allergies, Rogaine for baldness and matrix for migraine.  DTCA might be inaccurate; from 1997 to 2001, the FDA issued 94 notices of violations, mostly because benefits of the drug were hyped and risks minimised.   In 1999 drug companies began ‘public awareness campaigns’ in England. These had little to do with health education, for the material and the advertisements were not about inexpensive diuretics, immunisation or cervical smears, but unsightly rashes and cures for baldness. In 2001 the European Commission proposed changes in EU law to allow DTCA for three disease areas, AIDS/HIV, diabetes, and asthma for a 5-year period followed by a review; the proposal was categorically rejected by MEPs the following year. When drugs were cleared for over the counter sale by a pharmacist, as was simvastatin 2004, companies lost little time in advertising it directly to the public.

Internet also increased the availability of public knowledge of pharmaceutical products available and inevitably, there was increased pressure on doctors to prescribe the drugs publicised. The drug industry regarded Internet as an essential part of their DTCA campaigns, and one aimed at people actively searching for information. (e.g. www.emc.vhn.net )  Such developments were slower in Europe, where governments inevitably wished to control drugs budgets.  

The health service was being overtaken by an increasing number of expensive but clinically effective drugs sometimes "life-style" in nature.  Prozac, HRT, and Viagra were examples of pharmaceutical advance that might improve qualities of life to which medicine had previously paid less attention.  In January 2001 NICE approved three new drugs for the treatment of mild or moderate Alzheimer's disease.  A new anti-obesity drug, Xenical, offered an alternative approach to a common problem by reducing fat absorption; NICE agreed in March 2001 that it could be prescribed under the NHS when patients were motivated to lose weight and obesity was significant and posing a threat to health. In April 2002 NICE recommended the use of bupropion (Zyban) and nicotine replacement therapy (NRT) for smokers who wished to quit.

The decade also promised a new round of expensive yet effective drugs, for example statins for coronary artery disease and stroke.  Adults with diabetes of the insulin resistant type stood to benefit from a new class of drugs, the thiazolidinediones.  Organ transplantation became more reliable with the development of new immune-suppressers. New drugs were available for schizophrenia, which had been adopted rapidly in North America and Scandinavia.  The treatment of benign prostatic hyperplasia, a common condition, was improved by combination therapy with doxazosin and finasteride which reduced the risk of acute urinary retention and the need for surgery.

Drug resistance 

Bacteria are adept at developing drug resistance and this ever-increasing problem led to alarm.  The Standing Medical Advisory Committee (SMAC) reported upon it in 1998 - The Path of Least Resistance.  SMAC believed that up to 75% of antibiotic use was of questionable value, yet there seemed to be inevitability to the problem. Society demanded easy answers and there was increasing use of broad-spectrum antibiotics. People might be treated inappropriately or too long; antibiotics were used on fruit-trees and salmon farms. The most vulnerable members of society were often crowded together.  There are worldwide pressures for greater efficiency in health systems with higher bed occupancies, and stretched nursing and medical care, and particularly high hospital bed occupancy in the UK. With patients waiting admission from A & E, people with infected wounds might be admitted to wards wards which should have been kept bacteriologically clean.  In the 19th Century hospital infection was worst in the busiest hospital, and history was repeating itself.  Yet the essentials of control are well known, reducing antibiotic use, improving hygienic measures and hospital cleanliness.

Staphylococcus resistance had been a problem in the 1950s-1960s, then becoming far less troublesome.  In the eighties infection by methicillin resistant Staphylococcus aureus (MRSA) began to increase once more, and by 2000 roughly a third of strains isolated in hospitals were resistant.  Some now showed resistance to the only remaining antibiotic, vancomycin.  The number of patients from whom MRSA had been isolated had multiplied more than ten fold over ten years. The National Audit Office reported in 1999/2000 that dirty hands and unsanitary conditions in hospitals caused 5,000 deaths a year and over 100,000 inpatients became seriously ill with infections, costing the NHS £1 billion a year.  A follow-up report in 2004 showed only patchy progress.  Voluntary surveillance of hospital-acquired infection had long been undertaken; government made it mandatory in April 2001 and launched initiatives to attempt to improve hospital hygiene and lower infection rates.

Until the 1980s a steady stream of new antibacterials had become available. The 1980s saw little new investment in them, but that began to change. The continuing emergence of resistance strains established the need, and three approaches were followed, the modification of existing agents, genomic approaches and vaccine development. Agents such as the fluoroquinolones, active against anaerobes and streptococci, began to appear.  In January 2001 Zyvox, a new antibiotic for the treatment of resistant organisms including MRSA was approved for hospital use.  With a multiplicity of antibiotics, and ever increasing microbial resistance, accurate information on antibiotics and their proper use became essential.  A free peer-reviewed database was provided on the Internet by Johns Hopkins, Baltimore.

Radiology and diagnostic imaging

Digital radiographic systems continued their development and, under the Department of Health’s IT programme, the Picture Archiving and Communications System would enable images to be stored and mailed electronically rather than printed on film and filed manually.  Health professionals across the NHS would, it was planned, be able to access the information at the touch of a button. 

Computed tomography was developing rapidly.  In the late eighties the rotation of the x ray source was combined with continuous movements of the table on which the patient was placed. Because the tube was rotating while the subject moved smoothly through the scanner, the x ray beam described a spiral pathway. This meant more rapid scans, closer spaced scans, and a scan within a single breath-hold, giving three-dimensional images.   Images were better providing new applications for the imaging technique.  For example, the colon could be viewed in exquisite detail.  Next, multi-slice scanners were introduced with not one row of detectors, but up to eight.  Image acquisition was even faster and a larger area could be covered.  The newer scanners were inevitably more expensive, but there was a danger of rising radiation dosages.

Magnetic Resonance Imaging was developed to be a rapid imaging tool for the whole body.  Its ability to reveal skeletal spread of cancers, sometimes when no primary tumour had been found, made it particularly useful because radiation was avoided.

In 2000, Nutt and Townsend working first in Geneva and later in Pittsburgh, combined computerized tomography scanners (CAT) with positron emission tomography (PET).  The result was a single machine that could simultaneously image anatomical structure, for example cancerous tumours, and metabolic processes, reducing the time for a diagnosis and reducing patient discomfort.  Conformational radiotherapy, which enabled accurate dosage to be given to precisely the required field even if it was irregular in shape, enabled higher doses to be given with less tissue damage and, hopefully, better outcomes. "Intensity modulated radiotherapy" enabled different doses to be administered to different parts of a tumour.  Electron beam imaging was also under development.

Progressive development of imaging systems also aided the development of minimal access surgery. Image-guided surgery used imaging systems during a surgical procedure to assist its performance. Magnetic resonance imaging was the best technique, but it had not been practical because the machines had been fully enclosed. The first truly open scanner was installed in Boston in 1994, but in 1999 one was installed at St. Mary's Paddington. Surgeons had full access to any part of the patient's body, while simultaneously that part was scanned. Endoscopic views could be combined with MRI images, and important structures could be identified and safeguarded during surgery.

Surgery

Surgeons and surgery figured frequently in the medical issues covered by the media.  Sir Barry Jackson, when President of the Royal College of Surgeons, was frequently seen on TV, providing quiet and thoughtful comment on cases of clinical misadventure, for example Bristol.

Cosmetic surgery was becoming a growth industry, and in some circles an obsession.  Both in the UK and the US the demand was growing rapidly.  In 2001, over 13,400 patients were registered as having had a breast implant. The most common reason was cosmetic augmentation (77% of total). The NHS was providing, if anything, less of a service and therefore less training for young surgeons, the private sector mushroomed.  Professionally, the main controversy was who should be regarded as qualified and competent to carry out plastic surgery, for some of those operating were clearly lacking appropriate skills.  The use of botulinum toxin (botox) to reduce wrinkles was popular; in the US it was approved by the Food and Drugs Administration for the removal of wrinkles and Botox parties were commonplace.  In the UK Boots planed to provide facilities in some of its larger stores.  Collagen fillers were widely used and sugar molecule injections looked set to become the next hot cosmetic item.

Minimal access surgery

Minimally invasive surgery continued to progress facilitated by improvements in miniature video cameras producing good images so the operator and the assistant could work together.  Virtual reality simulators became available for training. Laparoscopic cholecystectomy was becoming the technique of choice. 

New surgical procedures, unlike new drugs that were subjected to clinical trial before licensing, might be developed anywhere in the world and introduced by a surgeon locally without much in the way of formality.  Indeed, many operations - for example those on the heart - would never have been developed if the high mortality among the earlier cases had been considered as would have been the case for a drug.  Operative procedures were now considered by the National Institute for Clinical Excellence (NICE).  Twenty years previously  minimal access surgery had been hailed as a major advance, saving the patient pain and reducing the length of admission.  Subsequent reassessment revealed the complication rate of such operations, and the techniques of open operations were improving in any case, as in the case of inguinal hernia.   NICE reviewed minimal access surgery for this condition of which there were 100,000 new cases each year.  NICE recommended in December 2000 that laparoscopic surgery should not be used for colo-rectal cancer, and in January 2001 that people with first time hernias of the groin should have ordinary (open) surgery rather than a minimal access procedure.  For the repair of hernias that reoccurred or were on both sides minimal access surgery should be considered, a totally extraperitoneal procedure, which did not involve opening the peritoneum, was preferable.  It was recommended that such surgery should only be undertaken in surgical units with appropriately trained operating teams that regularly do these procedures.  The open procedure was, in general, cheaper.  Centrally formulated guidelines were increasingly affecting the decisions of surgeons. 

Virtual reality in surgery

New technologies developed in the eighties and nineties, in particular virtual reality and robotics, were coming to practical fruition.  In general surgery simulators were introduced, for example to train and assess new professionals.  Neurosurgeons were using image guided surgery and augmented reality.  "Master-slave" robotic procedures were used for minimally invasive coronary artery bypass grafting and laparoscopic surgery. Instruments permitted smaller incisions, and tremor free operating.

Fast track surgery

Newer approaches to pain relief, better - sometimes regional - anaesthesia, minimally invasive techniques, optimal pain control and aggressive postoperative rehabilitation, were reducing the patients' responses to stress, shortening the recovery time.  As a result earlier discharge was possible, and fast track surgical units extended the longstanding achievements of day surgery.  Operations such as splenectomy, vaginal hysterectomy, and mastectomy were becoming possible on a day or 24 hour stay basis.  Purpose-designed fast-track surgical units were under development, and these were seen as one way to reduce lengthy waiting lists for treatment.

Orthopaedics and trauma

Major accident units had, sadly, a number of occasions on which their skills were required, including railway disasters. Increasing numbers of gunshot injuries in London and some other big cities related to illegal drugs, sent trauma surgeons in search of the training available in countries with longer experience in this field.  In the wake of the terrorist attacks on the World Trade Center hospitals reviewed their emergency planning.

The improvement of imaging, for example MRI, had a substantial impact on orthopaedic practice.  Musculo-skeletal imaging, for example of the knee joint, make greater accuracy possible in the assessment of suspected cartilage and ligament injuries, often substantially altering the optimal treatment.

Trauma and orthopaedics that had seen many changes over the previous 20 years looked set for greater advances as a result of the development of new materials, computer aided manufacturing technology, and molecular biology.  From the physiological standpoint, improved understanding of the way in which the body responded to major trauma and severe multiple injuries led to the introduction of new methods of managing them. Sometimes it appeared best to intervene less in the immediate phase after injury.  Rapid restoration of fluid volume and blood pressure might lead to further catastrophic bleeding; hypothermia could sometimes protect from brain and tissue damage.  New drugs were introduced to reduce the likelihood of multiple organ failure in the weeks after injury.

Roughly 50,000 hip arthroplasties were performed annually, mainly for osteoarthritis.  Younger patients, leading an active life, were likely to wear out the replacement hip, and NICE suggested that they should be considered for a metal-on-metal resurfacing arthroplasty, in which the femoral head and the joint were both fitted with new metal wearing surfaces.  In the USA minimally invasive hip arthroplasty was introduced, using a 3" incision and specially lit instruments, reducing pain, the time spent in hospital, and the speed of recovery to pain free activity.

Femoral fractures in children had traditionally been treated with traction and hospital stays of 4-12 weeks. A new technique, flexible nailing of the femur, developed in Switzerland, allowed early mobilisation. Flexible nails produced from new metal alloys were small enough to fit the intramedullary canal in children but were also able to maintain their shape after contouring and were strong enough to provide stable fixation. They were inserted through the skin through a 5 mm incision. The length of time spent in hospital was reduced allowing earlier weight bearing, movement, and return to school, in addition to fewer complications.  The nails were removed after the fracture had healed.

Sports injuries were an ever-growing part of the work of accident and orthopaedic departments.  While in the seventies and early eighties knee replacement was widely considered a poor operation, by the nineties the basic principals of successful surgery had evolved. The joint would be re-surfaced, reproducing the normal anatomy with a low friction joint, the remaining ligaments providing stability. Some 35.000 operations were now performed per year, with about a 90% success at ten years.  

Many injuries, including sporting injuries, damaged articular cartilage which had poor potential for repair.  Damage might lead to arthritis many years after injury. Transplantation of hyaline cartilage had been used for a number of years, but there are few sites where donor articular cartilage could be harvested without damaging the joint. So only small defects can be treated with this method. However, a new patented technique, autologous chondrocyte transplantation, allowed small amounts of hyaline cartilage to be harvested, the chondrocytes extracted, and the cell population increased in tissue culture. The number of cells increases by about 15 times over four weeks. These cells could then be reimplanted beneath a periosteal patch which is sutured over the articular defect. 

The mortality and morbidity of cardiovascular disease ensured it a significant place in plans for improving the health of the population.  Developments were taking place on many fronts, medical and surgical. Professionally inspired and governmentally encouraged, a National Service Framework for Coronary Heart Disease was introduced in 2000 and outlined current good practice in hospitals. Specialist smoking cessation clinics, rapid access to chest pain clinics, rapid thrombolytic treatment, shorter delays for assessment and treatment, more effective use of aspirin, beta blockers and statins after a heart attack and more coronary artery surgery were required. Guidelines for preventing cardiovascular disease, for example by blood pressure reduction, were refined.  Death from ruptured aortic aneurysm, some 6000 per year, was shown to be reducible by ultrasound population screening.

Many of the common problems in clinical practice relate to thrombosis, e.g. myocardial infarction and stroke. Estimation of cardiovascular risk became the starting point of therapy, using risk tables covering age, sex, blood pressure, smoking and cholesterol status, and other conditions such as diabetes.  Clot formation was associated with common cardiovascular disorders such as atrial fibrillation and heart failure and was also be found in other clinical problems including various cancers and after orthopaedic surgery. Wald & Law suggested that heart disease and stroke could be reduced substantially by giving, on a population wide basis, e.g. to those over 55 years, a "polypill" that would reduce low density lipoprotein, cholesterol, platelet function and blood pressure.  Possible constituents might be aspirin, a statin, a ß blocker, a thiazide,  an ACE inhibitor, an angiotensin II receptor antagonist and folic acid.   Diagnostic techniques improved; better imaging, a clearer understanding of the pathology of coronary arterial plaques and better blood tests such as the measurement of plasma myeloperoxidase made it easier to predict  risk of myocardial infarction.

It became recognised that some drugs used to treat disturbances of heart rhythm could themselves have dangerous effects.  Implantable cardiac defibrillators were also used to treat malignant ventricular arrhythmia; automatic cardioverter defibrillators could be life-saving and promising new developments took place in pacing technology.  The treatment of disorders of heart rhythm, particularly in younger patients, was also improved substantially by the introduction of  catheter ablation, in effect the accurate destruction of an area of the heart responsible for the disturbance of rhythm, through a catheter within the heart. Some patients with heart failure could be treated, multiple leads could be inserted to synchronize contractions of the different chambers of the heart and improve heart output.

Coronary artery surgery continued to develop; two main interventions were available for opening up blocked coronary arteries: balloon angioplasty and open heart surgery. Coronary artery bypass grafting (CABG) is more invasive and requires lengthy rehabilitation.  However new techniques allowed bypass grafting on the heart while beating, reducing the morbidity associated with the pump and induced cardiac arrest. Percutaneous coronary angioplasty (PTCA) usually required one or two days in hospital, and patients can expect to be back at work within a week. Primary angioplasty could, indeed, be used in the early stages of a heart attack and seemed to improve patient outcome.  In some areas of the USA ambulances were routed past hospitals towards cardiac centres equipped to perform primary angioplasty 24 hours a day.  This was not an option within the NHS.

 In angioplasty, first undertaken in 1977, a wide lumen catheter is fed from the groin up to the aortic root and into the coronary arteries. A guide wire is passed through the catheter and across the stenosis in the coronary artery. The wire guides a balloon (with a stent mounted on it if necessary) into the diseased section of the artery. The balloon is inflated, pushing the atheroma outwards, sometimes splitting it, and enlarging the lumen of the artery.  A stent was now often introduced, increasing the artery diameter and reducing the risk of restenosis. Once in place the wires and the catheter are removed. Acute vessel closure may occur soon after the procedure as a reaction to vessel injury. The rates of subsequent death or myocardial infarction are similar after either strategy. However, repeat revascularisation is more often required after PTCA than after CABG.  Restenosis used to occur in over 30% of patients but with advances in stent design and improved techniques for implanting them the rates now lie between 10% and 20%. This is comparable to the 10% of vein grafts that are lost in the year after bypass grafting.  Newer stents, expensive and not yet in general use, are made of metal coated with a cytostatic agent such as sirolimus or paclitaxel.  These agents are released slowly and locally to reduce proliferation of smooth muscle. Early trials with these stents suggest that less than 5% of people will have arterial restenosis.

Source  UK Transplant

While heart transplantation had a high early mortality, perhaps one in five, afterwards the death rate fell to 4%/year, so half the patients were alive ten years later. Since 1995 there had been a significant fall in the number of patients receiving new hearts, lungs, or heart and lungs through transplantation,  the direct result of fewer suitable organs due to improvements in road safety and treatment of trauma. In 2000 265 patients in the UK were treated and there were six heart and lung transplant centres in England (Birmingham, Cambridge, London, Manchester, Newcastle and Sheffield).  The need to ensure that centres undertook enough operations to maintain expertise was appreciated, and a National Specialist Commissioning Advisory Group took on responsibilities for commissioning heart and lung transplants for both adult and children.

The techniques necessary for the re-attachment of limbs had already been developed and in 1998 the first  hand transplant was carried out in France, a second – more successful – was undertaken the following year in the USA.  

Stem cell transplantation was revolutionizing the outcome of a range of malignant and non malignant blood disorders, including immunological diseases.   Stem cells could be obtained from blood, bone marrow and umbilical cord blood.  Cord blood banks were established in London, Bristol, Belfast and Newcastle to collect, preserve and type blood products, and to test for viral contamination.  

Neurological disorders account for 10-20% of hospital admissions, stroke being one of the commonest causes. Most were treated by general practitioners or general physicians, rather than by neurologists who had easy access to precise imaging systems and vascular surgery. Only 35 hospitals have a neurological centre or a neurology/neurosurgery centre.  200 district general hospitals do not have a 24 hour on call neurological service, usually relying on visiting neurologists from elsewhere.  Improvements in treatment were therefore relevant to many doctors without specialist training.  For example the outlook of patients with stroke was improved by very early thrombolytic therapy if intracranial bleeding could be ruled out.