Chronology: the second decade
Ten years on
The beginning of the second decade of the NHS saw the end of the years of post-war austerity. The NHS was also about to make substantial progress. Public opinion surveys showed that the vast majority wanted the NHS to continue, with or without modification. The Lancet, which had initially feared that the NHS would prove inflexible, was pleased this was not so. Having urged government to take tuberculosis more seriously and build to provide more beds, this was not now necessary. In the face of the shocking over-crowding of mental hospitals, more beds seemed to be needed. Now enterprising hospital units were looking at a system in which most patients would go on living at home while under treatment. Within another ten years one might be wondering what to do with the many mental hospitals that were plainly unsuitable for the proper practice of psychiatry. The Lancet noted that fresh approaches were affecting the nature of the hospital itself; many more patients would in future visit the hospital instead of living in it. ‘Cafeteria medicine’ had a real future and it was futile to waste the service of skilled nurses on people who did not in the least require them. GPs should pay close attention to the way in which hospitals were reaching out ever further towards the home. A family doctor should give everyday medical care, but a high level of general practice would not be preserved unless those with faith in it were prepared to translate their faith into works.1
Although medical staffing had been improved, hospital laboratories and X-ray departments were lagging behind and were ill-equipped to meet new and complex requirements. There had been neither the money nor the time to deal with the run-down condition of hospitals. The BMJ saw much in the NHS that was good, and much that was bad. It was the job of the medical profession, in co-operation with the government, to improve matters. The NHS should not be regarded as something fixed and immutable and the private possession of Mr Bevan.
The end of the first decade of social revolution finds the profession in no mood for jubilation. The politicians must inwardly regret their enormous errors of calculation. Whatever benefits it has received, the public is beginning uneasily to wonder whether the price has not been too high in this free-for-all scramble for medical attention.2
The BMJ suggested looking at the systems in other countries and thought that patients might take a more direct financial share in their own welfare, though the Chairman of Council of the British Medical Association (BMA) conceded that from the point of view of the ‘consumer’ it had been an enormous benefit and success, as anyone taken ill on holiday rapidly discovered.3
During the anniversary parliamentary debate Bevan, now Shadow Foreign Secretary, was on his feet. Two concepts underlay the health service. First was the provision of a free comprehensive service, and all the drugs and facilities that would not have been available to the masses under the old system. Second was the redistribution of income by central taxation so that those who had the most paid the most. The Conservatives had opposed this redistribution. He spoke of private practice and pay-beds, concessions that were sometimes seriously abused. For financial reasons, he said, some consultants enabled private patients to jump the waiting list. The Minister, Walker-Smith (the seventh in the first ten years of the NHS), pointed to the successes - health promotion, poliomyelitis vaccination and fluoridation of water; the need to plan health services for the ageing population; the developments in mental health; and the potential for economy in the hospital service by using work study, and organisation and methods studies.4
Lord Moran had fought for the consultants’ interests. He wrote that the overwhelming majority of them would prefer the current conditions. Bevan’s plan had been more liberal than that of Willink, the previous Conservative Minister. Under the Conservatives the doctor would have been a local authority employee. Consultant services had expanded; in the Newcastle region there had been 164 consultants in 1949 and in 1957 there were 409. Hospitals had been upgraded and a third of consultants got merit awards. Moran said that clinical research in the NHS was not starved of money - the problem was shortage of good researchers. Under the NHS academic medicine had grown in prestige and influence. However, someone, sometime, somewhere must call a halt to the soaring expenditure on the NHS. Rebuilding was relatively unimportant, particularly of mental hospitals. The priority was people of first-rate ability to add to knowledge of the mind in health and disease. The Ministry should bid in the open market for the best brains; there must be rewards for a few people at the top comparable with those offered in other callings.5
Changes in the hospital service, 1949-1958 (England and Wales)
Source: Annual Report of the Ministry of Health for 1958
Sir Harry Platt, far more progressive than most of his generation, also supported the service. The unification of hospitals of all types into a single system, the establishment of the region as a planning unit and the more even distribution of specialists were substantial achievements.6 Problems included the fragmentation of the service into three parts. There was excessive expenditure on drugs when the money could be better spent by upgrading hospitals, building new ones and enabling leading hospitals to keep abreast of medical science, particularly the university hospitals.7
The BMA representative meeting in Birmingham established a committee with the Colleges and the medical officers of health (MOsH), to review the NHS in the light of ten years’ experience, and to study alternative schemes for a health service.8 It was called the Porritt Committee after its chairman, a natural choice for such a role. Not since the Medical Planning Commission’s interim report of 1942, said the BMJ, had a group as representative of all branches of medicine been asked for an opinion on how the nation’s health services should be organised. The NHS had come to stay but it must not be allowed to become stale.9
On becoming Minister of Health in 1960, Enoch Powell agreed that there were risks of rigidity in a great, but centralised, service. He saw three trends running side by side: the growth of community care and after-care of the sick, relieving the hospital; the development of preventive and remedial measures; and the more intensive and efficient use of hospital accommodation. He wanted fewer beds in newer hospitals. The three separate financial systems for hospitals, local health authorities and general practice were a great weakness. The BMJ wished his stay in the Ministry long enough for the provision of effective remedies.10 When in due course he moved from the Ministry, he was one of the few ministers whose departure was a source of ‘deep regret’ to the profession.11
Changes in society
According to Sir Francis Fraser, a physician, Director of the British Postgraduate Medical Federation and one of the group that produced The development of specialist services, changes in society were affecting medical practice.12 Social barriers were disappearing. There was an increasing number of people seeking help for illnesses in which social or mental conditions were important or dominant. Was this the result of the lack of support from religious beliefs, the mechanisation of industry, the loosening of family and community loyalties, increasing urbanisation and new towns, the boredom of life under the welfare state, and a dependence on newspapers, television and wireless for ethical and moral values and codes of behaviour? Many people seemed unable to adapt to the speed of change in social conditions. The young had been acquiring a new degree of economic and social freedom that affected their personal relations with everyone, including their doctors.
Before the second world war Stephen Taylor had described suburban neurosis, anxiety and depression among people living on estates, which he attributed to boredom, loneliness and a false set of values. The war and the air-raids had done much to build a community spirit and reduce neurotic illness. Now new building, large blocks of flats and relocation in new towns were re-creating suburban neurosis. The incidence of ‘nerves’ on new estates was double that in more settled areas.13 A more dramatic problem was the emergence of a drug sub-culture. Flower-power, and ‘the iconoclasm of hippiedom and the ill-considered advocacy of people who should know better’ were creating an atmosphere not only of drug taking but also of opposition to firm action to control its spread. Designer drugs such as the hallucinogen STP, a powerful and dangerous amphetamine derivative, spread from across the Atlantic.14
Medicine and the media
Charles Hill, ‘the radio doctor’, had been broadcasting on health issues since the early 1940s and the media were telling people more about medicine. Many doctors thought that, although people should know about health promotion, detailed knowledge of disease was not desirable. The BMA’s own publication Family Doctor trod carefully. It did not carry advertisements for the Family Planning Association. There were ‘obviously grave doubts about the wisdom of publishing in a popular health magazine issued by the BMA to the public, and read among others by teenagers and by the immature, an advertisement which might be held to give the green light to contraceptive practices.’15 There was a row in the BMA when, in 1959, Family Doctor ran articles on ‘Marrying with a baby on the way’ and ‘Is chastity outmoded’. The entire stock was ceremonially pulped amid accusations that the BMA was engaging in censorship.16 The BBC televised a series of five programmes on The hurt mind, described by Kenneth Robinson (Minister of Health (1964-1968), son of a GP, protégé of Bevan and a member of a regional hospital board (RHB) with a keen interest in mental illness). as perhaps the most significant breakthrough in the mass communication field. Doctors, however, alleged large numbers of patients crowded down to their surgeries to ask for electro-convulsion therapy (ECT). Now a new series was planned, Your life in their hands. Charles Fletcher, a physician at the Hammersmith Hospital who presented them, was concerned about the problems of doctor-patient communication. He thought doctors failed to explain adequately the nature of illness and its treatment. The programmes included cardiac surgery, a brain operation and an operation on the liver. This open approach was unpopular with many of his colleagues. The BMJ considered that it was demeaning for doctors and nurses to appear as mummers on the stage to entertain the great British public. People’s anxiety about their health would be heightened, increasing hypochondria and neurosis. Hopefully the BBC would not televise a death on the table in its presentation of topics that, though familiar to medical men, were full of mystery, fear and foreboding to the ordinary person.17 A doctor wrote to say that as a result of a programme a patient had correctly guessed that he was suffering from cancer. A ward sister was anxious that patients in her ward receiving deep X-ray therapy would realise what it was for. People had fainted while watching televised operations, sustaining head injuries. Writers to the Nursing Times were divided in their views: one said that the programmes had sparked interest in nursing among schoolgirls; a patient wrote how encouraging it was to see the rapid developments in medicine; and a third compared the programmes to bygone Sunday visiting at Bedlam and said the BBC had lost all refinement of feeling and sense of proportion.18 TV had discovered a new and popular genre.
The lay press relished the attempt by some doctors to keep their own secret garden. William Sargant, medical adviser to The hurt mind, said that there were 5,000 suicides each year, many among depressed people for whom help was available. If even a few of them went to the doctor to ask for treatment, was this wrong?19 The BBC’s audience research team found its audiences liked the programmes. The study fell short of the quality the BMJ expected. Inference from the population studied, it said, would demand a degree of recklessness that would land most statisticians in Emergency - Ward 10. Casting its own scientific standards to the wind, the journal said ‘There can be no doubt of the danger to the unstable with a morbid curiosity about blood and bowels, to frail worriers, and to those with serious disease who may receive interpretations different from those given by their own doctors’.20
The Ministry received many complaints about the gulf in communication between doctors and their patients. Enoch Powell, then Minister of Health, asked the Standing Medical and Nursing Advisory Committees to advise on what could be done. Lord Cohen reported in 1963 that well-founded criticism was rare, but that poor buildings, crowded facilities and lack of secretarial services did not help.21 Nevertheless, the doctor, nurse and patient were at the centre of the service and must take responsibility. Outpatients should be treated as individuals and listened to, staff should identify themselves and some might wear badges. Clear information about hospital life should be available. The BMJ thought it a disappointing report, not based on enquiries into the extent of the problem. The difficulties lay in the hurried conditions of hospital practice, and the value of ministerial missives was doubtful. When there were enough hospitals, fully staffed and planned on modern lines, doctors would have the time and space to correct the lapses of behaviour that were inevitable when faulty communications corrupted good manners.
Health promotion and screening
By the 1960s many countries were beginning to realise that they faced new health problems requiring different solutions. Infectious disease was being conquered but demographic trends and the growing proportion of old people were leading to a greater prevalence of chronic disease, and mortality from cancer of the lung and coronary thrombosis was increasing. There was concern about persisting inequalities in health and health care and the emergence of new environmental hazards that urgently required regulation. Smoking was prevalent in all classes but public knowledge about the associated health risks was vague and ill-formed. In 1967 the Health Education Council was established, a successor to the Central Council for Health Education, to co-ordinate planning and organisation of health promotion, paving the way for a more scientific approach, a broader conceptualisation and the first tentative attempts at evaluation.22
Screening is the presumptive identification of unrecognised disease or defect by the use of tests or other procedures that can be applied rapidly. Screening tests sort out apparently well people who probably have a disease from those who probably do not. They are not diagnostic; suspicious findings are referred for diagnosis and treatment.23 Screening may be undertaken for research, to protect the public health as in the investigation of an epidemic, or to attempt to improve the health of individuals. It stands apart from traditional medicine in seeking to detect disease before there are symptoms and medical help is sought. Screening therefore had an ethical dimension, for it could change people’s perception of themselves from healthy to sick. Intervening in the lives of those who are at no great risk is unreasonable; one cannot assume that diagnosing a disease earlier will necessarily help without randomised controlled trials to check the effectiveness of earlier diagnosis.24 Multiple screening programmes evolved in the USA during the 1950s. British medical opinion was divided on whether clinical examination and a battery of laboratory tests and X-rays were worth while. The BMJ came down against them, saying that the lay view of matters medical was usually ill-informed and singularly opinionated.25 Check-ups carried dangers of missing disease already present, false reassurance or undue alarm about an abnormality best ignored.
The regular examinations in child welfare clinics were one form of screening. Among the ideas being explored were selective examinations and ‘at-risk’ registers. The discovery that screening babies for an inborn metabolic disease, phenylketonuria, was possible, led the Medical Research Council (MRC) to call a conference in 1960. As a result local health authorities were advised to screen babies between four and six weeks old, a task that fell to health visitors.26 In many areas screening tests for single diseases were now widely applied, for example accurate hearing tests in school children. By the early 1960s pre-symptomatic identification of a wider range of disease was possible. In Rotherham the local authority health department organised screening for five problems: anaemia, diabetes, chest disease, deafness and cancer of the cervix. For three weeks once a year the department did nothing else. Individuals at the lowest risk flooded in; those at high risk did not come. There were a substantial number of positive findings that were referred to GPs, but the communication between the MOH and the GPs was sometimes poor.27
There was a naive belief that if something was diagnosed early one could cure people, and if several tests were combined there was a synergy. Some thought that screening should be carried out by group practices, in health centres or with the agreement of the local GPs in local health authority clinics. Others sensed a premature rush into untried and possibly ineffective procedures. People in the MRC, the Nuffield Provincial Hospitals Trust and the Ministry felt the need for caution. Max Wilson, a senior medical officer at the Ministry of Health, was sent to the USA for several months to study screening there and was the joint author of a key report from the World Health Organization.28 A subcommittee of the Standing Medical Advisory Committee (SMAC), chaired by Thomas McKeown, Professor of Social Medicine at Birmingham, was established to take a calmer look at the possibilities. Archibald Cochrane, who had been involved in several projects related to screening, was a member.
There were four important requirements before screening should be undertaken
· There should be an effective treatment.
· There should be a recognisable latent or early symptomatic stage.
· There should be a suitable test or examination acceptable to those to whom it was offered.
· The criteria for diagnosing the disease should be agreed.
There was little doubt that the early detection of some diseases such as anaemia, glaucoma and cervical cancer was important. It was necessary to have a way of establishing contact with high-risk groups; antenatal services and infant welfare services enabled contact to be made with some age groups, but for others, for example the elderly and those at risk from cancer in middle life, accessibility was not so easy.
Changes in hospital care
A profound change was taking place in medicine, altering the style and organisation of clinical services. Formerly treatment was often determined on a once-for-all basis, and the consultant could visit daily or even only twice a week.29 Now treatment was a continuous process that in serious cases might alter from hour to hour, in which laboratory investigations played an important part. Diagnosis had depended on history taking, a precise and carefully taught system of questioning to determine exactly what patients experienced, and the timing and nature of symptoms. Although laboratory tests had been available to confirm and occasionally make a diagnosis, the patient’s story was pre-eminent, often more revealing than physical examination. Lord Moran had looked after Winston Churchill throughout the war, during heart attacks and other serious illnesses, with no more complex equipment than a stethoscope. Outpatient care became more common and a smaller proportion of patients needed admission. Gone were the days when the outpatient department was merely the place in which eager doctors found candidates for their beds, or dismissed those who had recently occupied them. Whether the outpatient was given the same thoughtfulness, care, understanding and explanation that inpatients could expect from the nurses was doubtful. The responsibility for the patients’ comfort, wrote an outpatient sister who later became an author of renown, lay primarily with the nurse but also with doctors, who should remember that to the patients their time was not expendable.30
Much depended on an increasing ability to measure bodily structure and functions. The introduction of computers aided the process.31 Better measurement improved the understanding of the physiological effects of disease and the effect of intervention. Radio-isotope techniques, a byproduct of research at the Atomic Energy Research Establishment at Harwell, led to a wide range of new tests for blood loss and blood formation, and for thyroid disease. A paper dip-stick test for protein in the urine made a common procedure quicker and more pleasant.32 Biochemistry laboratories reported workloads increasing by 15 per cent a year. Automation in the laboratory became possible. In histology it aided the preparation of specimens, and in haematology the Coulter counter used changes in conduction as cells passed in single file in a rapidly flowing stream through a narrow orifice. In biochemistry continuous flow analytical methods were incorporated into the AutoAnalyzer.33 Twenty-five different tests were adapted to run on the AutoAnalyzer and multi-channel equipment was developed. Laboratories began to offer package deals in which several related tests were carried out whenever one of them was requested.34 Bewildered doctors, having asked for a blood urea, found the report gave the results of eleven other unsolicited tests as well! Doing the lot was cheaper than a single test separately. Sometimes the tests that had not been requested were abnormal. That might be a good thing if, for example, a new diabetic patient was identified, but sometimes extra time and effort went into chasing an aberrant result to an unwanted investigation.
The MRC’s randomised controlled trials provided a new way of determining the effectiveness of treatment. Archibald Cochrane took up and publicised the idea while working at the Pneumoconiosis Research Unit in Wales, arguing for its immense potential. Cochrane’s devotion to this cause, and the later publication of Effectiveness and efficiency in 1972, left a lasting mark on health care and the health service.35
The establishment of the NHS coincided with growth in highly specialised fields of medicine and surgery. Techniques that during the years of war were being laboriously developed in a very few centres, advanced so far that they were becoming an essential part of a regional hospital service.36 Specialisation, though of great benefit to patients, was not solely a matter of altruistic doctors seeking an ever-deeper understanding of disease. Christopher Booth has suggested that specialisation had three main roots, the most important being the drive of technology. Modern ENT surgery, diagnostic imaging, interventional radiology and minimal access surgery were based almost entirely on the development of instrumentation, and the division of general pathology into biochemistry, histopathology, haematology and microbiology was partly related to major differences in the supporting technology. Secondly, individual doctors pushed themselves and their expertise out of enlightened self-interest. In the nineteenth century this led to the development of the single specialty hospitals; the same motivation exists to this day. Thirdly, those in minor areas of medicine sometimes mobilised sympathy for themselves and their patients. The higher their profile, the greater was their access to distinction awards.
The need to provide specialised services, and sub-specialisation, drove an increase in the number of consultants from roughly 4,500 in 1948 to 7,000 by 1960. George Godber said that specialisation had probably not yet gone far enough; specialist skills should be more widely distributed than they were. Yet there was a need to avoid the division of the care of patients between a multitude of specialties, and a risk of failed communication between disciplines.37 The main growth was not in the traditionally glamorous fields, but in anaesthetics, radiology, pathology, psychiatry and, later, geriatrics. There was a shortage of recruits and NHS money was sometimes used to establish university Chairs, improve training and raise status. General medicine and surgery divided into sub-specialties and the officially recognised specialties doubled in number. Cardiology split from general medicine although respiratory medicine remained a part of the work of the general physician. Special investigative techniques in cardiology, respiratory medicine and neurology were far past the experimental stage and were needed in at least one centre in every hospital region. Such techniques were central to the development of intensive treatment units (ITUs), born in the early 1960s. The infectious diseases were diminishing and there were fewer consultants in that specialty; in the future it was likely that there would be infectious disease units attached to district general hospitals. Paediatricians were increasingly concerned with the neonatal period. In 1948 it was considered normal for general physicians to look after the chronic sick and elderly as part of their duties. Now geriatrics was developing and appointments of consultant geriatricians were being made. No longer was a consultant pathologist wise to attempt to handle all four sub-disciplines of haematology, biochemistry, histopathology and bacteriology.
In surgery, operations on the central nervous system, the heart and the lungs were now commonplace and these regional specialties were growing. Rapid advances in cardiac surgery had led to its extension to all the principal thoracic surgical units, previously largely concerned with tuberculosis and bronchiectasis (dilation of the bronchi or bronchioles). Traumatic and orthopaedic surgery were developing, and urology and paediatric surgery were becoming the province of specialist rather than general surgeons.
Some GPs still hoped for their reintegration into hospital work. Others, such as John Fry of Beckenham, were more realistic.38 Much health care was outside hospital, and more could be if there were better access to hospital diagnostic facilities and more support were available for the care of patients at home. That was what was needed, and not nationwide schemes to give family doctors beds in hospitals. Hospitals served many more than were within their walls.
The drug treatment of disease
In 1959 Beecham Research Laboratories discovered a method for the large-scale production of the penicillin ‘nucleus’ and within two years was able to prepare several hundred new synthetic compounds. Three seemed useful. Phenethicillin was acid-resistant and could be given by mouth. Methicillin had to be injected but, being resistant to penicillinase, was effective against penicillin-resistant staphylococcal infections, and helped to control the large hospital outbreaks of infection of the previous decade. Ampicillin had, for a penicillin, the remarkable property of a wide range of effectiveness.39 Griseofulvin was also discovered in 1959 and was the first antibiotic active against fungi that could be given by mouth. It was discovered by ICI but sold to Glaxo because of apparent side effects. Glaxo found that these were temporary and minimal and that griseofulvin could be used to treat fungus infections whether systemic, of the skin or of finger and toe nails. Griseofulvin seemed to protect new skin and nail cells from infection, so if it was administered long enough new healthy tissue replaced the old areas of infection. The clinical results were so dramatic that, when cases were demonstrated at a dermatologists’ conference in the USA, the hotel lines were blocked by doctors phoning their brokers to buy shares. Broad-spectrum antibiotics such as tetracyclines were found to be highly effective in treating acne, a common and sometimes disfiguring disease, although how they worked was uncertain. In 1960 metronidazole (Flagyl) was introduced for the treatment of vaginal discharge caused by Trichomonas vaginalis.
In the past the treatment of heart failure had been rest, digitalis and mercury-based diuretics such as mersalyl that was given by injection. This meant hospital treatment or regular visits by the district nurse. The discovery in 1957 of chlorothiazide, the first effective oral diuretic, was probably the most important advance in drug treatment since penicillin.40 People with heart failure could now live a much more normal life, at home, while under treatment. Other more potent compounds of the same group followed rapidly and in 1965 frusemide was a further improvement.41 The treatment of high blood pressure improved steadily with the introduction of new drugs. Rauwolfia, acting partly as a tranquilliser, was replaced by the oral diuretics often in combination with ganglion-blocking drugs such as mecamylamine, although these produced constipation, blurred vision and difficulty in urination. Adrenergic-blocking drugs (e.g. guanethidine) had fewer side effects, and early death from severe hypertension was now seldom seen.42 Angina was shown to be relieved by propranolol, a member of a new family of drugs, the beta-receptor blockers.43
Pressurised aerosols were introduced for the treatment of asthma in 1960 and rapidly became popular. If used too often they could be toxic, and patients sometimes over-dosed instead of calling for medical help.44 A GP who found a young asthmatic dead with an inhaler in her hand did not forget the experience. To the surprise of doctors, deaths from asthma rose. A fivefold increase led to a warning in 1967 about the possible dangers of inhalers. Often those who died had never received corticosteroid treatment that could have been life saving; sometimes, incorrectly, doctors had administered sedatives.
A new drug, indomethacin, for the treatment of arthritis, rheumatism and gout, was released in 1965. Although no panacea it was helpful in the relief of pain, inflammation and stiffness.45 Immunosuppressive and cytotoxic drugs developed for cancer found uses in dermatology, because their action on rapidly dividing cells could control conditions such as psoriasis, pemphigus and systemic lupus erythematosus.
After small trials of oral contraceptives in 1959, the Family Planning Association undertook two large field trials to assess the use of Conovid and Anovlar. The results were good and the products were approved for clinic use.46 Lower dose preparations of the oral contraceptives were later introduced. By 1968 roughly a million women were using oral contraception. In the early 1960s an alternative became available, intrauterine contraceptive devices that were shown to be highly effective and comparatively safe.47
Drugs for the treatment of diseases of the mind came on the market with increasing frequency. Amphetamines had been available since 1935 and until the late 1950s were considered relatively non-toxic, rarely addictive and without serious ill-effects. It then became clear that many people were taking far more than therapeutic doses and were using subterfuge to obtain them. Side effects including psychosis were observed. Weaning patients off amphetamines and ‘purple hearts’, an amphetamine-barbiturate mixture, was difficult.48 An alternative group of drugs, the benzodiazepines, came into use. It included chlordiazepoxide (Librium), diazepam (Valium) and nitrazepam (Mogadon). In the laboratory these drugs calmed aggressive animals; in humans they reduced anxiety though with some tendency to produce addiction. Caution and short-term use were recommended, for they made people sleepy, and the additive effect of alcohol could be dangerous.49 In 1958-1960 drugs for the treatment of depression became available, first the monoamine oxidase inhibitors and then tricyclic drugs such as amitriptyline and imipramine. The treatment of even fairly severely depressed patients became possible without admission to hospital, but the drugs might cause a flare-up of schizophrenia and could not entirely replace ECT.50 The difficulty of designing good clinical trials made it hard to determine the best way to use the drugs and some had unexpected side effects. Severe headaches after cheese sandwiches seemed unlikely to be related to monoamine oxidase inhibitors, but this was the case and the chemical interaction responsible was identified. Interaction of drugs was a growing hazard; the thiazide diuretics increased the potency of digitalis if the patient became depleted of potassium, and phenylbutazone increased the response to anticoagulants. There was every reason to reduce the risk by prescribing as few drugs as possible for any single patient.51
Better anaesthetic agents made for easier induction of anaesthesia, safer operation and speedier recovery. However, it was now usual to give one drug to produce unconsciousness, another as a pain reliever and a third to relax muscles to make it easier to operate. This cocktail of drugs made the classic signs of the depth of anaesthesia difficult to interpret, if not useless. Cases were reported of patients remaining conscious during surgery if the balance of drugs was wrong. Patients had no way of signalling the fact because muscle relaxants paralysed them, yet they suffered extreme pain and could recall staff conversations during the operation.52
Old, if cynical, advice to medical students had been to use new drugs while they still worked. That was now a dangerous strategy. Penicillin produced allergic reactions. Tetracyclines, considered to have few side effects other than loosening bowel motions, were found to turn children’s teeth yellow. Barbiturates, used as sleeping tablets, proved addictive and many family doctors imposed a voluntary ban on their prescription. Was sufficient advice available from independent clinical pharmacologists to put manufacturers’ claims into perspective? The pharmaceutical industry spent a great deal of money, took big risks and occasionally produced products of outstanding value. There were vast improvements and economies in medical care. But within the industry were firms with a high sense of duty and others with a high sense of profit.53 Were drugs released on the market prematurely?
The thalidomide disaster brought professional anxieties to a head. It was released in Germany in 1956, where it was available over the counter; when it was released in the UK in 1958 it was available only on prescription. It was an excellent drug for inducing sleep and an overdose seldom killed - the patient slept soundly and then woke up. Thalidomide was even promoted as safe around a house where there was an inquisitive infant. Then, with little warning, it was found to produce limb deformities in the unborn child. At a paediatric conference in November 1961 it was reported that there was a possibility that, if taken in pregnancy, thalidomide might have harmful effects on the developing embryo. It was rapidly taken off the market. Defects of the hands, the long bones of the arms and legs, and oesophageal abnormalities were rapidly reported world-wide but the number of cases seen in any one clinic was extremely small. Registers of congenital malformations, kept for research purposes in Birmingham and London, provided clear evidence of an epidemic. Medical records were not always available; some had been destroyed. Sometimes people had taken tablets prescribed for friends and relatives, or tablets left over from a previous illness. The reaction was rapid. Assessment centres were established for the sufferers, voluntary agencies offered help and parents’ associations were formed. The total number of cases in Britain who survived long enough to be recorded was about 300, far less than in Germany where the problem had first been reported.54
There were issues of principle at stake. Fifty years earlier, Sir William Osler had said that the main distinction between humans and the higher apes was the desire to take medicine. Doctors now had to be wary of their instinct to help by reaching for the prescription pad. No systems existed for the early detection of congenital defects, to ensure that new products were safe and efficacious, or to track adverse drug reactions so that the medical profession could be informed. The call for an independent organisation to examine new drugs, particularly for effects on the fetus, intensified.55 The SMAC suggested that there was a need to assess new drugs before release, detect adverse effects rapidly and keep doctors informed about the experience of drugs in clinical practice. After consultation the Committee on Safety of Drugs was formed, chaired by Sir Derrick Dunlop.56 It devised a system of checking new drugs that came into operation from January 1964. Drugs then passed through three stages of assessment: laboratory toxicity trials, clinical trials on humans (such as the MRC trials of the anti-tuberculosis drugs) and ‘post-marketing surveillance’.57
There was still no system to ensure the identification of a rare effect that might arise after general release of a new drug, perhaps only once in a thousand patients. The Committee decided to rely on voluntary notifications and the ‘yellow card’ scheme was introduced. An estimate of drug usage was obtained from the central prescription pricing bureau and from trade sources. There were two limitations to the yellow card scheme. First, reporting was incomplete and the degree of incompleteness was unknown and variable. Secondly, it was not possible to determine how many patients had been given a drug, or their age and sex. The incidence of a reported reaction could not be compared with its normal incidence in the sick or those who were healthy. Occasionally adverse reactions in a preparation not of vital importance led to its withdrawal, for example a slow-release form of an influenza vaccine. Sometimes there were ‘reactions’ which were likely to be coincidental, or which, though probably genuine, were outweighed by the undoubted benefits of the drug. In these cases a warning was issued but the drug was not withdrawn.58 This group included monoamine oxidase inhibitors, pressurised aerosols for asthma and oral contraceptives.
Radiology and diagnostic imaging
Advances in nuclear medicine, and the tracking of isotopes, depended on technical advance in detectors. Rectilinear scanners were developed in the 1950s and allowed the source of radiation to be located and mapped, line by line. The process was slow; in the mid-1960s a liver scan could take up to an hour and the definition of the pictures was poor. Rectilinear scanners were made obsolete by the development of gamma cameras, the first prototype of which was displayed in Los Angeles in 1958.59 As the quality of gamma cameras improved, and they were coupled to computer systems, they were used to scan the lung, brain, heart, bones, liver and thyroid, providing new information to improve diagnostic accuracy.
The first alternative to radiation in the production of body images was ultrasound, the off-shoot of wartime sonar. Ultrasonic equipment had been used by industry for some years to detect flaws in metal. Ultrasonic sound waves were propagated as a beam, penetrated body tissues and, because some were reflected, could be used to create images. In the 1950s a number of dubious clinical claims were made for the technique. The development of a clinically workable tool was dominated by a few individuals, such as Ian Donald in Glasgow, and workers in the USA and Sweden. In 1958 Donald published the results of investigating 100 patients, mainly gynaecological and obstetric cases. Ovarian cysts, tumours and fibroids could be seen.60 Twins were also diagnosed.
Between 1954 and 1970 three inventions, all introduced by Harold Hopkins from Imperial College, changed the face of endoscopy and paved the way for minimally invasive surgery.61 For a century endoscopes had been rigid metal tubes and it had only been possible to examine the inside of the oesophagus, rectum and colon, lung or bladder until one came to a bend. In any case it was an uncomfortable procedure and much skill and psychology was needed. That all changed. First came the flexible light guide made up of bundles of glass fibres each coated with glass of a different refractive index along which light of unlimited brightness could be guided into any body cavity. The second advance was Hopkins’ revolutionary telescope. Instead of using tiny glasses separated by spaces of air, Hopkins used air lenses separated by rods of glass. Needing no tubular metal to keep the lenses apart, the entire width of the telescope was available for the transmission of light. Furthermore, because the rods could be held steady, it was possible to grind and coat their surfaces to a new order of accuracy and the rod-lens telescopes had the precision of a microscope. The powerfully illuminated images amazed the older generation of endoscopists. The third invention was to wind the glass fibres on a wheel and glue them together at one point, at which they were cut. Except at this point the fibres were enclosed in a loose sheath so they were entirely flexible. Where they were cut the fibres coincided with each other so that an image put in at one end came out at the other in dots, like the image of a newspaper photograph. A new family of flexible endoscopes quickly emerged, making it possible to perform gastroscopy, colonoscopy, bronchoscopy, cystoscopy and laryngoscopy without danger or great discomfort. They were steadily improved, so that comparing newer with older ones was like comparing a jet with a piston engine. Through these instruments it was possible to take biopsies, cut strictures, remove stones, destroy small tumours and stop bleeding with diathermy or laser.
Infectious disease and immunisation
The decade saw the conquest of poliomyelitis and the reduction of cases of diphtheria to a trickle, although small localised outbreaks continued to occur mainly among people who had not been immunised. The burden of the infectious diseases and the need for beds were reduced. The waning of the great killing diseases led to a false sense of security and masked their continuing evolution.62 Few doctors or nurses were now trained to handle them. There was ignorance and an assumption that most of the problems had been solved. Yet food-borne infection increased. The exotic viral haemorrhagic fevers were recognised for the first time; in 1957 a previously unknown communicable disease was reported from Germany. Twenty-seven workers preparing polio vaccine in Marburg developed headache, fever, rash and haemorrhages after contact with African vervet monkeys. Seven patients died of ‘Marburg fever’ and no form of treatment seemed effective.
Measles vaccine had been under development for several years and was in use in the USA. After a trial by the MRC, the Joint Committee on Vaccination and Immunisation decided in 1965 not to launch a general vaccination programme but to make the vaccine available to GPs wishing to use it. Measles epidemics were a bane of general practice; every second year there would be dozens of calls to miserable and sick children who needed careful supervision because of chest and ear infections, for which antibiotics were frequently prescribed. Some GPs immediately began to immunise ‘their’ children, seeing a benefit to patients and a reduction in their work. By 1967 their hunch had been validated by a further MRC trial that also revealed the large number of complications, the cost of the antibiotics prescribed, the 5,000-10,000 hospital admissions annually and the deaths that occurred. Routine vaccination against measles was recommended.
The introduction of the injectable Salk polio vaccine reduced the number of cases and deaths but protection was not complete. In 1959 there were 591 cases of paralytic polio in unvaccinated people, but there were also 40 in people who had received an apparently complete course. The MRC organised a trial of a new live attenuated vaccine developed by Albert Sabin.63 Theoretically this could be expected to give better protection and it did. In 1962 oral polio vaccine was introduced into the routine immunisation programme. The same year Tom Galloway, MOH of West Sussex, pioneered a new approach to the organisation of immunisation programmes. The local authority computer was programmed to use the information collected by health visitors who called to see newborn infants, to summon them to clinics or to their GP’s surgery at the appropriate age.64 A rapid rise in the immunisation rate was achieved and other local authorities soon adopted the system. West Sussex applied the same technique to cervical cytology and Cheshire to child surveillance.
Smallpox entered the country from time to time; in 1962 there were five small outbreaks of smallpox with 62 indigenous cases introduced by travellers from Pakistan, some of whom had presented false vaccination certificates. There was a rush for vaccination: local authority clinics vaccinated more than 3 million people and there were queues outside GPs’ surgeries. It was impossible to reassure people that, outside the areas of infection, the risks were virtually non-existent. The SMAC considered the smallpox vaccination programme and decided that, if there were no basic immunity in the population, control of epidemics might not be easy. It recommended continuation of the routine smallpox vaccination programme.65
Deaths in England and Wales from infectious disease
Tuberculosis Diphtheria Whooping Measles Polio
1948 23,175 156 748 327 241
1957 4,784 4 87 94 226
1958 4,480 8 27 49 154
1959 3,854 0 25 98 87
1960 3,435 5 37 31 46
1961 3,334 10 27 152 79
1962 3,088 2 24 39 45
1963 2,962 2 36 127 38
1964 2,484 0 44 73 29
1965 2,282 0 21 115 19
1966 2,354 5 23 80 22
1967 2,043 0 27 99 15
Source: On the state of the public health - annual reports of the Chief Medical Officer
Tuberculosis remained a major problem although notifications and deaths were steadily getting fewer. Routine Heaf tests at the age of 13 showed the extent to which asymptomatic infection was occurring in the community, and a progressive reduction in the number of positive tests was clear evidence of reduced spread. The effectiveness of treatment, particularly in early cases, was an added reason for identifying patients as rapidly as possible, for treatment quickly reduced their infectivity, breaking the chain of spread. Well-organised domiciliary treatment was practicable, effective and safe for family contacts.66 As the incidence of tuberculosis fell, mobile miniature radiography units picked up fewer cases of tuberculosis, but cancer of the lung was occasionally diagnosed in this way. Because mobile miniature radiography delivered a large radiation dose, their continued use was questioned. The Public Health Laboratory Service continued to grow, and the introduction of tissue-culture led to an expansion of its work in virology. It studied the development of hospital-acquired infection and of food poisoning, and became increasingly involved in the epidemiology of infectious disease.
In 1955, coincident with the increase of immigration, figures for gonorrhoea and non-specific urethritis began to rise and by 1962 had passed the 1939 level. Granada Television reported on the growing health hazard, interviewing a man who said he had been infected by a debutante and a prostitute who had placed too much faith in a regular check-up.67 Three causes were suggested, immigration, homosexuality and to a small extent promiscuity among the young.68 Syphilis seemed controllable, by penicillin and contact tracing, even though extramarital sexual intercourse was coming to be regarded by many as a normal and permissible activity. However, gonorrhoea was less amenable.69 In women there were often no symptoms to bring them to the clinic. Just under half the male cases were from the indigenous population, a quarter were men infected abroad and a quarter West Indian men. Most of those from the West Indies were infected in the UK, usually by promiscuous women. Indeed figures from Holloway Prison showed that about a third of the prostitutes in prison were infected. A third of all infections in women were among those between 15 and 20 years of age.70
Information on the work of the hospital service was now available from the Hospital In-patient Enquiry, a 10 per cent sample of the admissions to all hospitals in England and Wales other than those for mental illness and deficiency. Outpatient attendances and admissions were steadily increasing. The commonest cause of admission up to the age of 5 years was for removal of tonsils and adenoids (Ts and As). From 5 to 14 years appendicitis came second to Ts and As. From 15 to 29 head injury and appendicitis were commonest for men and, excluding midwifery, appendicitis and spontaneous abortion for women. Men between 30 and 70 years of age were admitted mostly for hernia, duodenal ulcer, cancer of the lung and prostate disease. Women suffered from disorders of menstruation and prolapse, and leg fractures in the older age groups.71
The length of stay in hospital continued to shorten. The Aberdeen Royal Infirmary, faced in 1960 by lengthy waiting lists, adopted Farquharson’s technique and established a special team to treat people with hernia and varicose veins as outpatients. Patients went home a few hours after operation and, although the hospital offered to provide after-care, the GPs were more than willing to take this over. Initial anxieties vanished and, because of the noise, poor facilities and irksome discipline, many patients were pleased to leave hospital rapidly. Waiting lists fell, the cost of treatment was probably lower and the results seemed quite as good.72 By the end of the decade it was seen that, with proper selection of patients, suitable accommodation and organisation, and good communication with GPs and community services, more patients could be dealt with as outpatients or on a day basis. Some now believed that outpatient surgery and day patient facilities should be part of any modern hospital and that the ratio of operating theatres to beds should be increased. Advice on the design and running of day units was published.
Orthopaedics and trauma
Following the work of Danis and Müller, Swiss orthopaedic surgeons formed a group to study the value of fixation and compression of fractures, and to undertake experimental work. This group, the AO or Arbeitsgemeinschaft für Osteosynthesefragen, began to collaborate with the Swiss precision engineering industry, which produced the components emerging from research. An educational programme was created to teach the techniques, John Charnley being among those attending.
The opening of the M1 motorway in 1959 led to a new style of driving and a new pattern of serious injuries. On urban roads, pedestrians were the main victims. On country roads it was motorcyclists. On the motorways the vast majority were occupants of cars. Injuries, the chief killer between 1 and 35 years of age, were more frequent, more severe, occurred throughout the 24 hours and were widely dispersed geographically. In 1966 Dr Ken Easton, realising that people were dying unnecessarily in serious road accidents because blood loss was not treated and the airway was not secured, started an organisation of GPs who were prepared to offer immediate care. This later became the British Association of Immediate Care Schemes (BASICS). Seat belts were made mandatory in new cars in 1967, and it became an offence for someone to drive with over 80 mg of alcohol per 100 ml of blood.
Surgeons knew how massive blood loss could be and that very large transfusions might be needed. The treatment of serious and multiple injuries required immediate blood replacement, diagnosis, ventilation, suction, blood volume studies, metabolic checks, radiology and surgery. A full team was necessary, available only at special centres. The SMAC set up a group to study accident services, chaired by Sir Harry Platt; the group thought that the accident and emergency units (A & E) should be reduced substantially in number, so that staffing was always adequate.73 A BMA committee also considered the problem in 1961. It examined experience in Birmingham, Oxford and Sheffield. A three-tier system was proposed, with a central accident unit usually attached to a teaching hospital, other accident units in selected hospitals, and support from peripheral casualty services.74 There was wide agreement that effective treatment of injuries required experience and good facilities that were well organised. A country-wide accident service organised regionally was now necessary, but such a service never became an agreed NHS policy.75
John Charnley, funded by the Manchester RHB, made an unsurpassed contribution by developing the surgical, mechanical and implant techniques of hip replacement. He added two elements to McKee’s operation. He concentrated on engineering issues, designing a low-friction arthroplasty using a small metal femoral head articulating with a plastic insert in the acetabulum. His first attempts used stainless steel for the head and Teflon for the pelvic component. The wear rate proved unacceptably high, the joint would fill with fine particles of Teflon debris and the femoral head might wear through the cup. With the engineers at Manchester University, he explored the engineering and lubrication problems and switched to ultra-high molecular weight polyethylene. This low-friction arthroplasty proved successful. His second contribution, in 1962, was the introduction of polymethylmethacrylate cement to distribute the stress from the metal components evenly over the bone. His results steadily improved and he was not a person to seek to make private profit out of his work. An impressive speaker and writer, he had data to back his claims and the best technology then available. As he improved the technique, he set about training others in it. Surgeons turned their attention to the knee. By the early 1960s three different prostheses were in use, all cobalt-chrome hinges attached to stems running into the bone cavities of the tibia and femur, in the lower and upper leg. They were not widely used because the early results were not encouraging and if the operation failed revision was difficult.
Cardiology and cardiac surgery
Disorders of heart rhythm commonly cause death because, when cardiac arrest occurs, oxygen lack rapidly causes brain damage. Prompt restoration of the circulation is necessary: if any attempt was made to restart the heart, the method was to open the chest where the patient lay to massage the heart. Following the development of closed heart defibrillation, external cardiac massage was developed at the Johns Hopkins in Baltimore.76 Successful resuscitation, though rare, encouraged a more energetic approach to cardiac arrest. With these new techniques of monitoring and resuscitation, coronary care units were developed.77 In 1963 Toronto General Hospital reported the centralisation of patients in a unit with special provision for early detection and treatment of disorders of heart rhythm and cardiac arrest. The improvement in survival was far from spectacular, but a trend was established.78 As a result, many of the sickest patients in a hospital were moved to a new facility that required nursing staff with new skills. The knowledge needed by intensive care nurses, and the speed with which they had to take decisions, made frequent staff changes impracticable. The nurses developed the necessary expertise and were often able to guide young doctors in the diagnosis and management of cardiac arrhythmias. Although deaths from heart attacks occurred soon after the onset of symptoms, the delay before admission was on average nearly 12 hours. In 1966 Pantridge, at the Royal Victoria Hospital Belfast, introduced a mobile intensive-care unit - a specially equipped ambulance - to provide skilled care to people on their way to hospital.79 Mouth-to-mouth respiration and external cardiac massage began to be taught to the public by the first-aid organisations, with professional approval.80
Patients with a slow heart rate from heart-block had a high death rate, a low cardiac output and were unable to meet the demands of exercise or emotion. Electronic developments, and the ability to insert a tube or wire safely into the heart, led to the development of pacemakers. Electrical impulses were used to restore a normal heart rate. The first pacemakers were external and uncomfortable for the patient but in 1960 an implantable unit was developed and from then on pacemakers developed rapidly. Improvements in technique, and the development of ‘demand’ pacemakers that allowed variable rates of pacing, cut the mortality and enabled increasing numbers of patients to live a near normal life with a greater sense of well-being. Some patients with good heart function could even return to work, and the mortality rate for patients with complete heart-block was greatly reduced.81
More effective surgery within the heart became possible with the introduction of heart-lung bypass techniques from the USA. Accurate diagnosis, the surgical skill to correct hidden and undiagnosed abnormalities and good teamwork were the keys to success.82 Characteristically, a procedure had a high mortality when first introduced, but this fell rapidly as experience was gained. From the patient’s point of view there was often a case for delay until techniques improved and risks were lower.83 It was essential to have a well-trained team that could carry out successful perfusion, not only under ideal conditions but also when things went wrong. The Hammersmith Hospital reported a series of cases in which the heart-lung machine was used in ventricular septal defect. Paul Wood, at the National Heart Hospital, said that 85 per cent of cases of congenital heart disease were now operable. Though the risks of operation on septal defects between the left and right side of the heart were falling, morbidity from complications such as cerebral embolism was substantial. Operations were also developed to replace damaged heart valves that either leaked or were blocked. A ball valve designed in the USA by Starr made possible the replacement of the mitral valve, and later of the aortic valve as well. Initially the mortality rates were up to 20 per cent, and replacing more than one valve increased the mortality.84 Donald Ross, at the National Heart Hospital, was the doyen of aortic valve grafts, also successfully using the patient’s own pulmonary valve to replace the more important aortic valve.
Direct surgical attack on blocked coronary arteries now seemed within reach, but a clear picture of the arteries was required before this was possible. Coronary angiography, injecting contrast medium into each artery, was developed at the Cleveland Clinic and introduced to the UK.85
Narrowing of the carotid artery had long been known to be one cause of strokes. Surgical treatment was increasingly used for patients who had transient symptoms suggesting impaired circulation to the brain - difficulty with speech or vision, or transient weakness.86 In the USA the operation rapidly became popular but a more conservative approach was adopted in the UK and soon proved better.
Renal replacement therapy
The nature of renal disease was changing. Nephritis after streptococcal infection was becoming rare; yet there was no reduction in the numbers developing chronic renal failure. Steroids had completely changed the picture in another kidney disease, nephrosis. There were major advances in the treatment of both acute and chronic renal failure. Intermittent renal dialysis was in use in the USA in the early 1950s, and in Leeds from 1956:87 the patient’s blood was passed through coils immersed in special solutions into which impurities passed, before it was returned to the body. Over the next four years several other units that could treat acute renal failure were established, mainly in teaching hospitals. The chief problem was that clots formed in the veins, which could not be used again. It was technological development that altered the nature of the care available. In 1960 Scribner demonstrated an implantable arterio-venous shunt that could be used repeatedly, and although the shunts were not trouble free there was no longer a temptation to dialyse for a long time to delay the need for the next treatment. The combination of the shunt and better dialysis equipment that required no donor blood to prime it raised the possibility of treating chronic renal failure on a considerable scale. The procedure was on probation in the US from 1960 to 1962, when it was recognised as a considerable advance. Clinical opinion in the UK was divided. Douglas Black, in a Lancet editorial in 1965, said that such programmes made exacting demands on skills, time and money, and their claims should be compared with other forms of intensive care. (An outbreak of hepatitis in his unit at the Manchester Royal Infirmary affected eight staff and one died.) Other clinicians and patients were indignant; young people were now being treated and, as a result, were leading an active and productive life; should they be allowed to die?88 A further technical development largely replaced the Scribner shunt and made repetitive dialysis available to virtually everyone.89 A surgically created interior arterio-venous fistula between the radial artery and vein was developed by Cimino and Brescia in 1966.
Unfortunately, money and trained staff were limiting factors and it was impossible to offer treatment to all who could benefit from it. Renal medicine was one of the first specialties to face the ethical problems of selection of patients and the economic problems of provision. The Ministry set up an expert group chaired by Professor Sir Max Rosenheim, of University College Hospital, to plan development and arrange the supply of dialysers. Exceptionally, government provided money specifically for renal dialysis, £10 million per annum. Plans were made for 10-20 centres and also for home treatment. Nation-wide only 70 patients were receiving treatment in 1965 but between 1967 and 1971 units opened in each region. Further outbreaks of hepatitis affected those in Leeds and Liverpool, with deaths among patients and staff. Some patients were found to be hepatitis carriers, and cross-infection was all too easy. Antibiotics were no answer. Patient care had to become more hygienic and barriers were needed to prevent the transmission of infection.
Renal transplants were undertaken in the early 1960s in patients who were gravely ill, using unrelated kidneys and attempting to suppress rejection by total body irradiation or drugs that had been effective in animals. There were a few successes. Successful transplantation required good surgical techniques, for example a reliable way to join blood vessels, and growth in knowledge about immunology and tissue rejection. Results improved with the introduction of azathioprine in 1965 and transplantation emerged from the experimental stage.90 Britain was slow in developing a comprehensive policy for handling renal failure; a transplant service became essential, for without it enormous sums would be spent on dialysis. Yet transplantation was possible only on the basis of a renal dialysis service. Who should be treated and how were decisions to be taken? A serious ethical difficulty faced doctors looking after patients with irreversible renal failure. Some 6,000 died annually, half between the ages of 5 and 55, and both dialysis and renal transplants offered over a 50 per cent chance of surviving a year or more. Was the selection of patients, a life or death decision, best left to the consultant?91 Most units, faced with the impossibility of treating more than a few of those in need, rejected elderly people and people with diabetes in favour of ‘happily married patients with young children, who were reliable, stoic and endowed with common sense’. Some preferred to take patients as they presented if a vacancy on the treatment programme was available.92
Experimental transplants of the pancreas, lungs, heart and liver were undertaken in animals. The difficulties were greater than with the kidney, where renal dialysis could maintain the recipient in good health. That was not possible for somebody dying of heart or liver disease. The transplanted organs were also harder to maintain in good condition.93 Because of the wider use of organ transplantation, the Human Tissues Bill was introduced in 1960 to allow, subject to the consent of relatives, other parts to be removed (e.g. skin, arteries and bone).94 Bone marrow transplants began on an experimental basis. It was found that after lethal whole-body doses of X-rays that destroyed existing lymphoid and myeloid cells, grafts from donors ‘took’. After an accident with a nuclear reactor in Yugoslavia, several physicists were treated in this way. Aplastic anaemia (failure of the bone marrow to produce blood cells) was also treated by bone marrow transplantation. However, immunological problems remained and, when tissue typing and matching was imperfect, the graft might attack the host, even if the danger of the host rejecting the graft was overcome.95 Liver transplantation was pioneered in Denver in the early 1960s. The path to heart transplantation in humans was opened by workers such as Shumway at Stanford, who developed the surgical technique and showed that immunosuppressive agents would prolong the period of graft survival. In December 1967 Professor Christiaan Barnard, in South Africa, replaced the heart of a 55-year-old man, who subsequently died, with that of a road accident victim. Four further heart transplantations were carried out in the next few weeks, arousing worldwide interest.
Neurology and neurosurgery
With the growth of transplantation, determining the time of death of potential donors became increasingly significant. The absence of respiration or a heart beat was no longer enough, for life could be prolonged by the ventilators and organ support systems that were being developed. Removal of organs for transplantation could not be undertaken until it was clear that the body could no longer function as a unified system. It was found that, when the integrating mechanisms in the brain stem failed, recovery was impossible and body dissolution began to take place. Mollaret, a French worker, identified this condition as ‘coma depassé’ in 1962, and over the next few years many industrialised countries developed and published criteria of brain stem death.
The only treatment available for Parkinson’s disease had been brain surgery, for example pallidectomy. A major breakthrough began when workers in Austria discovered that, at post-mortem, the basal ganglia of patients with Parkinson’s disease were depleted of dopamine. Infusions of dopamine helped sufferers, but it did not work by mouth because it could not pass the blood-brain barrier. However, in 1966 Cotzias, working in New York, showed that a chemical precursor, levodopa, when administered in large doses relieved symptoms substantially. For the first time a biochemical mechanism had been discovered for a major neurological condition. More important, it was possible to improve the situation somewhat, and the drug industry became more interested in neurological disease. The management of epilepsy was also improved with the introduction of sodium valproate.
Routine hearing tests in childhood were introduced. The hearing aid manufacturers introduced innovative behind-the-ear and spectacle aids that were much less conspicuous than the body-worn models. Such aids became available through the NHS in the late 1960s and remain the commonest type in use.
Much deafness was the result of the inability of the small bones in the middle ear to transmit sound. Operations were developed, often overseas, to improve the ability to conduct sound; for example, surgical reconstruction of the middle ear ossicular chain. In 1963 William House, working with neurosurgeons in Los Angeles, developed a new translabyrynthine approach to the internal auditory canal, for the removal of tumours in and around the auditory nerve (acoustic neuromas). Neurosurgeons had been treating these tumours, but the introduction of the operating microscope made new operative techniques possible. The operating microscope was also used in surgery on the nose and larynx.
The application to the eye of drugs such as steroids, antibiotics, and beta-blockers in glaucoma saved sight on an enormous scale. Lasers, developed in the early 1960s, rapidly found an application in the treatment of eye disease, replacing older techniques, improving the success rate and reducing the duration of treatment. Coupled with an ophthalmoscope, they could be directed at any part of the internal eye and used for treating detached retina and vascular abnormalities.96 After early disappointments, lens implants using purer plastics and lenses with loops to aid attachment led to an improvement in the results achievable, but the operation usually chosen was lens extraction followed by the use of high-powered spectacles or contact lenses.
The mortality from cancer exceeded 100,000 for the first time in 1962 and even in children it was becoming a more significant cause of death. Supervoltage radiotherapy was now well established, and as equipment improved it was possible to deliver the dose more accurately to the important area. Computing was applied to treatment planning. Increasingly radiotherapists became aware of what they could cure, and what they could not. Radioactive implants, a long-standing form of treatment for some circumscribed tumours, became more sophisticated.
There was an increasing recognition that cancer was a systemic disease, often with distant spread (metastases) very early on. Consequently, a precise knowledge of where the cancer was mattered less than the availability of chemotherapy. A new group of drugs became available, vegetable extracts that shared the property of arresting the separation of chromosomes during cell division. Derivatives of colchicine were used for a while in the treatment of Hodgkin’s disease and chronic myeloid leukaemia. Vinca alkaloids from the West Indian periwinkle (vinblastine and vincristine) were also introduced. The first proof that chemotherapy cured metastatic disease came from the work of Li, Hertz and Spencer at the National Cancer Institute in the USA.97 In 1956 methotrexate was used on a patient with metastatic choriocarcinoma, a rare but rapidly developing tumour that sometimes followed childbirth or miscarriage. Urine tests could identify the cancer, allowing the effect of treatment to be monitored. Actinomycin D and vinblastine were also active, and it was shown that daily treatment was less effective than the administration of one or more drugs every four or five days. Bagshawe at the Fulham Hospital introduced the treatment for choriocarcinoma to England. He advocated a centralised follow-up and treatment service, and a death rate of 95 per cent was turned into a survival of 75 per cent.98 In the early 1960s a survey showed that 159 patients who had been treated for acute lymphoblastic leukaemia with a variety of agents had survived five years or longer. No patients survived five years without chemotherapy; this led in the USA to the establishment of an acute leukaemia task force to see if cures could be increased. The cure of acute lymphoblastic leukaemia was an important milestone because a rational basis for curative chemotherapy was being developed, bringing together knowledge of the processes of cell division, pharmacology, toxicology, good nursing and development in clinical medicine.99 The objective became the destruction of every last leukaemic cell by every means possible, as just one cell could cause relapse. A given drug killed a fraction of tumour cell populations but resistant cells remained and multiplied. There were then five active drugs and switching from one to another, or a combination, killed further cells. Combinations of drugs were used in leukaemia, Hodgkin’s disease and testicular cancer. A marker or index for tumour activity was very important; one treated until the marker disappeared, and then some more. Clinicians were learning the right way to use the drugs. Large-scale trials were now necessary to define the best treatment schedules.100 Some workers, including Farber, suggested that drugs might control metastatic relapses when combined with surgery and radiation. Adjuvant therapy of this type was shown to increase the survival rate after surgery for Wilms’ tumour of the kidney.101 Cancer centres in the UK were slow to adopt the aggressive forms of treatment being developed in the USA. There were few medical oncologists, and surgeons or radiotherapists treated cancer. Some antibiotics showed activity against cancer and the pharmaceutical industry followed up this line of research. By the end of 1967 more than 88,000 compounds had been screened for effectiveness against cancer.
Cervical and breast cancer
Exfoliative cytology, for some years patchily available in specialist departments, offered another chance for reducing cancer. Cancer of the cervix, the fifth most common cancer in women, might be identified early and at a pre-invasive stage. The feminist movement took up this issue as one of it first causes. Political pressure for a service was substantial; if population screening proved practicable it offered a chance to save life. By 1963 it was clear that trained cytologists were rare, so five national training centres were established. In 1965 it was decided to aim for a service offering five-yearly smears to all women over the age of 35 years. The size of the task was substantial and many women were reluctant to accept screening although it was free and became easily available. Those at greatest risk, often in the lower social classes, were the most reluctant to present themselves for screening.
A breast cancer screening programme was launched in 1963 by a health insurance plan in New York. The screening subcommittee of SMAC believed it would be premature to implement such a programme until there was good evidence of its worth; had one been introduced, the UK’s radiologists would have had little time for anything else. This recommendation was one of the earliest occasions on which a professional group prevented the national introduction of a procedure for which there was inadequate evidence. The BMJ agreed that it would be prudent to consider the costs, value and practicability of mammographic screening, because such a programme would be beyond the resources of most countries.102
Smoking and cancer
The epidemic of lung cancer pursued its predictable course, with a steady increase in men and signs that women would suffer more as time passed, because of their increased use of cigarettes. By the early 1960s the public did not lack information, only conviction or willpower. Local health authorities ran health education campaigns without winning the battle. Only by the end of the decade were there any encouraging signs; there appeared to be a reduction in registrations of lung cancer in men aged 40-59.103 Charles Fletcher, Secretary of the Royal College of Physicians (RCP), and George Godber at the Department of Health needed a way to bypass political constraints and obtain an outspoken report from an authoritative body. The RCP seemed best to both and Sir Robert Platt, who had just been elected its President, agreed. In 1962 the RCP, having studied the available evidence, published Smoking and health, showing the connection and also an association with chronic bronchitis.104 Enoch Powell, a non-smoker, agreed to push the report but would not accept a ban on advertisements; if a company could trade legally, it could legally advertise its wares. The report sold 50,000 copies and had a worldwide influence. Following its publication, doctors began to give up smoking; the public was slow to follow their example and cigarette consumption continued to rise. Tobacco companies began to be concerned about the tar content of cigarettes and reduced it considerably. The difficulty in giving up something that clearly had the features of an addiction became increasingly obvious. Discussions with tobacco manufacturers were unsatisfactory. In 1965 a ban was placed on TV advertising of tobacco. In 1967, when Kenneth Robinson was Minister, no voluntary agreement could be reached with manufacturers to ban coupon gift schemes. The government announced that it would take powers to ban coupons and control other forms of advertising.105 The case against smoking could be made on many grounds, but not on economics. The non-smoker on reaching pensionable age lived, on average, seven years longer than his smoking colleague.
The hospice movement
For many, cure from cancer was not possible. Too often professionals were ill at ease with the dying, to whom adequate pain relief was not available. Cicely Saunders, initially a nurse at St Thomas’ and later training there as a doctor, pioneered better terminal care at St Joseph’s Hospice.106 Helped by a clinical research fellowship in pharmacology, in 1958 she began to investigate terminal pain and its relief. Many new drugs, which complemented the traditional opiates, had become available during the previous ten years. Service, teaching and research were combined with high quality care. A new hospice, St Christopher’s, opened in Sydenham in 1967, supported by the Borough of Bromley, the City Parochial Foundation, the BBC Week’s good cause, the Drapers Company, the King’s Fund and the Nuffield Foundation.107 The hospice movement inherited the long-standing charitable and voluntary tradition in health care. It treated each patient as an individual, was prepared to look death squarely in the face and to encourage the dying and their families to do the same. Only by facing difficulties honestly could the problems and the fear of death be overcome. Controlling pain by large, regular and fully adequate doses of opiates, relieving unpleasant symptoms and providing strong emotional support allowed death to be natural and dignified. The idea slowly spread. From its inception the hospice movement, though voluntary, worked closely with local NHS services to improve quality of care, and co-operated with primary health care teams to raise standards of care for terminally ill people within the community. Consultant posts in palliative care, and training positions, were progressively established. Specialist nurses were appointed in the community, for example the Marie Curie and Macmillan nurses who gave supportive care to people with cancer and their families. The hospice movement had a lesson to teach the health service about the limitations of technology in medicine and patient care.
Obstetrics and gynaecology
The review of maternity services by the Maternity Services Committee, recommended by Guillebaud and chaired by Lord Cranbrook, reported in 1959.108 To the dismay of obstetricians, Cranbrook saw a need for co-ordination and co-operation rather than reorganisation and unification of services under consultant control. Local liaison committees were therefore established. Cranbrook recommended the maintenance of a good domiciliary maternity service but considered that the balance of advantage favoured hospital rather than home delivery. A hospital delivery rate of 70 per cent was suggested, a figure without scientific justification, derived from a report by the Royal College of Obstetricians and Gynaecologists (RCOG) in 1944. More careful selection of patients for hospital was needed, with local authorities looking at social circumstances, and professionals booking for hospital those with possible obstetric problems, those who had borne four or more children or who were over the age of 35. A first baby was not, of itself, an indication for hospital delivery. Antenatal beds might be needed for 20-25 per cent of deliveries. The Committee supported the traditional ten-day postnatal stay, while welcoming careful investigation of early discharge. The Central Health Services Council (CHSC), examining maternity services in 1961, argued for more humanity.109 Hospitals were asked to review their procedures and make arrangements for mothers to have companionship and information in labour. The proportion of hospital deliveries began to rise, reaching the Cranbrook target in 1965 and 80 per cent in 1968.
Mothers were pressing for hospital delivery, and discharge before the tenth day became increasingly common. In spite of some opposition from the midwives, planned early discharge became more common, sometimes only a few hours after childbirth as soon as the mother was fit to be moved. Often mothers had been admitted only because their previous deliveries had been complicated. If all was well there was no reason to retain them. Less than 1 per cent needed readmission and there were few problems if there was careful selection and good relations between hospital and community staff.110 The duration of hospital stay began to fall nationally and kept falling. Beds ceased to be in short supply and there was increased pressure for nearly all deliveries to take place in hospital. With a reduction in home deliveries, obstetric flying squads were required less often, and tended to restrict themselves to resuscitation before the mother was transferred to hospital. It became policy to co-locate GP maternity units with the consultant units, allowing GPs to practice safely in the knowledge that unpredictable emergencies could be handled in surroundings with better facilities.111
The three-yearly reports from the confidential inquiry into maternal deaths showed that childbirth was increasingly safe. The top four causes of death remained constant: toxaemia, haemorrhage, abortion and pulmonary embolism in which arteries in the lungs were suddenly blocked by a blood clot that had formed in leg veins. The surveys showed that avoidable factors were often involved, such as failure to attend for antenatal care, booking the delivery at home or in a GP unit when specialist facilities were required, or failure to seek specialist advice when necessary. They showed the need for the highest anaesthetic skill when women were in labour.112 Merely by conscientious and wise application of the knowledge available the number of maternal deaths could have been nearly halved.113
In 1958 the National Birthday Trust Fund, with the support of the Ministry and the RCOG, undertook a survey of every birth taking place during the week beginning 3 March.114 NHS staff, nurses, midwives and doctors recorded detailed demographic information, including social class, complications of pregnancy and delivery, and outcome for mother and baby. Analysis of the 17,000 records took a long while, and ill-managed presentation at a press conference in 1962 led to headlines about ‘kitchen table midwifery’, giving an impression that the survey was an attack on domiciliary midwifery and GPs.115 The report did not appear until 1963, and the research, both sociological and clinical, had a major influence on the development of maternity services.116 It had much to say about social class. The death rate of babies in the professional classes was half that in the unskilled labour class. Scarce maternity beds were not allocated equally; better-off women were more likely to give birth in hospital or GP maternity units. The report showed how poor antenatal care might be; blood tests might not be done and blood pressure was often not checked. It was shown that pregnancies lasting more than 42 weeks were associated with higher perinatal mortality rates than those of average duration. This appeared to support the decision taken by some units to induce labour in mothers who were two weeks overdue, a policy later shown to be open to question. Further analysis of the data showed that mothers who smoked had smaller babies and more of them died.117 One question could not be answered by the survey - the safety of home delivery compared with hospital. The survey assumed that hospital birth was safer, but it was not clear from the data.118 The cohort of children was followed up annually for many years to see how they developed.
Increasing attention was paid to emotional factors in illness. Katharina Dalton, a GP and a clinical assistant at University College Hospital, interviewed a group of women in prison, and found that almost half of them had committed their crime during menstruation or the premenstruum. Premenstrual tension appeared to be a factor.119
Oral contraception steadily increased, as did the use of intrauterine devices. However, male sterilisation, though a comparatively simple operation, was regarded as a potentially criminal and maiming act. In the mid-1960s lobbying by family planing groups led to vasectomy not only being accepted but actively encouraged by government.
The Abortion Act
There was widespread agreement that some change in abortion law was required but not about what that change should be. Criminal abortion was a leading cause of death associated with pregnancy, but it was not known how many abortions there were. The RCOG thought they were few but others put the number as high as 100,000 a year. The College thought that termination of pregnancy was not so safe and simple as sometimes maintained and that the law did not seriously hamper current medical practice; 2,800 therapeutic abortions were carried out in 1962 and on the shady side of Harley Street business was brisk. Both the BMA and the Royal Medico-Psychological Association published their views, the latter stressing the significance of social circumstances as well as medical and psychiatric criteria.120 Jeffcoate, Professor of Obstetrics and Gynaecology in Liverpool, believed that a true medical indication for operation did not arise in more than one in a 1,000 pregnancies and that psychiatric indications were easily abused. Others took a more liberal view about psychiatric problems, reactive depression and anxiety states.121 In 1965 Lord Silkin introduced a Bill that the BMJ thought was hurried and ill-considered. When Harold Wilson called a general election in March 1966 it provided a pause for reflection. David Steel, a young liberal MP, drew a favourable place in a subsequent private member’s ballot, and introduced a Bill.122 Kenneth Robinson, as Minister of Health, and Roy Jenkins, as Home Secretary, ensured enough parliamentary time for it. As a result, under the 1967 Abortion Act termination of pregnancy was no longer illegal if two medical practitioners believed that
· The pregnancy would involve risk to the life of the woman, or of injury to the physical or mental health of the woman or any existing children greater than if the pregnancy were terminated.
· There was a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Because it extended the reasons for termination beyond the mother herself, the BMA was troubled by the ethics of including existing children in the definition. Within a couple of years a rapid increase in the number of abortions was apparent, increasing the strain on gynaecological outpatient and inpatient departments.
Pressure from some professionals, the British Paediatric Association, the BMA and the Association for Welfare of Children in Hospital, led to the establishment of a committee to study the arrangements made in hospital for children. It was appointed by the CHSC and chaired by Sir Harry Platt, reporting in 1959.123 The committee stressed the need to understand and care for the emotional needs of children, particularly when in hospital. There should be separate children’s outpatient departments, admission should be avoided where possible and children should not be nursed in adult wards. Children’s welfare should always be the responsibility of paediatricians and nurses trained in the care of children. Unlimited visiting of parents should be introduced.
The progressive appointment of paediatricians led to an intense interest in neonatal medicine, and some technologies that were developed improved the care of older children as well. Neonatology began to emerge internationally as a specialty. Efforts were made to transfer mothers in early labour to hospitals with special units, and to provide transport incubators for those born elsewhere. The main concern in caring for premature babies was respiratory distress, hyaline membrane disease, with obstruction to the small airways of the lung. Research revealed that this was the result of lack of ‘surface-active agents’, as a result of which some of the air cells of the lung collapsed. The principles of care were laid down by people such as Peter Tizzard, who established the first British research unit in neonatal medicine at the Hammersmith, and developed the measurement of arterial oxygen, carbon dioxide and pH. Treatment included the prevention of aspiration (inhaling feeding fluids), early feeding and early attempts at mechanical ventilation that were not particularly successful.
The breakthrough in haemolytic disease of the newborn came in 1967. Two groups, Cyril Clarke in Liverpool and another in New York, showed that it was possible to destroy any fetal cells found in the maternal circulation after delivery (the cause of rhesus sensitisation), by a suitable antibody. The Kleihauer technique had just been described, which allowed the detection of fetal blood cells in maternal blood. It was possible to prevent mothers developing antibodies by giving them anti-D immunoglobulin shortly after the birth of the babies.
Haemophilia, a genetic disease appearing in the male, led to persistent bleeding after minor injury, and bleeding into joints such as the knee. It was treated by freshly collected whole blood or frozen plasma transfusions. It was known that the anti-haemophilic factor (factor VIII) could be separated from plasma, and in the 1960s there were advances in preparing it, by cryoprecipitation and later by plasma fractionation.124 Patients’ outlook changed dramatically as it became possible to reduce the disabling complications.
The rising number of immigrants increased the incidence of two other genetic diseases of childhood. Beta-thalassaemia major, found in people from the Middle East, Africa and southeast Asia, was characterised by the inability of bone marrow to produce an adequate number of red blood cells. Anaemia, slow growth, cardiac failure and death in the late teens were the result. The development of regular blood transfusion regimens, in 1961-1964, was a major advance, for it allowed patients with thalassaemia to grow and to live longer. The result of monthly blood transfusion, however, was to overload the body with iron, which led to liver fibrosis, endocrine deficiencies and growth retardation. The use of iron chelating agents by intravenous injection, which bound the surplus iron and assisted its excretion, helped somewhat. Sickle-cell disease was found in populations of West African origin and in 1949 it became the first genetic disease in which the molecular basis was determined. Sickle-cell crises, with acute pain caused by the blood cells breaking up and blocking the arteries, sometimes produced acute and chronic organ damage. By the age of 40 years, half those with severe disease were dead. The only treatment, temporary in nature, was exchange transfusion in which the patient’s blood was replaced with blood from a donor. It was the first disease in which the molecular basis of genetic disease had been determined, in 1949. As a result of this discovery the scope of human genetics was widened and many other ‘haemoglobinopathies’ were discovered.
In the late 1950s and early 1960s there was a trend to push operative treatment for babies with congenital defects of the spine and brain, meningomyelocele, beyond reasonable limits. Babies with mild degrees of spina bifida could be operated on with a measure of success but those with severe defects might be helped to live for only a while, usually being left with complex physical and mental handicaps, and producing great emotional strain on the families.125 Yet some units undertook repeated heroic surgery. A paper was put to SMAC with the suggestion of a national conference attended by all shades of opinion, including parents. From that conference came a paper discouraging surgery in cases in which the long-term outlook was hopeless.
The treatment of children of short stature, when due to failure of the pituitary to produce enough growth hormone, was helped by using human growth hormone prepared from pituitary glands obtained at autopsy. Supplies were scarce and treatment, which began in 1959, was centralised in a few units and supervised by the MRC.126 The children treated grew well. Not for many years was a hazard to this treatment discovered.
Nowhere was the contrast between what existed and what was possible more stark than in the care of elderly people. The illnesses and disabilities of ageing loomed increasingly large. Most old people did not to report their difficulties until they were well advanced, and mental deterioration was an increasing problem.127 GPs knew less than they liked to think about patients’ sight and mobility. It was difficult to recruit consultants to the specialty, and a large proportion of those who entered it had qualified overseas and for whom geriatrics was often not their initial specialty of choice.
Components of a comprehensive psychogeriatric service
· An organisational structure that encourages integration between the services provided by the three parts of the NHS and the voluntary sector
· Psychogeriatric assessment units for early ascertainment of those at high risk
· Community and domiciliary services, clubs, day centres, outpatient clinics and day hospitals
· Hospital inpatient services for short periods of acute illness, and for non-ambulant patients, with an accent on rehabilitation
· Long-term accommodation and sheltered housing
Source: Kay et al. 1966.128
Guillebaud had recognised the need for better housing and domiciliary services so that elderly people could continue to live, wherever possible, in their own homes. Almost 5 per cent of people aged 65 years or more were accommodated in institutions of one type or another. Many were admitted to acute wards of district general hospitals (DGHs), but psychiatric and social problems were quite common among them, emphasising the need for psychiatric and geriatric services in the DGH. Geriatric wards tended to be occupied by people over 75, and there was no clear division between the patients in them and those in the acute wards, although many would clearly not be restored to a fully independent life. Half had some form of mental illness or dementia. A third group of elderly patients, those in mental hospitals, were often suffering from irreversible senile degeneration, but many had physical illnesses as well. Finally both mental and physical problems were common among those in residential homes.128
Defining the characteristics of a modern geriatric service was not difficult. It was much harder to develop one. In 1961 the Birmingham RHB published a report on its geriatric services. Some were hospital slums that did no more than provide storage space for patients under conditions of considerable difficulty, and often unpleasantness, for the nursing staff. Many hospitals were fit only for demolition and replacement; some were 100 and some 200 years old. Many had no lift and when patients had been manhandled upstairs they were marooned there for the rest of their days, often at considerable risk from fire.129 In 1965 The Times published a letter from a group including Lord Strabolgi, academics, social workers and clergymen. They had ‘been shocked by the treatment of geriatric patients in certain mental hospitals, one of the evils being the practice of stripping them of their personal possessions’. They appealed for confidential information about such malpractice. The response overwhelmed them.130
Easy and effective treatment, possible with the new drugs, enabled GPs to manage many patients with mild and moderate degrees of anxiety and depression. Psychiatrists were few, their waiting lists were long, and only severe cases generally reached the hospital services. William Sargant, at St Thomas’ Hospital, was a protagonist of physical methods of treatment. A charismatic, immaculately dressed, controversial and not universally popular man, he believed that medicine and psychiatry had drifted steadily further apart and needed to be reunited. He thought that the future would see the replacement of specialised psychiatric and psychotherapeutic treatment by physical methods including drugs, and there would be greater understanding of the physiological basis of psychiatric disease. Some psychiatrists, in his view, preferred to remain a segregated group, advocating general philosophies about the need to treat and heal the ‘whole person’. Yet it was only when general medicine stopped bothering about the whole person - the internal humours and external vapours - and insisted on treating the liver, the heart, the blood stream, the brain and the nervous system, that general medicine really got started. Each year 20,000-30,000 distraught people tried to kill themselves, many of whom would be helped by simple methods. During the war the Maudsley Hospital, where Sargant had worked, had been evacuated to emergency hospitals without locked doors; military patients were not officially considered mad and refused to think of themselves as such. Locked provision had not been necessary. Subsequently, as the new drugs appeared, these could be assessed in trials on outpatients, and the best ones for different types of depression could be determined. Improvement was often rapid, although it was as essential in psychiatry as in general medicine for the correct dosage to be used for the proper length of time. It was crucial, Sargant thought, to break away from philosophical and metaphysical concepts of disease and the psychotherapeutic approaches that failed most of the neurotic and the mentally ill.131 ‘From being a backwater, ignored as much by the rest of medicine as by the public at large,’ said the Lancet, ‘psychiatry is becoming one of the major specialties. Its professional standards have risen rapidly; it is already based on an impressive body of organised knowledge; and its results on the whole are probably no worse than medicine or surgery.’132
The two major reforming pieces of legislation of this century, the Mental Treatment Act 1930 and the Mental Health Act 1959, followed world wars. The 1959 Act, resulting from the recommendations of the Royal Commission in 1957, created a new basis for the treatment of the mentally ill with no more formality than for other illnesses. It aimed to break down segregation, and the feelings of isolation, neglect and frustration that this engendered.133 Services would now be planned across hospital and community boundaries, by specialists, family doctors and local authority staff, nurses and social workers. Since the 1940s many psychiatrists had realised that long-term residence might result in institutional neurosis, with apathy, withdrawal, resignation and loss of individuality.134 It was in the best interests of those able to live in the community to do so. Expansion of domiciliary services, residential homes and hostels, day-hospitals and social clubs would be needed and local authorities began to plan buildings to support the new policy.
Earlier treatment was now possible and its effectiveness increased the demand for psychiatric services, particularly outpatient ones. The Manchester experience began to be discussed. Maurice Silverman, from Blackburn, described a comprehensive district service with no selective criteria for admission, dealing with all cases from a population of 254,000. His unit of 100 beds had 488 admissions and 479 discharges in one year and provided domiciliary visiting and day patient facilities. Four of the eight psychiatrists in the Manchester region, each with a population of 250,000, said that they did not need facilities of the large mental hospitals.135 In setting up the units, the one thing the RHB was not generous with was consultant staff. Units were run on a shoe-string; supporting staff were thin on the ground, and with so few staff only the severely ill could be treated. That reduced bed needs. There was a sturdy resignation among Lancastrians; they were prepared to suffer and put up with it. The policy was cheap and resulted in the run-down of some very large mental hospitals. The Ministry took note.
Psychiatrists hotly disputed the future organisation of mental health services. TP Rees at Warlingham Park, Macmillan at Nottingham and Russell Barton at Severalls Hospital emphasised the value of the traditional mental hospital that was likely to diminish in size from an average of 1,000 beds to 500. Such hospitals provided a better basis for staff education and, because many psychiatrists worked together, research was easier. Large hospitals could have a range of specialised units impossible within the restricted space of a DGH. In spite of active treatment and rehabilitation some patients would continue to present long-term social and clinical problems.136 They needed space in which to be peculiar without upsetting others. Thomas McKeown, Professor of Social Medicine at Birmingham, on the other hand, wanted to unite all services including mental illness in one place. He believed that the chief problems that would confront medicine in the future would be prenatally determined mortality and morbidity, mental subnormality and mental illness, and the disease and disability associated with ageing. These would be the functions of the hospital of the future, and a balanced hospital community would be needed. The association of mental illness with other services would raise staffing to a satisfactory level, make for efficiency as common services could be shared, and reduce the stigma and isolation of mental illness.137
In 1961 Tooth and Brooke, a doctor in the Ministry of Health and a statistician in the General Register Office, published in the Lancet a prediction of future bed requirements based on cohorts of patients admitted in 1954, 1955 and 1956. It showed that the tide had turned in 1954 and that, although admissions were increasing, the number of inpatients was decreasing and discharge was faster. The paper predicted that there would be a rapid and continuing reduction in the number of beds required, such that in 16 years’ time the bed requirements might have fallen from 150,000 to 80,000.138 Enoch Powell, Minister of Health, was interested in mental care.139 Seeing the draft before publication, he surprised his audience at a conference at Church House, Westminster, in March 1961 by speaking in dramatic - almost messianic - terms about future policy on mental hospitals. He said of the old hospitals,
There they stand, isolated, majestic, imperious, brooded over by the giant water tower and chimney combined, rising unmistakable and daunting out of the countryside ..
Not more than half the present number of places was likely to be needed, a redundancy of 75,000 beds. The beds should be in general hospitals. The change would imply the elimination of the greater part of the existing hospitals, a colossal undertaking. He said he would resist attempts to foist another purpose on them. Many staff had given years of service to the doomed institutions and a new pattern of working would demand no mean moral effort from them, as a whole branch of medicine, nursing and hospital administration was transformed.140 Richard Titmuss, a social scientist, replied that the British tended to express aspirations in idealistic terms. There was little evidence of attempts to hammer out the practice, as opposed to the theory, of community care although policies assumed that somebody knew what it meant. To scatter the mentally ill in the community without adequate provision was not a solution, even financially. Powell’s proposed reduction implied a remarkable degree of optimism about readmission rates and the part to be played by GPs and local health authorities. Titmuss thought there was drift into a situation in which the care of the mentally ill was transferred from trained staff to untrained or ill-equipped staff or no staff at all. Experienced physicians in mental hospitals had grown wary of miracles and felt in their bones that the psychiatric millennium was not yet at hand. Russell Barton asked whether education for the new service could make up for the failure of teaching hospitals; they were producing doctors lacking even a barn-door knowledge of psychiatry. The involvement of GPs would be essential, though few were enthusiastic or trained for this.
Powell was a crusader and the Ministry had previously seen the NHS benefit from the closure of sanatoria, freeing money that would otherwise have been difficult to obtain. General hospital psychiatry might be economic and the clinical answer to hospital over-crowding. No new large hospitals would be needed. ‘We need more psychiatry in fewer buildings,’ said Sir George Godber.141 Inpatient treatment was seen as only an incident in the management of most mental disorders. The aim was to return patients to ordinary life, with support if necessary, as soon as possible. In 1967 new figures showed a continuing fall in numbers, 20,000 between 1954 and 1963.142 Morbidity surveys and community registers, such as the Camberwell Register created in 1964, offered hope of a better epidemiological basis for planning mental illness services.143
Three mental health objectives were fed into the newly developing policy: improvement of the quality of care, reduction of institutional care and transfer into community care. The proposal that the bulk of acute cases would in future be admitted to district general hospitals was an implicit judgement on the traditional unit. It implied that existing mental hospitals were the product of an age that thought in terms of custody, and they had no permanent or valuable role in society. Their functions could be split between district hospitals and the community. No one was likely to defend the image painted by Enoch Powell. Nevertheless, while units based on district hospitals clearly could work, there was an alternative that many other countries had adopted.144 Sizeable inpatient psychiatric centres could provide clinical treatment plus sanctuary, be large enough to provide all the facilities needed for socialisation of patients and support a team of psychiatrists who could specialise and learn from each other. The impetus towards community was derived from several sources - the new wave of psychotropic drugs, the possibility of cheaper forms of care, and a group of civil libertarians who maintained that mental hospitals were effectively prisons, depriving their inmates of ‘freedom’ under an authoritarian regime, from which discharge meant a return to a normal life. The doors were opened to a wave of non-medical mental health workers, social workers, nurses, counsellors, self-help groups and patients.145 There was no doubt that patients could be discharged and the beds reduced to the required numbers, but nobody knew what the cost to the community would be. It was not appreciated that many patients would indulge in antisocial conduct, or need 24-hour supervision, or be incapable of caring for themselves. Patients did not always take their drugs after discharge and deviant behaviour might distress relatives. A full community care system was still in its infancy.146 Local health authorities did not have enough trained staff, nor family doctors the time and experience. The burden on families might be substantial. There were few hostels available and a lack of enthusiasm for their provision. Was a social isolation being substituted for a geographical one? asked the BMJ. What was the state of discharged patients? How many were among the 9,000 offenders referred by the courts for psychiatric reports, the 28,000 homeless discovered by the National Assistance Board or the thousands sleeping rough?147
The policy of general hospital psychiatry created uncertainty about the physical conditions in old, over-crowded hospitals with old-fashioned toilet facilities and in poor decorative order. If parts of them were to be closed, what should be spent on upgrading? Some mental hospitals began to divide into two sections, a small short stay-unit with about 20 per cent of the total beds that treated 80 per cent of new admissions, and a larger long-stay section dealing with the chronic sick, those who might recover more slowly and elderly patients too disturbed to be cared for elsewhere. Sometimes a hospital was divided into units with different geographical responsibilities. Alternatively, each team took a special interest in particular types of care.148 These hospitals had to interdigitate with an increasing number of district hospital units offering intensive treatment to patients from a local catchment area. There was a danger of a split service and two-tier provision. The patients who increasingly went to the district hospitals were the more acute, the younger and the more hopeful. Those in the large old hospitals were the chronic and the elderly severely mentally infirm. Some consultants might be unwilling to work in large chronic hospitals. Nurses from the older hospitals might be rejected by the district hospitals, and some members of staff themselves seemed in need of sheltered employment.149
The task and the status
When young doctors entered general practice, they soon discovered that the spectrum of medical problems they encountered was not that of the hospital. Clinical medicine differed from the medicine taught in the teaching hospital, so they had much to learn; indeed ideally much of the GP’s education should take place within general practice itself.150 Care in general practice had to reflect the way human beings behaved and related to each other, and the society in which they lived. The work of Balint at the Tavistock Clinic suggested dimensions of clinical practice quite unlike anything taught or learned at medical school.151 Ann Cartwright studied general practice in north London from a sociological perspective.152 Two GPs, John Fry in Beckenham and Keith Hodgkin, continued their analyses of the work of general practice and of the difference between hospital work and their own. GPs managed 90 per cent of their patients alone and hospital specialists saw only 10 per cent, even in conditions that might be regarded as ‘hospital’ in nature, such as high blood pressure and peptic ulcer.153 John Fry analysed his hospital referrals. Roughly 18 per cent of his patients were referred each year, 3.7 per cent for an outpatient consultation and 3.8 per cent for admission; the rest were for a test or X-ray. He tried to determine the outcome of hospital referral, which proved difficult. Excluding maternity cases, a year later just over half seemed better, but almost the same number were little different or worse. Perhaps, Fry said, greater attention should be paid to the long-term results of long-established therapies that had become blind routines.154 GPs had long known that psychiatric illness was common in general practice. A paper in 1966 by Michael Shepherd from the Maudsley showed that it was one of the most frequent causes for consultation and that GPs dealt unaided with the vast bulk of such cases. The implication was that the main need for improvement of mental health services was not a proliferation of specialist agencies, but a strengthening of the family doctor’s therapeutic role.155
Comparison of morbidity in general practice and hospital per 1000 incidents
Source: Hodgkin 1963, adapted by Fry 1964152
Although the 1952 Danckwerts award had remedied the initial injustice of the GPs’ pay, specialists regarded themselves, in George Godber’s words, as a superior kind of animal. Before the NHS they had received fees from patients referred to them by GPs. Being hoity-toity with colleagues was hardly profitable. Now that most of the consultant’s income came as a salary, matters were different.156 GPs felt that they were held in little respect. Matters were not improved by the evidence of Lord Moran, President of the RCP, to the Royal Commission on Doctors’ and Dentists’ Pay in 1958.
The Chairman: It has been put to us by a good many people that the two branches of the profession, general practitioners and consultants, are not senior or junior to one another, but they are level. Do you agree with that?
Lord Moran: I say emphatically No. Could anything be more absurd? I was Dean at St Mary’s Hospital Medical School for 25 years, and all the people of outstanding merit, with few exceptions, aimed to get on the staff. It was a ladder off which they fell. How can you say that the people who fall off the ladder are the same as those who do not? . . . I do not think you will find a single Dean of any medical school who will give contrary evidence.
The Chairman: I think you are the first person who has suggested to us that general practitioners are a somewhat inferior branch.157
Lord Moran later attempted to retract, stressing that he only wished to secure material rewards for those who spent long years of training as specialists, waiting in comparative penury.158 Family doctors did not forgive him. John Horder, later President of the [Royal] College of General Practitioners (RCGP), made the introduction of effective vocational training his long-term objective. In the College journal he wrote
Specialists expect to remain under part-time training until they are from 33 to 40 years old. Is it surprising that some of them have feelings of superiority - and some of us feelings of inferiority - when our own training is so much shorter? Unless this differential is altered what right have we to expect much change in the other differential.159
The young doctor could immediately become a principal, even ill-prepared for general practice. Few became vocational trainees; the scheme had a bad name, the number participating was decreasing and those who did might be used as cheap labour without a systematic programme of education.160 A national system of vocational training by selected and trained teachers seemed crucial, but only in a few places, for example Inverness and Wessex, had there been attempts to construct a training programme.161 The Wessex course was planned in 1958 and was sponsored by the University of London, with a grant from the Nuffield Provincial Hospitals Trust. It provided two years in hospital posts and one in a training practice. George Swift, the postgraduate adviser, selected the hospital posts and practices, and provided courses for the trainers and trainees.162 A working party of the RCGP was formed to consider vocational training and John Horder was largely responsible for its evidence to the Royal Commission on Medical Education in 1966. The RCGP asked for two years’ postgraduate education in supervised general practice and three years in hospital posts.163 The BMJ thought this idealistic and doubted whether it would be wise to make vocational training compulsory; offering GPs good working conditions was more important and the urgent need was for more pairs of hands.164
The RCGP also wished to see academic departments of general practice in every medical school to ensure that students were presented with a balanced picture of health and disease. The first Professor of General Practice, Richard Scott, was appointed in Edinburgh in 1963. England only slowly followed suit as in Manchester. Keith Joseph later used his contacts to obtain money for Chairs of general practice at Guy’s and St Thomas’. The early appointments were of men who had learned their craft in a practical school. There were no academic routes for them to follow and long-established colleagues in other disciplines did not take them entirely seriously. It was another 20 years before Marinker could say that the absence in a medical school of a department of general practice was no longer the hallmark of the traditionalist or super-technologist but merely of the quaint.165 Academics, for their part, did not feel that the RCGP was the right organisation to press their interests, composed as it was largely of doctors whose main raison d’être was to provide health services and who might lack a feel for academia.
In 1962 John Fry visited 33 ‘good’ practices to examine their organisation and premises. There was an ‘extraordinary sameness’ in them. Even newly built surgeries were inflexible, with little thought for future development and poor accommodation for ancillary staff. Half the practices used an examination room, a third had appointment schemes and almost all worked an off-duty rota. Fry thought that GPs needed an advisory service and financial incentives to plan and redevelop practices.166
The health centre had been considered the solution to poor quality premises, paid for, designed and built by local authorities for their own nursing staff, and for GPs who might rent accommodation. In the first decade barely a dozen had opened. Surveying them, the Medical Practitioners’ Union (MPU)* found that only 134 GPs were involved and only 33 worked exclusively at the centre. Why had they been so unpopular?167 It was a good idea to have local health authority staff working alongside the GPs, but communication was often minimal, and sometimes there were even separate entrances. GPs lacked confidence in local authorities, with whom they were often at cross-purposes. They might not be consulted before a new centre was planned. Often the last thing to be built on a new estate, the new residents were already on the lists of neighbouring GPs. Too much had been expected too soon. Although there was a concealed subsidy, rents might be high. Whilst the arguments for health centres remained valid, some new approach such as group practice was required because the nature of society and modern medicine demanded it. GPs in groups practised together, employing ancillary staff. The MPU asked for financial incentives to encourage the development of better premises and the employment of ancillary staff, and local health authorities’ support for the groups.
[* The Medical Practitioners’ Union was founded in 1914 as a trade union and campaigning organisation. A firm supporter of a free NHS, its central belief has been planned and salaried general practice.]
Group practice and primary health care teams
The Danckwerts settlement provided a first stimulus to practice expansion; there was a slow but steady increase in the number of doctors working in partnerships and in the closer proximity of group practice. Following MacDougall in Hampshire, John Warin in Oxford, a member of the Jameson working party on health visitors, tried several ways of achieving co-operation between health visitors and GPs. Liaison schemes proved largely ineffective. In 1956 he arranged the attachment of health visitors to practices and by the end of 1963 every local practice had its own. GPs did not always have adequate accommodation for the health visitor, who needed a car to cover the wider area. However, the difficulties were overcome, nobody wished to return to the former method of working and several practices had begun their own child welfare and antenatal clinics. In 1963 attachment of district nurses to local practices began. It was an immediate success and in 1964 midwives were involved as well. Almost unnoticed, there had been a major development. In Oxford the evolution of the GP/nursing team was near completion, with the GP the leader of the domiciliary team.168 Other local health authorities also began to ‘attach’ health visitors or home nurse/health visitors to group practices and health centres. The pattern of nursing in the community changed. Previously each nurse or health visitor had served a small geographical area; now her population became that of the GP’s practice.169 The Queen’s Nursing Institute approved the altered orientation of the district nurses, seeing attachment as a watershed in their history.170
As the decade progressed primary health teams increased in number and size. A typical team might be four or five GPs, two health visitors, two district nurses, one midwife, one bath attendant and two relief nurses. The incorporation of nurses was most rapid in rural areas. Here, for geographical reasons, the territory of community nurses and GPs usually coincided. In the cities progress was slower for there was a criss-cross pattern of practices. Although city streets had been allocated to individual nurses, in each there might be 30-40 GPs with a few patients. Nurse management, public health doctors and GPs with a socialist approach to the NHS thought GPs should zone their practices so that their population was local and defined.171 Senior nurses often opposed attachment schemes, preferring to care for a population defined by geography rather than by GP registration, and fearing the loss of control of community nurses who developed loyalties to the GPs and their patients. Senior community nurses controlled attached staff tightly, determining their numbers and what they might do, rarely permitting them to work within the surgery. GPs, more concerned with individual patients than groups, were not prepared to be organised in this way. In many practices doctors gave injections, took blood and applied dressings. Increasingly GPs began to employ nurses. They valued nurse colleagues increasingly and found it easy to agree a mutually acceptable pattern of working.172 The two sides failed to see that some services were best provided on a population basis, and others on a practice one; GPs, with a few exceptions, reacted more to patient demand than to the requirements of a population as a whole.
Group practice and practice organisation went hand in hand. In 1959 Bruce Cardew, Editor of the Medical World and a leader in the MPU, wished to offer GPs guidance on the introduction of appointment systems. A small group was assembled and produced a handbook and film, sponsored by a drug firm, Lloyd-Hamol Ltd. The company provided free appointment diaries to GPs wishing to use them. The uptake was slow at first, but by 1967 at least a third of the practices had introduced appointments for their patients, to the satisfaction of all concerned.173 Waiting rooms became more pleasant and less crowded.
The average duration of a consultation was only five minutes and some doctors began to feel that further advance in general practice would occur only if patients were given more time; where was this time to come from?174 Perhaps home visits, with all the travelling involved, were clinically unproductive. Increasingly, GPs reduced visiting, cutting out routine calls to elderly patients whose condition seldom changed, and to sick children whose parents could bring them to the surgery for an immediate appointment. There was more delegation to ancillary staff to free time for longer consultations. Geoffrey Marsh, a GP in the northeast of England, found that his new practice nurse could successfully relieve the GPs of part of their workload.175
There was rapid growth of deputising services in urban areas where the density of the population made them economic. Doctors without access to a deputising service were generally disparaging, but when a service opened most freed themselves of night work for at least some of the week.176 In 1965 the BMA formed links with a commercial deputising service, providing ethical oversight of its methods of operation and receiving fees in return. Communication systems improved, surgeries installed more phone lines and practices increasingly used radiotelephones.177
The trend to more prescriptions at increased cost continued. In its final report in 1959 the Hinchcliffe Committee found no evidence of widespread and irresponsible extravagance.178 The Committee believed that expensive elegant preparations should give way to simpler preparations of the same drug, and doctors should be convinced of the superiority of a branded product before prescribing it rather than its generic equivalent. It would be a mistake to develop a limited list of drugs but perhaps the quantity prescribed should be kept to a week’s supply, save in chronic cases. The Committee disapproved of prescription charges; they were a tax and like all taxes led people to avoid them when they could, and get as much as they could for their money when they had to pay. The Labour Party had never liked prescription charges although they constrained demand. In February 1965 Labour abolished the charge of two shillings (5p) per prescription. More prescriptions were issued for cheap products that patients had previously bought for themselves, such as pain killers and dressings. The number rose by 19 per cent and the total cost by 22 per cent. The incentive to prescribe large quantities to save the patient’s pocket disappeared, and smaller amounts were prescribed more often.
The gathering storm
Improved premises and more staff, in the wake of Danckwerts, inevitably meant higher costs. GPs were paid from a ‘pool’ of money, a global sum divided among GPs. Nothing was ever more meticulously founded on agreement with the medical profession, both in principle and in detail, than the pool. The GPs’ accredited representatives had accepted every provision, and many had been warmly advocated to the Royal Commission on doctors’ pay or insisted on taking part in negotiations with the Ministry. Practice expenses were reimbursed, but reimbursed unselectively, so that those who spent less than average got back too much and the rest too little. Doctors paying little attention to their facilities were financially better off than those trying to provide a good service.179 There was also a problem about additional work undertaken outside the NHS for government or local health authorities, for example work for the prison medical service. Extra activity reduced the amount paid for general medical services. The Royal Commission and the Review Body had done well by the consultants but failed to recognise the changes taking place in general practice. Merit awards for GPs as well as consultants had been suggested and a working party proposed that a committee consisting largely of GPs, and advised by local assessors, should select GPs and recommend them for merit awards of not less than £500.180 At the GPs’ annual conference in 1962 they rejected the proposal along with the £500,000 allotted to them.181
In 1961 the SMAC established a sub-group to look at the work family doctors were likely to be doing over the next 10-15 years, the organisation of general practice and the support it would require. Chaired by Annis Gillie, the membership included many GPs of experience and distinction. The report, published in 1963, drew attention to educational needs and backed the emerging pattern of groups with attached staff in better premises and more efficient organisation.182 Gillie saw the GP of the future as the co-ordinator of the resources of hospital and community care, mobilising all those that the patient needed. It was a vision that surprised the older doctor, on his own but doing a straight-forward job under difficult conditions, and fuelled increasing anger among the GPs.
By 1963 GPs were frustrated and the annual BMA meeting in Oxford threatened to raise a hurricane over money. The BMA wanted doctors to speak with a single voice but the consultants were unhappy that the Danckwerts award in 1952 had left them out, and the GPs believed the gap between their pay and that of the consultants was still too wide. One of the effects of the NHS had been to divide the service into three parts, and the same tendency had appeared in the profession’s own organisation.183 By 1964 the correspondence columns of the BMJ fairly burst at the seams with protests from disillusioned GPs about the terms of service.184 Few understood the complexities of their pay system, even when advantageous, creating difficulties for their leadership. A General Practitioners Association was formed as a group to prod the BMA into action. The MPU saw its membership rocket. The chairman of the General Medical Services Committee (GMSC) resigned when draft evidence to the Review Body was savaged, and James Cameron, a thoughtful and experienced Scot, to his horror was elected to a job nobody wanted. The BMJ said that there were two problems: payment for the work done and the reform of general practice. There was no unanimity on solutions. Some such as Ivor Jones, a GMSC negotiator, argued for fee-for-service on an American model; a few sought a salaried service and others would have been quite happy to see the NHS disappear.185 At a conference in May, Ivor Jones outlined the problems:186
· Since the NHS had been established the number of consultants had doubled while the number of GPs had increased by only 20 per cent.
· The temporary reduction in medical school intake was affecting the numbers qualifying and the corrective expansion of medical schools would take six or seven years to work its way through.
· Many doctors were elderly and approaching retirement.
· A rise in the numbers of the young and the old was increasing the number of patients for whom the greatest amount of work was necessary.
The Fraser working party
In 1964 Anthony Barber, the Minister, set up a working party, chaired by Sir Bruce Fraser, the Permanent Secretary, which for the first time brought together the Ministry, the BMA and the new College of General Practitioners. It was to recommend changes in the light of the Gillie Report. Local medical committees were asked for their views. Most GPs wished to remain independent contractors, there was little support for either a salaried service or fee-for-service payments to replace capitation, and there was a wish for help with the provision of premises and access to hospital facilities.187 By August 1964 the ground work had been done, and there was an outline agreement to refund directly part of the cost of providing practice premises and employing practice staff. The Ministry also accepted the principle of improvement grants for premises of up to a third of agreed costs.188
In October 1964 a general election was called, Harold Wilson led Labour to a narrow victory and Kenneth Robinson became Minister. Robinson found GPs in a state of ‘absolute turmoil’ with extremely low morale and, compared with hospital consultants, poorly paid. He and the Fraser working party, were overtaken by a near rebellion. 1964 saw the first reduction in the number of GPs and the numbers fell for the next two years. The mood of dissatisfaction was fanned in January 1965 by an unsympathetic report from the Review Body. While admitting that the number of GPs was not rising, the Review Body would not increase GPs’ pay to aid recruitment, for that would produce problems for the hospitals. Nor was it greatly moved by the increase in workload of a more elderly population or GP emigration. The changes recommended would have given GPs on average £250 more, the lion’s share going to reimburse the higher expenses of GPs who had invested in their practices and who had previously been underpaid. It looked very much like a nil-settlement and it detonated the profession who denounced without qualification much they had previously advocated.189 The profession’s leaders said the proposals were an insult and a snub, to the irritation of Kenneth Robinson, who wondered whether the eruption would have been so violent and bitter under a Conservative government. Perhaps, he thought, the crisis was deep-seated and could be traced to the family doctor’s feeling of insecurity about his place in the world of medicine, working in isolation and unsupported.190 Dr James Cameron, the new GMSC Chairman, said that the award must inevitably raise in GPs’ minds whether it was in the best interests of the patients and the profession to continue to offer professional services within the NHS.191 The GMSC demanded talks with the Minister on an entirely new contract of service and called for undated resignations to be sent to BMA House for use if necessary. It received 14,000 within a fortnight.
The GPs’ charter
Aims of the 1965 Charter
· Increasing recruitment, reducing maximum list sizes to 2,000
· Undergraduate education orientated towards practice, and good postgraduate education
· Improved premises and equipment, and an independent corporation to provide funds
· Adequate supporting staff
· Direct reimbursement of staff and premises expenditure
· Incentives for skills and experience
· Pay to reflect workload, skills and responsibility
· Reasonable working hours with time for study and leisure; freedom from unending responsibility to provide services personally
· Proper pay for work done outside the normal working day
· A worthwhile, effective and satisfying career with clinical freedom in a personal family doctor service
James Cameron, a remarkable but modest man, had to lead from the front because of pressure from the militants, some of whom were for abandonment of the Review Body and direct confrontation with the Ministry. In Birmingham two dozen GPs resigned from the NHS and set up an alternative service; others watched as their experiment slowly failed. Cameron knew that direct confrontation would bring down the GP service, and the GPs’ action was already deeply unpopular with the consultants who saw their differential being squeezed.192 He submitted a ‘Charter for the Family Doctor Service’, drawn up by the four negotiators behind closed doors over four days at Hove.193 The far-reaching changes proposed were mainly derived from Hugh Faulkner of the MPU and had been published as a Blueprint for the future - a ten point programme. This programme was astutely adopted by the BMA as its own at the last minute. It sought a reasonable workload with time for leisure and postgraduate study, at a reasonable level of pay, and the money for the space, the equipment and the staff necessary for the work. The Charter aimed for a list of 2,000 patients, a reduction in time-consuming form-filling and a limited working day. Better access to hospital facilities, the ability of practices to choose their method of payment and finance for premises were sought.194
Kenneth Robinson thought it disgraceful to be expected to negotiate under the pressure of resignations when he wanted to improve matters anyway. He believed the key to modernising general practice was the encouragement of groups with good supporting facilities. Flanked by George Godber and a new Permanent Secretary, Sir Arnold France, he went into an intensive period of negotiation, covering everything save the level of remuneration, which was for the Review Body. to decide. The negotiations were lengthy and intense, and invariably Kenneth Robinson led for the Ministry. GPs never gave their leaders full negotiating powers; everything had to be taken away for approval. Ultimately Kenneth Robinson dropped his insistence on a salaried service option, the profession its desire for item-of-service payment, and an atmosphere of trust developed.195 Two joint reports published during 1965 showed that progress was being made. The family doctors held their hand to give negotiations a chance. Better incentives were built into the system. There were proposals for an independent finance corporation to make loans for the purchase, erection and improvement of premises. Much of a GP’s income would continue to be the traditional payments per patient, but this capitation fee would be higher for people over 65 who needed more attention. To encourage the provision of better services there would be direct repayment of 70 per cent of the cost of employing a receptionist or a nurse so that practices providing good facilities were less penalised. There would be direct repayment of the costs of providing premises, a notional rent reflecting their quality. The central pool was modified so that it covered only general medical services.196 A basic practice allowance would be paid, and allowances would be greater for practice in groups, in unattractive areas, after vocational training and for seniority. There would also be a small fee for every immunisation given and cervical smear carried out. There would now be more paper work, because the GP’s income became the sum of many fees and allowances, each a reward for work done or an incentive to improve the practice.
GPs were balloted on the proposals and agreed that they should go to the Review Body for pricing. There were two last-minute crises. Labour had only a small majority, a general election was called and the Review Body report was delayed. Labour was returned, and Kenneth Robinson continued as Minister. The wisdom of the GPs in going to the Review Body was shown when, taking account of the falling number of GPs and the workload, the Review Body changed its tune and to Kenneth Robinson’s surprise suggested a rise of about a third in net remuneration. By then an economic crisis threatened an award of this size and it was rumoured that Kenneth Robinson had threatened to resign if the government reneged on the deal. The recommendation was accepted, albeit phased in over two years.197 Ivor Jones, one of the doctors’ negotiators, developed a plan for an independent medical service as an alternative to the NHS, which was stillborn.198
The Charter turned the tide. In 1967 the number of GPs in England and Wales rose (although only by five), continued to rise and list sizes fell. It was the first time that GPs had publicly resigned from the health service and the last time they could credibly threaten to do so. Neither the profession nor the government appreciated that the new dispensation, and public funding for premises and staff, made GPs so dependent on the NHS that any possibility of quitting en masse and practising outside the NHS had vanished.199 During discussions on the Charter the government returned to the question of extra payments for special experience and service to the NHS. The GMSC looked at the issue; it was certainly true that some doctors had greater abilities and some worked harder than others. There was no career structure in general practice but no agreement about the characteristics of the ‘better’ GP. A GMSC working party suggested ‘advancement awards’ that did not imply professional merit in the quality of care given to patients, but preparation for practice, postgraduate study, practice organisation, teaching research, administrative service or work for the community. It got no thanks for its efforts. GPs were balloted on the principle and turned it down again, by four to one. Some felt that awards would suborn their leaders; GPs were not going to be divided into sheep and goats.200
There was an upsurge of interest in health centres, for the high rentals were now no longer a charge against personal income.201 Fourteen were opened in 1967 bringing the total number to 45 and another 94 were being planned or built.202 In the first decade the NHS had opened only ten; now the number rose to a peak of 100 a year in England in the 1970s.203 Not only were there more centres, they were built for larger populations, often serving 25,000-30,000 or more. An imaginative one was proposed for Thamesmead, a new town within the Greater London Council boundaries, housing 60,000 people on a large area of waste land, with distinctive architecture and a balanced community. The proposals caught the attention of John Butterfield, Professor of Medicine at Guy’s, and with the help of Nuffield a model medical service was planned to link the three parts of the NHS and bring preventive and curative medicine together.204 Doctors were increasingly building their own premises. As they were spending their own money, the designs were carefully sized and seldom luxurious. The way the services were delivered was changing; secretaries and receptionists, nurses, health visitors and midwives were increasingly part of group practice teams and needed space. Trainee GP assistants might be employed. Postgraduate education required library space, and if a practice replaced the medical record envelope (which dated back to Lloyd George) with A4 records the space needed for files trebled. No sooner were new surgeries opened than they were found to be cramped.
George Godber saw his vision of health care as a complex of district hospital and community services, in which centres of general practice were the focal points, coming to pass.205 He thought it right for immediate needs and any foreseeable development in medicine. Partnership of primary health care and specialised medicine was needed and this meant physical regrouping of the GPs, alongside nursing and other professional help, and a close relationship with the DGH and its resources.
The power of the regions
As development money flowed, RHBs became ever more powerful. It was the region that determined the priority of new hospital building. The region was in charge of medical staffing, held most consultants’ contracts and (save for the teaching hospitals) made senior appointments. Consultants seeking to influence events had to have regional influence. For example, in the South East Metropolitan RHB specialist services were dominated by large teaching hospitals, Guy’s and King’s. The senior administrative medical officer (SAMO) decided to raise the standing of the hospitals at Canterbury and Brighton, so that there would be centres of expertise nearer the coast. Money was invested in them. The same process was repeated throughout the country and increasingly every hospital became, to a greater or lesser extent, a ‘teaching hospital’ training postgraduates, family doctors, nurses, auxiliaries and the specialist staff themselves.206 Regions varied in their ethos; those in the south were used to working in close co-operation with the Ministry of Health, which might be to their advantage. Those in the north were more independently minded and received less money. The teaching hospitals managed by boards of governors certainly required higher staffing levels than non-teaching hospitals, but the balance of advantage in both quantity and quality seemed too much in favour of the teaching hospitals as opposed to the others.
As the health service developed, new ‘professions supplementary to medicine’ developed, seeking recognition and status. This meant, as for doctors and nurses before them, registration. In 1959 a Bill was published naming eight bodies to register chiropodists, dieticians, medical laboratory technicians, occupational therapists, physiotherapists, radiographers, remedial gymnasts and speech therapists. Each would maintain a register, approve training courses, supervise training institutions and remove from the register those guilty of misconduct. The medical profession sought dominance on the bodies; they obtained representation but not a majority.207
The district hospital system
The concept of the district general hospital had been accepted on the basis of the Hospital Surveys (1942-1945) and a population of at least 150,000 was required for the basic specialties. Some specialties, for example ophthalmology and ENT, required nearer 500,000. Cancer care and thoracic surgery needed a minimum population of 1 million, for centralisation was necessary. The regions had populations of this size but it was possible that some services would be so esoteric that even a region would not be large enough and a supra-regional service would be required. Providing the equipment was uneconomic and the results of treatment might be poor if doctors did not see enough cases.
Hospital development had so far been piecemeal and the London teaching hospitals were active in pushing their case. Some used their endowment money for preliminary design work, so they were ready to take any opportunity that presented itself. St Thomas’ bought additional land, moved Lambeth Palace Road, paid £250,000 for a block of flats to rehouse displaced tenants, and in 1958 presented plans for a complete rebuild of an eleven-storey patient block fronting the river.208 A few new buildings began to rise. In 1959 the foundation stone was laid at the new Welwyn-Hatfield hospital. The first stage of the new teaching hospital at Cambridge was completed at the beginning of 1961. In the same year a fine and accessible site in Harrow was chosen for a new district hospital to be built in association with a Clinical Research Centre (CRC) required by the Medical Research Council. The CRC would be an integral part of a hospital dealing with current medical problems and be able to keep in touch with day-to-day clinical practice. There would be 185 beds for clinical research, the emphasis being on common conditions.209
Hospital development and design
In 1958 hospital redevelopment was becoming more of a practical proposition. George Godber forecast that it would involve the replacement of multiple, small, bad, old hospitals by large, well planned, modern ones, fewer in number and with fewer beds in total. The mentally ill would probably be accommodated in psychiatric units at general hospitals.210 Tom McKeown, Professor of Social Medicine in Birmingham, examined the use of beds in all types of hospital in Birmingham. He challenged the traditional organisation of hospital services as outmoded. He thought that only in the acute hospitals was the idea of investigation and treatment established. Otherwise people were separated into different hospitals because the infectious had to be isolated, the mentally ill locked up and the chronic sick housed with the destitute. Instead of separate hospitals for each function he proposed a ‘balanced hospital community’ serving patients of all sorts, classified according to the intensity of care they needed, not their age or mental state. Patients might need full hospital facilities with frequent medical attention and nursing (54 per cent in Birmingham); only simple forms of nursing (9 per cent); supervision only because of their mental state (31 per cent); or no hospital facilities at all, being resident essentially for social reasons (6 per cent). In the balanced hospital community he proposed, the same medical and nursing staff would treat all patients. A single site might become something of a hospital-city, providing buildings of a variety of types with a range of commercial and leisure facilities, so that it blended into the town. The setting would be domestic rather than institutional. From the service point of view it would be better because doctors and nurses would be willing to spend some of their time on the chronic and the mentally ill if they could reconcile that with their other interests. Showing students a more representative selection of patients would improve their education. Research would be better because bright doctors would see common, difficult and inadequately studied conditions. The hospital would no longer look like a forbidding block of flats, but a well-planned housing estate or university centre.211 It was an interesting idea, but not one suggesting deep clinical insight.
· More medical activity meant more complex and expensive ancillary rooms
· More demand for privacy meant more single rooms and small bays
· Fewer patients were bed-fast
· Nurses’ journeys were less in short thick buildings
The Nuffield studies were beginning to influence events. The Ministry of Health established a small research unit, and regional boards were studying hospital design.212 Experimental buildings made it possible to test new ideas - medical wards at Larkfield Hospital in Scotland and surgical wards at Musgrave Park Hospital in Belfast. Nuffield’s surveys of the case load in Norwich and Northampton produced surprisingly low estimates of bed requirements, partly because of ever-shorter lengths of stay. They raised at least a doubt about the traditional view of the number of beds a population required. Many patients in hospital could have been treated at home. If GPs were provided with diagnostic facilities, they might send fewer people to the outpatients department. Nuffield criticised the provision made for children. Many were accommodated in adult wards, particularly for operations on the eyes and for tonsillectomy. The Platt Report213 argued for admission only when really required, and for children’s units with specially trained nurses.
Hospitals were living, changing entities. The problem resembled town planning, where traffic routing was necessary so that different zones of a hospital could expand at different rates. In 1958 the Central Consultants and Specialists Committee of the BMA invited two consultants, Lawrence Abel and Walpole Lewin, to report on the increasing inadequacy of hospital buildings. They thought that the hospital building programme, having patiently taken its place in the queue for ten years, should have much higher priority.214 Advances in medicine and surgery were straining already inadequate buildings. A glaring example was the problem of cross-infection in wards and operating theatres. There was now a far clearer idea of what was wanted. Urgent action was needed, not another survey. New towns should have priority. The policy of the DGH was logical, and would often lead to the immediate closure of smaller hospitals and financial savings. Designs should be flexible to accommodate change, and, to expedite building, some standard designs should be accepted. Tailor-made hospitals would only delay rebuilding.
Since 1939 neither architects nor hospital staff had experience of major hospital schemes, and in 1960 a group from the regions toured the USA, helped by the American Hospital Association and the US Public Health Service. Walpole Lewin and JOF Davies, the senior administrative medical officer of the Oxford RHB, reported on the introduction of central sterilisation, centralised and air-conditioned operating theatres, recovery rooms, progressive patient care and intensive care units. Davies argued for centralisation of district services onto a single site. With adequate domiciliary services to support GPs, the avoidance of admission on purely social grounds and early discharge, the number of acute beds might be reduced to 3 per 1,000 population.215
George Godber asked Davies to produce a chapter on hospital design for his first report as CMO in 1960 and Davies echoed Godber’s own thinking. There could be no standard design because sites and needs varied so much. Hospital design should reflect social change, as patients expected a greater degree of privacy. It could not be assumed that medical or nursing practice would remain the same. The trend would be towards fewer hospital centres, large enough to justify consultants in the main clinical and service departments. To the traditional DGH should be added 70-80 beds for short-stay psychiatry, 100 for maternity, 60 for the rehabilitation of elderly patients and provision for infectious disease. Selected hospitals would have radiotherapy and neurosurgery which required provision on a regional basis. Hospitals would be highly specialised diagnostic and treatment centres, with a large outpatient service to handle all who could be treated without admission, which meant that diagnostic departments should be positioned to serve outpatients and inpatients equally. A regional plan for accident services would also be needed.216
Richard Llewelyn Davies who had run the Nuffield Unit (established to consider the architectural designs required for a modern hospital) was now in private architectural practice. Hospitals grew over time as departments expanded. Ordered growth and change had to be allowed for and the site should be planned with this in mind. Expansion had to be possible without cutting off traffic routes or invading space already used for other purposes. Service departments were changing and expanding rapidly and should be separated from ward areas. Llewelyn Davies thought it unlikely that the need for beds would alter radically for a long time ahead. If beds could be used flexibly by any specialty, wards would be the most static part of a hospital. He thought that low buildings were better than high ones, for they were easier to expand, but pointed to experiments with high rise hospitals where all the wards were placed in a tower block over a central stores, kitchen and laundry. In such hospitals nothing was stocked or prepared in ward kitchens; even a glass of milk was sent up when necessary.217 The Ministry began to play an active role in hospital design, drawing substantially on work by the Nuffield Provincial Hospitals Trust.218 It undertook research and development, building departments and whole hospitals to test ideas about planning and design, and issued guidance. An early building note, The district general hospital, emphasised the importance of the interrelationships of departments of a hospital - theatres and wards, service departments and the wards and outpatient department.219 While a nationwide spread of well-trained consultants was steadily raising the standard of clinical care, the hospitals in which they worked did not match their skills. Momentum for greater expenditure on hospital building had been growing since Guillebaud but the costs involved had been so enormous that people recoiled from the idea.220 Now rising sums of money were becoming available for capital development. In their 1959 election manifestos all political parties committed themselves to rapid hospital development, in line with a new vogue for long-term planning. Hospital building was one way of improving the uneven distribution of health services across the country, because revenue went with a new hospital.
The Hospital Plan
Three people were largely responsible for the Hospital Plan. George Godber had long been interested in the organisation of health services. In 1960 Bruce Fraser became Permanent Secretary at the Ministry of Health, replacing a man who had been sick; Fraser recognised that hospital development had been a manifesto commitment.221 In July 1960 Enoch Powell became Minister and proved a godsend; he might not have been philosophically committed to the principle of a national health service, but he made it hum. He was shown the five-year plans of the Oxford and Wessex RHBs and saw that, if all 14 regions had similar plans, they could be brought together and turned into a national scheme that the Treasury might be persuaded to fund. Powell decided the principles that were appropriate for a plan and applied them consistently, systematically and nationally. RHBs were asked to reassess their needs and submit proposals for the next ten years. After negotiation with the Ministry these became the basis of the Hospital Plan published in January 1962.222 This proposed the development of 90 new hospitals from scratch, and the upgrading of 134. The Minister sent a message to his staff.
The Hospital Plan will determine for many years to come the broad lines of development of the hospital service, and indeed of the Health Service as a whole. No other nation has had - or taken - the opportunity to refashion its hospitals so comprehensively and on so large a scale.
The morning after it was published Enoch Powell called his team together and asked for a further document on local health authority plans. However, local authorities were not under the control of the Ministry, as were the RHBs, and there was little information about any plans that they might have. Powell asked them about their community services, for there was no point having a hospital plan that presumed the existence of facilities in the community if they were not going to be there. Powell was under no delusion that community care was a cheap option. Putting people into an institution was cheap; community care was by definition staff-intensive, and therefore expensive care.
The Hospital Plan aimed at a network of DGHs of 600-800 beds, normally serving a population of 100,000-150,000. District by district it outlined phased redevelopment over the next decades. The goal was usually the unification of separate hospitals that worked together as a DGH. The waste of consultant time travelling between different hospitals, the difficulty of providing complete training for nurses, the need to bring geriatric and psychiatric services within the curtilage of the DGH and the improvement in clinical care possible on a single site made this desirable. It was also essential to bring ophthalmology, chest medicine, paediatrics, obstetrics, accident services and the long-stay specialties alongside general medicine and surgery.223 The BMJ welcomed this drastic reorganisation. Powell had seen the task not as one of rebuilding, but of changing the pattern and content of the hospital service. Finance, the journal shrewdly observed, might be the main problem.224 The plan contained only passing references to preventive and community services. It suggested the level of provision of beds per 1,000 population for acute, geriatric, maternity, mental illness and mental subnormality services, bearing in mind the support from local authority and GPs. For acute services 3.3 beds per l000 population was proposed, the national provision then averaging 3.9 beds per 1000. The studies by Nuffield and the Oxford RHB for Reading suggested even fewer, 2 beds per l,000.225 The plan acknowledged the opposing pulls of centralisation and accessibility to patients, but considered that the benefits of grouping outweighed the disadvantages of patients having to travel further. DGHs would provide all ordinary specialties but not those that needed a larger catchment area such as radiotherapy, neurosurgery, plastic surgery and thoracic surgery. Outpatient departments would include theatre facilities and there would be day-wards for those not requiring admission. A maternity unit with full and continuous consultant cover would be a normal part of the DGH and most, but not necessarily all, would have an accident and emergency department. Some forms of care previously provided at separate hospitals would now be brought into the DGH. For example, there should be an active geriatric unit (although some patients might move to separate long-stay annexes), and a unit of 30-60 short-stay beds for people with mental illness. The Hospital Plan saw little future role for the existing mental hospitals; some probably could continue, if reduced in size and improved, but eventually many should be abandoned.
The Hospital Plan was sent to local health authorities with Powell’s questions about their own plans. Local authority services needed to be organised in parallel with the hospitals, and councils were asked to draw up ten-year programmes. Health policies were set out where they had an influence on local authority services. For maternity there were the recommendations of the Cranbrook Committee that there should be hospital beds for 70 per cent of confinements and a ten-day length of stay, already out of date. The Mental Health Act 1959 meant there was a need for training centres, residential accommodation and social centres. Policy for elderly people was to help them remain in their own homes as long as possible. There proved to be little correlation between health and local authority planning although the norms of the Hospital Plan depended upon community support. Because of their autonomy, the Ministry could not impose any commonality upon them. However, the local authorities responded by developing substantial plans to build residential homes for elderly people and homes and hostels for people with physical or mental disabilities or who were mentally ill.
New hospitals cost more and took longer to build than predicted, and regions’ proposals proved wildly optimistic. If a scheme cost more than estimated, it was tailored, or other projects postponed indefinitely.226 In 1966 the plan was revised as the Hospital Programme.227 Running costs also rose, and more staff were needed because services were better and more extensive. However, the bed norms were found to be too high, as better facilities meant more patients could be treated. Sometimes, as with maternity services, an early discharge policy meant that a bed shortage changed rapidly into a bed surplus. As lengths of stay fell progressively, revisions of the plan lowered the norms of provision to 2.0-2.5 per 1000 of the population.
Teaching hospitals and the problems of London
Because the teaching hospitals had a national role in education and research, patients might be specially selected, and those requiring more mundane forms of care were often treated in hospitals run by regions and hospital management committees (HMCs). The case-mix of the teaching hospitals, especially those in London, was therefore atypical. Educationally this was silly, for students most need to see ordinary illnesses and a full range of emergency admissions. Was a ward devoted to the rare diseases of calcium metabolism, as at University College Hospital, appropriate for undergraduate teaching? Teaching hospitals would be short of some types of patients, as for example in the case of midwifery, and the medical schools would rely on RHB hospitals. As the RHB hospitals steadily improved, fewer patients came to the teaching hospitals. The plight of those in London was increased by the fall of the central population that had been taking place since the late nineteenth century, speeded by the post-war housing problem of the London County Council. Some teaching hospitals rethought their position. They tried to develop stronger links with local communities and with good DGHs away from the centre. After much debate the policy of ‘designation’ was agreed. From the mid-1960s some hospitals previously managed by RHBs were transferred to the teaching hospital boards of governors, increasing the beds at their disposal, and placing district responsibilities upon the teaching hospitals.228
In London four RHBs with differing approaches and artificial boundaries operated side by side. The structure of many hospitals required urgent attention and a plethora of small specialist units were developing. London still trained many of the country’s doctors, there was a need to balance service and teaching needs, and to agree which hospitals and regional services such as heart surgery should be redeveloped. Yet the teaching hospital boards of governors were loath to face these problems. In 1964 four regional joint consultative committees were formed, to bring the RHBs and the boards of governors into more amicable discussion with each other, and a pan-London group was formed. Albertine Winner, an ex-deputy chief medical officer from the Ministry, took charge. The group produced a series of reports on the main specialties and broke new ground by examining requirements on a London-wide basis. Albertine Winner was well liked but no confrontationalist. Neither the RHBs nor the teaching hospitals felt bound by the reports, which were not implemented.
The London postgraduate hospitals
In London most special hospitals retained their independence in 12 postgraduate groups. Some were small and isolated, perhaps with as few as 40 beds, as in the case of the urological hospitals, St Peter’s, St Paul’s and St Philip’s (the three Ps). The Ministry believed that the small hospitals were not viable as independent units, and in the view of Keith Murray, the Chairman of the University Grants Committee, neither were their Institutes. Others were of substantial size, such as Great Ormond Street and the Hospital for Nervous Diseases. In June 1961 Enoch Powell proposed to relocate almost all in one of two groups, in Holborn and the Fulham Road. The BMJ approved, for one group would be near the centre of the University of London in Bloomsbury, and the other near Imperial College in South Kensington. Such a grouping in ‘friendly proximity’ might in the fullness of time lead to close links.229 However, the special hospitals had fought like tigers for a century to keep their independence. They were not going to give up without a struggle.
Sir George Pickering, who knew London from his St Mary’s days but was now Regius Professor of Medicine in Oxford, was asked for advice. Pickering was an original thinker yet completely acceptable in academic circles and he chaired a group of experienced clinicians to consider the principles involved in the organisation of the special hospitals and their postgraduate institutes.230 The key question was whether hospitals with world league expertise would maintain pre-eminence if they remained essentially single-specialty. The rewards and penalties of isolation were examined. In favour of the single-specialty hospital was the ability to concentrate on one goal, the ésprit de corps and the concentration of expertise. Against was the risk of intellectual isolation when medicine was advancing on a broad front. Inevitably some forms of specialised equipment and library facilities, possessed by the general medical schools, would be missing. Pickering came down firmly on the side of association, if not with a general medical school, at least with each other. The ideal association of the postgraduate hospitals and their institutes would comprise four or six of them grouped round the periphery of a circle, each maintaining its own identity, but with shared facilities. The Ministry held discussions in 1961 with the University of London and the two-site solution was agreed. In Chelsea a 19-acre site was identified, near the Brompton and the Marsden Hospitals. However, it proved difficult to get a clear site for development, and to decant and relocate units while keeping them working. Finding enough accommodation for the nursing staff was impossible, and the costs were high. The hospitals and their institutes fought a spirited rearguard action against relocation or merger, and there were too many unanswered questions - whether the hospitals really needed to be in central London, what the Royal Commission on Medical Education would say about the separation of postgraduate hospitals from undergraduate education, and whether such a scheme could succeed without a guaranteed and rapid succession of phases.231
Hospital management and Cogwheel
Many features of hospital management, always a fertile field for research, were examined by the Nuffield Provincial Hospitals Trust. Its Secretary, Gordon McLachlan, was in close contact with Sir George Godber and had a sure touch in the identification of key issues. Operational research was applied to outpatient departments, waiting times being a frequent cause of complaint. The BMJ agreed that it might be possible to introduce schemes that were helpful for everyone concerned, but the unexpected was apt to happen. More consultants were needed and it was possible to make too much of the problem; for many the regular visit to the outpatient department was the equivalent of going to a club for a good gossip.232 An emerging problem was the poor communication among the growing number of consultants in any one hospital. In 1948 it was usually possible to accommodate the entire consultant staff in a moderate sized room. The dining room provided a focus and the house governor or hospital secretary was a familiar figure. The doubling of the number of consultants meant that this was no longer the case. There were two or three consultants in most specialties and more specialties than ever before. Consultant services were ceasing to be coherent. Young surgeons would introduce new methods and shorter stays that the older ones might not accept. Clinical departments should have had agreed policies for their resources but did not. Professor Revans described the cult of individualism among medical staff as one of the most obstinate of all hospital problems. Doctors found it hard to talk to each other, let alone with management. The Advisory Committee for Management Efficiency argued that clinicians needed management training. In 1966 Sir George Godber established a working party nominated jointly by the Ministry and the Joint Consultants Committee of the BMA on the organisation of medical work in hospitals. The first of its reports was published in 1967 and was promptly called ‘Cogwheel’, after the cover motif.233 Its aim was to develop the review of clinical work in hospitals, and its outcome. Practising doctors could and should improve their administrative systems without waiting for organisational change. The Report offered a simple, credible and flexible solution that was already in use in some hospitals, the clinical division.
Specialties falling into the same broad medical or surgical categories should be grouped to form Divisions. Each division should carry out constant appraisal of the services it provides, deploy clinical resources as effectively as possible and cope with the problems of management that arise in its clinical field. A small medical executive committee composed of representatives from each division should be established.
Whether or not more money was provided, better management by doctors was necessary if the service was to be fully effective and the doctors were to retain their professional freedom.234 The tenuous links between individual hospitals in the same group and with general practice and local authority services meant inefficiency. GPs and local authority medical staff should be part of the divisional organisation. Clinical divisions should work closely with management, for the two were closely related. In this way the reasons for the substantial variations in clinical practice could be examined, as in the increasing treatment of varicose veins by day surgery and the declining use of tonsillectomy. The BMJ was anxious that clinical divisions did not usurp doctors’ proper clinical freedom, the traditional duty to treat patients in the way they believed to be best.235
Kenneth Robinson, Minister of Health, contrasted the technological developments in medicine, open heart surgery and brain surgery with the parallel managerial revolution in health planning.236 As in industry, it was logical to think in terms of bigger administrative units. A change in structure was coming; the initial one was curiously static and a system allowing evolution was needed. The Guillebaud report had avoided altering the NHS organisational structure, but this freeze had thawed. Partnership with the medical profession was needed even though the relationship of the profession with the state, as provider of resources, could never be entirely smooth. Successive governments tried to reduce the area of possible conflict but still there was lack of mutual confidence. Why? Ministers, like doctors, wished to provide the best possible service the nation could afford. Management must be effective, planners were needed who could make a common cause with the staff, and health economists were needed too. Partnership between doctors and the state was needed, as well as partnership between the hospitals of the future and group practices providing curative and preventive services. GPs and nurses, working in a group, would give a new dimension to the concept of an all-round personal physician. The BMJ said Mr Robinson was more sincere than most of his predecessors but, however well intentioned, he suffered from the layman’s inability to understand the finer professional feelings of the doctors with whom he was dealing. Rather than pondering on the irrational behaviour of a seemingly unappreciative lot of doctors, perhaps the Minster might examine the doctors’ discontents dispassionately: why were they emigrating, why did they not find satisfaction in the NHS, why had the men in Whitehall multiplied, making them the masters of the men in the field?237
Hospital information systems
Better information about activity was required to underpin the expansion of the service. In most countries hospitals had billing systems, accurate information was necessary, and other systems piggy-backed on financial ones. In the NHS there was no patient-related costing system on which to build. Since 1948 the Hospital In-patient Enquiry (HIPE) had provided a 10 per cent sample of inpatient treatment. Now this random sample was extended to 100 per cent coverage in pilot hospitals, and in 1964/5, throughout the Birmingham, Newcastle and Liverpool regions. Hospital activity analysis (HAA), as the 100 per cent system was known, grew out of a wish for patient-based information to help decisions on the use and allocation of hospital resources. HAA provided doctors and administrators at clinical and management levels with details relating to individual patients, including diagnosis and operations, sex, age and marital status of patients, date of admission, discharge and the length of stay. At low cost, it aimed at giving wide benefits to many users. Details of each admission were collected from a standard front-sheet to the notes. RHBs processed the data to provide management and clinical statistics. The scheme was introduced progressively with an emphasis on rapid feedback and accuracy.238 For the first time it was possible, in theory, for consultants to relate the use of resources to the characteristics of their patients, their diagnoses and operations. The feedback was slow and there were anecdotes about men having hysterectomies and women prostate operations.
HAA was based on admissions, not individual patients, and did not link one admission to another. In 1962 the Oxford Record Linkage System (ORLS) tried to make this link. ORLS was funded by the Nuffield Provincial Hospitals Trust and its first director was Donald Acheson, later to become CMO at the Department of Health.239 Births and deaths were linked with basic information about all hospital admissions, a time-consuming process as all data had to be extracted manually. Computer cards were punched and the files periodically scanned. Hospitals were sent lists of patients dying in the year after discharge, many of the deaths being unknown to the clinicians. Cervical cytologists were sent lists of patients subsequently developing cancer of the cervix, to allow feedback. As a laboratory scale demonstration it provided a new way of looking at patients over a period of time. National expansion was not practical.
Better data made it possible to explore the relationships underlying bed usage. Comparison of the regions showed that the more beds there were, the longer the average length of stay; Liverpool had many beds and lengthy stays; Oxford, with few beds, had the shortest lengths of stay and the highest bed usage.240 Efficiency became a watchword. An Advisory Committee on Management Efficiency met regularly and advised the Minister on the use of work-study in the hospital service and on management studies more generally. It looked at costing systems, the presentation and interpretation of hospital statistics and the building programme. In 1965 the RCP held a meeting on computers in medicine. A speaker from Honeywell said that his prescription for computers in medicine was to increase both the size and the frequency of the dose.241 The Ministry established a new computer policy and development branch and by 1966 the hospital service had eight computers.
The Ministry, concerned about the rising cost of the NHS, looked with increasing interest at hospital costs per patient-week and per inpatient stay. Guillebaud had criticised the existing cost returns as inadequate for management purposes and they were improved. When adjustments were made for the changes in salaries and prices the rise in the cost in real terms over the 1950s (1950/1-1958/9) had been minimal, no more than 10 per cent.242 A working party, set up in 1960 to review the system for estimating and allocating revenue, reported that the existing procedures were defective. The initial estimates from the RHBs added up to so much more than the sums likely to be available that each year regions had to revise their figures downwards. It suggested that forward-look estimates for a single year should be replaced by five-year projections, and that a change to unit and departmental budgeting - as opposed to functional budgeting across the entire authority - should be considered. Hospital costs continued to rise but increasing economic prosperity meant that more money could be spent on the NHS. Up to 1963/4, hospital costs adjusted for rises in pay and prices rose about 2 per cent per year; the rate of increase then rose to 2.5 per cent and the growth of the service was more rapid because of improvements in efficiency.243
Once it was appreciated that there would be a shortage of doctors, the University Grants Committee (UGC) faced a dual problem: expanding medical education as rapidly as possible without lowering standards, and adapting it to changes in medicine along the lines proposed by Goodenough. One suggestion, soon abandoned, was the establishment of 24 new schools. Central was the belief that the medical course should give students a university education on broad and liberal lines and the UGC was adamant about the need to maintain quality, which meant schools large enough to justify a wide range of specialties and facilities. The decision was taken to combine modernisation and expansion by rebuilding existing schools to about twice their previous size. The UGC defined the facilities and staffing a medical school would need. Large numbers of new academic staff were appointed and required space for learning, teaching and research. This was easier to accomplish in the provincial schools than in London, where the boards of governors were seldom sympathetic to the demands of their schools.
Doctors tended to settle near their medical school, a high proportion of students went to the London schools and specialists were still unevenly distributed. The Sheffield RHB was in the worst position and there was little point in raising its revenue allocation, for on what could it be spent? The region was already advertising for medical staff and attracting few. The solution had to be an alteration in the places where students trained. That required an agreement between the Ministry and the UGC that new schools were required. The new schools needed new and better clinical facilities, but these were also required for service reasons. The capital building programme was therefore modified. The first wave of expansion began about 1962 with the aim of rebuilding all the provincial teaching hospitals to the new requirements. There remained some fundamental structural problems with medical education. In the early 1960s the UGC proposed that there should be a Royal Commission to address three problems that could not be tackled by the UGC on its own. They included
· The further expansion of medical education.
· The organisation and expansion of postgraduate medical education, for which nobody carried statutory responsibility. A better infrastructure was needed if the university-style education recommended by Goodenough was to come to fruition.
· Problems of medical education in London, then training half the medical students.
John Ellis, of The London Hospital, supported by Janet Vaughan, drafted a proposal that went to the UGC and thence to the government. A general election was close, which meant that it was unlikely that the major parties would oppose the concept of a Royal Commission as a way of dealing with a difficult field. In June 1965, the Prime Minister, Harold Wilson, established one chaired by Lord Todd, Professor of Organic Chemistry at Cambridge and a Nobel prize winner.244 It undertook a fundamental review of the whole structure of medical education, its organisation, content and claims on resources.
Postgraduate education was of increasing importance. In 1960 three consultants from Exeter went to see George Godber at the Ministry and asked him to make a site available for an education centre, rent-free, in the grounds of the new Royal Devon and Exeter Hospital. A week later a group from Stoke-on-Trent went with a similar request. George Godber discussed the idea with Gordon McLachlan at the Nuffield Provincial Hospitals Trust and later with Sir George Pickering. A private conference was arranged at Christ Church Oxford in February 1961, under Pickering’s chairmanship, attended by the presidents of the Royal Colleges, representatives of the CGP, and staff from the RHBs. The conference seemed to catch a tide of interest at the flood. Considerable attention had been paid to undergraduate education; with the advance of medical and scientific knowledge the importance and relevance of postgraduate education throughout the doctor’s career was now acknowledged. Pickering stressed the importance of organising and improving it and the conference agreed that the basic unit should be the district hospital, each with a clinical tutor responsible for teaching arrangements. The necessary facilities included a seminar room, library, a clinical tutor’s room and a lunch room as a focal point where hospital medical staff and GPs could meet.245 There should be a postgraduate dean appointed by the university medical school, and a strong regional committee to oversee the provision.246 A sum of £250,000 was provided by Nuffield to supplement local appeals for centre development and the King’s Fund helped hospitals in the metropolitan regions. Centres by the score developed all over the country.247 Within four years 150 were in existence and the Stoke centre was one of the first, George Pickering laying the foundation stone in 1963.
Doctors’ pay and the Royal Commission
The Royal Commission recommendations (1960)248
The Royal Commission, chaired by Sir Harry Pilkington, took evidence from the Colleges, the Ministry and other organisations. Interested parties watched its work like hawks. The MPU, representing 4,000 GPs, gave evidence; some of its ideas, for example the reduction in the size of a maximum list to 3,000 patients and direct reimbursement of practice expenses, were adopted by the BMA.248 The Commission reported in 1960, and recommended the appointment of a permanent impartial Review Body that would advise the Prime Minister on pay, deliberate in private and deal with major matters only. The Commission saw no reason to raise pay to attract young people into medicine or dissuade doctors from emigrating. However, it believed that doctors’ pay was too low in comparison with other professions, and it recommended an increase of 22 per cent above the 1955/6 level. The Minister of Health agreed to accept the recommendations if the professions would do the same.249 The consultants already had the distinction award system with additional sums distributed by senior members of the profession under conditions of secrecy. The awards varied from £750 for the 1,600 ‘Cs’ to £4,000 for 100 ‘A+’ awards. The Commission suggested that an additional £500,000 should be set aside to recognise distinguished general practice. The Review Body was established in 1962 under the chairmanship of Lord Kindersley. It would determine pay by the analysis of data rather than by a power struggle, preventing pay disputes from disrupting the NHS. It would give doctors and dentists a guarantee that their wages would not be arbitrarily depressed for political reasons, and assure the taxpayer that the professionals were not earning too much. It would hear evidence from the professions and the health ministries and take into account changes in the cost of living, earnings in other professions and recruitment. Its proposals, though not binding on the government, should be rejected only for the most compelling reasons.
Government was virtually a monopoly employer of doctors, educating them largely at national expense and employing them on standard salary scales. There was no reason to train more doctors than required for the NHS, where the employment opportunities were determined primarily by government policies. In 1957 Willink had identified the main determinants of demand - the population size and structure, economic growth, policy decisions on the desirable pattern of health care, and assumptions on recruitment, emigration, retirement and death.250 Complex though the committee’s calculations had been, they did not allow adequately for rapid developments in medical technology, immigration of junior doctors from India and Pakistan or the extent of emigration of younger doctors fuelled by a world-wide demand for well-trained doctors. Willink had suggested a reduction by 10 per cent in medical school entry. A serious shortage was first predicted in 1960, and articles by John Seale, a supporter of private practice and a critic of the NHS, fuelled continuing controversy.251 Seale was bitterly attacked by the Ministry but shortages began to bite.252
Lord Taylor, in the House of Lords, drew attention to the fact that, outside the teaching hospitals, the NHS depended heavily on some 4,000 foreign doctors, mainly from India and Pakistan, who had come for experience and to earn a better living than at home. As they came in, British doctors were leaving for other countries.
I cannot recommend your Lordships to go into such hospitals as a casualty, for there is in many cases no casualty officer. A house-surgeon will have to leave the theatre when he can, to treat you, and his experience will be far less than that of your own general practitioners. When he comes he will probably not be a British graduate and he could well have difficulty in understanding what you say. This is at a time when speed and efficiency may be literally life saving.253
It was, he said, ‘a pretty ghastly, awful picture’. John Seale’s warnings were vindicated. A study by Brian Abel-Smith, commissioned in an attempt to refute Seale, showed that during 1955-1959 an average of 1,664 doctors born and trained in Britain were registered annually in the Medical directory. The estimated annual loss by emigration was about 390, nearly one-quarter.254 They were emigrating partly because those who had left teaching hospitals had little chance of ever becoming a consultant, and often saw general practice as a low status occupation.255 The Ministry sent a team to North America to help doctors who, having emigrated, might wish to return.256 Women were an increasing part of the workforce and by 1966 25 per cent of medical students were female. Surveys showed that about 80 per cent were working, half of them full-time.257 They might take time off for domestic commitments, but at least they tended to stay in the country. In November 1961 the Minister of Health proposed that the annual student intake should be 10 per cent above that suggested by Willink, and in 1963 the Ministry proposed a further increase of 15 per cent. In July 1964 the Minister of Health, Anthony Barber, informed Parliament that the first new school since 1893 would be at Nottingham and that finance would be available in 1967 for a school at Southampton. The annual intake of medical students was raised from about 1,800 to 2,450 between 1960 and 1967.258
The Platt Report (1961)258
· Reorganisation of the consultant service
· Increase the number of consultant posts
· Restrict the number of senior registrar posts in line with expected consultant vacancies
· A medical assistant career staff-grade
· Rotational training for senior registrars
Although there was now some control of the number of senior registrars, this was not the case for the more junior registrar grade. This was often used to solve staffing problems, and training might be seen as incidental to practical experience. The registrar grade was allowed to grow, often filled by doctors from developing countries seeking postgraduate experience. The specialties into which doctors crowded were not the ones where there was the greatest need, the ‘service specialties’ such as anaesthesia and pathology, and new sub-specialties required an increasing number of consultants, a message to be repeated regularly for the succeeding 35 years. To try to get the numbers right a working party on hospital medical staffing, chaired by Sir Robert Platt, was established by the Ministry and the profession in 1958. It was asked to advise on the principles by which hospital staffing should be organised. One of its first actions was to undertake the first detailed census of junior doctors at registrar level and below. Of the 8,272, no fewer than 3,408 had been born outside Great Britain, mainly occupying posts in the surgical specialties and the northern regions.259 The imbalance of junior and senior posts meant that only a minority of registrars could expect to achieve consultant rank. Two deficiencies were rapidly identified. In spite of the imbalance of juniors and seniors, from the service viewpoint there was a shortage of doctors below the level of consultant, particularly outside the teaching hospitals. There was a lesser shortage of consultants themselves. Platt recommended an increase in the number of consultants and restriction of the number of juniors; the government accepted these broad principles. More consultant posts were created year by year but never enough. The Ministry wanted 400 but seldom achieved more than 250. There was a perception that some consultants wanted assistants, not colleagues who might compete for private patients. Junior doctors began to appreciate that they could not rely on their seniors to negotiate for them and to talk about an independent body to represent their interests to the Ministry. The BMA wanted to maintain professional unity but there was a divergence of interests.
Nurse education and staffing
Hospital nursing staff* (England and Wales)
*Excludes hospital midwives
Although their numbers both in hospital and in the community had increased by roughly a third in the first ten years of the NHS, there were never enough nurses. The limiting factor was the ability to recruit staff rather than money. Nursing had to compete with other occupations and depended on the supply of young unmarried students and a smaller number of unmarried qualified staff who continued to work until retirement. If the nurses were rushed, it was hard to give good care and to supervise the clinical training of students.260 Advances in treatment increased the demand. Crowded wards with ‘extra beds’, poor rewards and widely reported problems in hospitals did little to encourage recruitment. There was a student wastage of 30-50 per cent, 10,000 a year failing to complete their training. Up to 30 per cent, said one matron, had to be accepted. The Editor of the Nursing Mirror, in 1958, recalled 20 reports on nursing problems in the previous 25 years. Job analysis, questionnaires, pilot studies and conferences had all taken place. Statisticians, management consultants, eminent doctors and administrators had given advice. Still the same problems remained, unpredictable off-duty, excessive hours, lectures given in off-duty time, outworn discipline, bad conditions, excessive responsibility on night-duty, insufficient care of the student’s health, haphazard practical training, ward sisters untrained in human relations and too-early entry through cadet schemes.261 Students looked forward to leaving the preliminary training school and starting work on the wards, for practical work was regarded as ‘real’ nursing. Yet young nurses were expected to take on responsibilities that, even with support, they were often incapable of handling. They got ‘second-year blues’ and gave up. A study in Oxford showed that a third of the students had qualifications that would have gained a place at a teacher’s training college, and 5 per cent could have been considered for a university. More than half of the entrants wanted to work in a hospital abroad, in the services, on a ship or as an air hostess.262
Believing that complete reappraisal of nursing education was required, in 1961 the Royal College of Nurses (RCN) established a committee, chaired by Sir Harry Platt, which reported in 1964. A reform of nursing education recommended two different courses for registered nurses and enrolled nurses. The student nurse must be a student in fact and the service she gave must be governed by her educational needs. An educational entry standard was essential (five ‘O’ levels). There would be two years’ academic study and controlled clinical experience, after which she would sit the final examination. A third year would be spent under supervision in hospital. University degrees for nurses should be established. Enrolled nurses, the second grade, would follow a less elaborate apprenticeship training, and ward assistants would support the nursing team.263 Writing in the Lancet, a Coventry consultant said that modern nursing and medicine required an understanding of the reasons for what was done, and if nurses were to be good observers they must know what to look for. Medicine and nursing were allies, each with responsibilities. The Nursing Times agreed; doctors should be allies not just in teaching but also in the selection of recruits and the organisation of the school of nursing.264 In 1962 a minimum educational standard was reintroduced for state registration.265 To improve the quality of training the GNC proposed that all nurse training schools should have access to a hospital or group of hospitals of at least 300 beds, and that the training course should include experience in general medicine and surgery, gynaecology, paediatrics, theatre work, ENT, ophthalmology and skin cases. This was implemented in 1964 and led to a reduction of about 100 in the 660 general nurse training schools. It became clear that a radical review of nurse training was required, to fulfil the demands of hospital and community services that were working increasingly closely. Basic training should prepare nurses for work in hospital, health centre, general practice attachment or other forms of community care. Post-basic training for specialised clinical care and management required development, and it would be necessary to use the facilities of the national educational system.266
Graduate nurses and research departments, though common in the USA, were virtually non-existent in the UK. Nurses with degrees had generally obtained them in unrelated subjects, before changing their career path to enter nursing. Some British nurses, with support from doctors, began to see university qualifications as a precondition of the improvement of the status of nursing. Charles Newman, Dean of the Postgraduate Medical School at Hammersmith, saw three reasons in favour: first, the more kinds of nursing education the better; second, the feminist argument that other professions pursued by women, such as architecture, science and medicine, were university based; and, third, the prestige and status helped to stimulate individuals to do their best. If nursing were university based, there would be more nursing research and the discipline would be more appropriate to current circumstances. Nurses, however, would have to set the matter in motion themselves, and not wait for others.267 There were counter arguments. Girdwood, an Edinburgh physician, doubted whether it was wise to have three types of nurses, those with degrees, those who were registered, and the enrolled nurses. Nothing should be done to make the trained nurses feel in any way second-class. Hospital doctors did not want ‘another colleague with whom to discuss the niceties of acid-base balance’; ward sisters were already well informed. Most girls wanting to be nurses wanted to be just that - not bachelors of science; most girls who wanted to be bachelors of science did not want to be nurses. There was certainly a place for a few university trained nurses, but only a few; the standard of a university degree must remain very high and the need for such a training in nursing was limited.268
To meet the demand for more leisure and shorter hours, the recommendation of the Nurses and Midwives Whitley Council that the hours of work should be reduced from 96 hours a fortnight to 84 was slowly implemented from 1958 onwards. At first the teaching hospitals were immune from the shortage of nurses, but not for long. The London matrons had a dining club; discussion started only after the aperitif and the dinner, and in the relaxed atmosphere they confided in each other. Each thought that only they had recruitment difficulties. All of them did. Something needed to be done, but recruiting trips round the schools showed that headmistresses now actively discouraged brighter girls from a career in nursing. The London Hospital built a new education department and better nurses’ accommodation, established a degree course in association with London University, and began training enrolled nurses. Like everyone else, nurses married earlier. The local health authority nursing services had long employed married nurses, many of whom preferred the hours and the flexibility of work in the community. The increasing number of young married nurses in hospital also demanded latitude in the hours worked. Increasingly, matrons and public health nursing officers found that they could not manage without married nurses, whether they wanted to or not. Attracting older nurses back into the service became important. Better use had to be made of existing resources. Nurses’ time should be spent on nursing; assistant nurses should be used increasingly and the growing number of part-time nurses should be encouraged.269 ‘Straight’ rather than ‘split’ shifts made it possible to bring married nurses back into the profession, although refresher courses might be needed. A drastic elimination of non-nursing duties began. Time was saved by central sterilisation systems, by centralising patients needing close supervision in intensive care units and by the introduction of progressive patient care. Five-day wards staffed mainly by part-time nurses were introduced, and a nursing cadet scheme was increasingly used.270 Midwifery was also short-staffed. One way to attract and retain staff, particularly in fields that were under strength, was the post-registration course, for example in ophthalmology. Increasingly, certificates were offered, each involving service in a hospital that had recruitment problems.
There was dissatisfaction with pay. The RCN represented most trained nurses and students. But two other unions, NUPE and COHSE, represented the enrolled nurses, nurses working in mental illness and mental handicap, and domestic staff. From 1960 to 1961 they were active in seeking higher pay and sometimes shorter hours. In July 1961 the Chancellor announced a pay pause, and while existing agreements were honoured during the pause, the implementation of new agreements would be postponed. In 1962 the nurses and ancillary workers mounted an all-night demonstration in support of pay claims. Planned as part of the opposition to government pay policy, it was followed by a debate in Parliament. The Minister, Enoch Powell, said there were more nurses than ever before. The opposition led by Kenneth Robinson said there were not enough and they were paid pitifully. The government was teaching the lesson that ‘power tells’ and imposing the pay pause on small people who could not fight back without injuring patients.271
Nurses struggled to solve nursing problems, while all the time medical advances and wider opportunities for women were overtaking them. Doctors never really considered what their clinical advances did to nursing. Shorter lengths of stay, less restriction to bed, active geriatric policies, and the increasing use of one-day-stay beds all had repercussions on the nursing services.272 The result, in the absence of unified and effective nursing leadership, was to turn the profession into a treadmill. Little thought was given to the intrinsic differences between the professions. Medicine, technology and the pharmaceutical industry had an in-built research ethos, with continual forward movement. If nursing was also to attempt to become research based, what would be the research focus? Much of the work of nursing, other than simple care and support, was dependent on medicine and technology, for these led change. From the moment it became possible to resuscitate a patient with cardiac arrest, having two nurses always on the ward was essential. Should the nurse tend mechanical devices or give traditional nursing care and stand back while technicians looked after the machines? ‘Progressive patient care’ was suggested as a way of using the limited number of nurses most efficiently.273 Patients needing constant nursing attention, and those who were ambulant and physically self-sufficient, were removed from the ordinary ward to be nursed in ‘intensive care’ and ‘self-care’ units. Some ways of running a ward, such as job allocation, centred control on the ward sister and made the use of lower grade staff easier. Others, for example team nursing, increased delegation and encouraged individual ‘patient-centred’ care.
Patient welfare was given greater attention with later waking times, greater privacy, better catering and more frequent visiting, particularly for children. Muriel Powell, Matron of St George’s, imaginative and described as ‘a new look matron’, chaired the Standing Nursing Advisory Committee (SNAC) and made her aim the improvement of the patient’s lot. Her committee challenged the early waking of patients, to which the Nuffield Report had drawn attention, and the perpetual noise from staff, hospital procedures and hospital equipment that had been the topic of an investigation by the King’s Fund in 1958. Two reports were issued in 1961, The pattern of the in-patient’s day and Control of noise in hospitals.274 The Standing Maternity Committee also issued a report in 1961 on Human relationships in obstetrics, about the need to improve the help, companionship and explanation available in labour.
From the start of the NHS there had been concern about the training of nurses for senior roles. The King’s Fund began courses for ward sisters in 1949 and later for matrons. Nurse tutor courses and diplomas in nursing were sometimes used as a preparation for nursing management. Yet, despite fundamental changes in medicine, the administration of nursing had barely changed. Florence Nightingale, said the BMJ, would probably notice little difference between nursing administration in her day and ours.275 Her contemporary, the great physician Henry Bence Jones, would not be so at home in the administrative maze surrounding the modern teaching hospital. In 1959 the RCN set up a working party to examine the position. In 1964, following the principles of the Bradbeer Report (1954), the RCN recommended radical change, establishing a framework for nursing resembling that for lay hospital management. There should be a group nursing officer with a sphere of control like that of the group hospital secretary. At hospital level a hospital nursing officer should match the hospital secretary, and there should be a ‘clinical nursing officer’ to serve specialised units, freeing the ward sister from administrative chores and giving her cover.
The Salmon Report
The Ministry of Health was persuaded, in part by senior nurses, that nursing administration particularly in the HMCs had problems. Matrons found contact with group secretaries, who were working at a more senior level, hard to achieve and unproductive. Nurse administration was said to be in a state of chaos (which it was) and to know little about management. The top of the nursing hierarchy was concerned about its status and there was an apparent shortage of staff above the level of ward sister. Matrons in large hospitals resented being lumped together with matrons at cottage hospitals, and hoped for a pay rise. There was no definition of the management and administrative functions of senior nurses from ward sister to matron, nor a recognised way of selecting or training senior nursing staff. In spite of the Bradbeer Report, which had suggested that a triumvirate of administration, medicine and nursing should manage hospitals, nursing occupied a secondary position behind medical and lay administration and was not represented effectively when policy was discussed.276 The Ministry did not have a clear idea about what was needed. In 1961 Enoch Powell announced his intention to set up an enquiry into senior nursing staff structure. Tricky negotiations over nurses’ pay delayed its establishment until July 1963 when Brian Salmon, Director of J Lyons and Vice-chairman of the Westminster Hospital board of governors, was appointed as Chairman. The Committee consisted in the main of nurses, although it included a regional administrator and a senior physician.277 Clinical matters and pay were excluded from the terms of reference.
The 1966 report proposed an entirely new pattern of nursing administration and a new grading structure.278 Nursing would match administration neatly all the way down. The decisions needed for policy formation, the programming of policies, and their execution at ward level were seen as three essentially different types. The concept of top, middle and first-line management was introduced. There would now be six grades of nurse manager, two at each level of the organisation. Based on the theory of line management, the report provided outline job descriptions to grade a wide range of nursing posts. Historically catering, cleaning, linen and laundry, and staff homes were usually placed in the matron’s sphere; the trend had been to relieve her of these responsibilities, rightly in the view of the Committee. While those who wished to practice a particular nursing specialty could do so, the promotion path to the highest levels of nursing administration would be open to all. Management training for nurses would be introduced and there would be uniform selection and staff reporting systems.
The Minister accepted the recommendations in general and by 1967 pilot trials were in progress. Salmon had provided many grades in the hope that organisations would mix and match, using only what they needed. The staff side took a different view. Every grade would provide a well-paid post. The path to promotion and high salaries was open. Even senior nurses sometimes saw an over-heavy structure as a symbol of status and created unnecessary posts. The results were painful in many ways. Matrons disappeared and unit officers took on management positions without formal training. Many had to reapply for their own renamed positions and sometimes found themselves rejected after years of doing their duties apparently to everyone’s satisfaction.279
There was growing concern about the nature, control and financing of the NHS. The early debates concentrated mainly on whether socialised medicine was better or worse than private enterprise medicine.280 NHS advocates drew attention to the inequities of the American pattern while detractors pointed to the obvious deficiencies of the NHS and the emigration of British doctors to apparently greener fields. The BMA fired early shots when it established the Porritt Review.
The Porritt Report
Sir Arthur Porritt, President of the Royal College of Surgeons and of the BMA, and later Governor General of New Zealand, was an archetypal surgeon of the old school. In 1957/8, when the BMA’s Committee of Inquiry into the NHS was established, he took the chair. He began as a sceptic, but came out convinced that the NHS had to continue and be improved. Appearing in November 1962, the Report gave two cheers for the NHS, finding the concept sound even though not all the benefits promised had materialised.281 A monopoly and state-managed service sometimes used for electioneering purposes was to be deplored, but an independent corporation had no practical advantages. Nevertheless, private practice should be encouraged to safeguard the public from the risk that government might in future lay down uniform standards and encroach on professional freedom. The tripartite services should be brought together under a single area board, with boundaries determined by the health needs of the community, on which the profession was adequately represented and whose chief officer was a doctor. The development of general practice should be supported and the size of list should be limited. Comprehensive area general hospitals were desirable and should be the basis of long-term as well as acute care. Individual specialties, recruitment and medical staffing received detailed attention.
Believing that running district hospitals would become ever more complex, the Institute of Hospital Administrators and the King’s Fund made radical proposals in a report published in 1967 on The shape of hospital management? To safeguard public interest and public accountability a hospital board was required, but there should be a clear chain of command with a general manager supported by medical and nursing directors, a director of finance and statistical services, and a director of general services. The work of committees would be reduced to the essential minimum.282
In June 1965 a deputation to Ministers from the Joint Consultants Committee said that, in the light of 17 years’ experience, the structure of the NHS should be re-examined. Kenneth Robinson told Parliament that it was a misconception that the royal road to co-ordination was by way of spectacular changes in administrative structure. Willing co-operation between individuals was the key, although he did not wish to exclude for all time the possibility of introducing a more unified type of administration.283 In July 1966 the BMA Council called for a Royal Commission to advise on the finance and staffing of the NHS.284 Twelve days later a pay freeze set in and discontents sharpened and rose to the surface. The BMA thought the NHS under-capitalised, over-worked and dependent on overseas doctors. It saw three options: to find more money, to ration free medical care or to let the service run down. Ministers did not consider major change feasible. In 1966 Enoch Powell wrote about the problems frankly in his classic book on politics and the health service. Articles in the medical press and a radio debate followed, between Powell and Professor Henry Miller of Newcastle.285
Powell saw that the combination of an unlimited demand and a supply which, though free, was inevitably limited was difficult to reconcile. Rationing through waiting lists was one way but rationing by the profession was more likely to be right than that by a non-professional. A health service free from parliamentary control was a non-runner. Ministers, if they could find a way of avoiding public accountability, would go for it like a shot. But while a corporation that raised money by sales could be largely free of parliamentary control, because the money for the NHS came from the tax-payer it could not. Faced with an inadequate service a corporation could say ‘we would love to provide you with a new hospital here, there and everywhere, but it’s the Chancellor of the Exchequer who gives us only this sum’. The thing landed back with the political authority. Powell said the phrase ‘adequate money’ was meaningless. Immediately any new advance was made in medicine, a new frontier of need was opened up. Unmet needs were discovered. Doctors, thinking how glorious it was in the NHS that patients did not have to pay them because somebody else did, had walked into a trap. That ‘somebody else’ had a limited purse to treat customers with no limitation on their demands. Worse, Powell believed that the NHS had delayed and prevented a vast amount of hospital building that would have taken place immediately after the war, when local authorities were raring to go. The same applied to the number of doctors and the pay of staff. A government decision on total expenditure ended with a pretty specific decision about expenditure on staff. The state had assigned priority to housing and education, not health care. Nationalisation had prevented people from showing what they wanted - more expenditure on health. If the profession wanted freedom and an ethos nearer to its own, some other source of finance than the state would have to be found.
This prescription was not now to the liking of the doctors. The medical profession that had fought about the pattern of the NHS, rather than its principles, was stung by Powell’s pessimism. There could be no going back on the NHS. How should it be moulded to meet the needs for care of an affluent and technocratic western society, to allow the full harvest of medicine’s great scientific advances? In March 1967 a conference was held in Newcastle. Delegates thought that there was no doubt that the service, getting only 4 per cent of the gross national product, was starved of money. Bring the share up to 6 per cent and many of its troubles would be over. And why not integrate the teaching hospitals, the regional board hospitals and the other two branches of the NHS?286 An advisory panel of the BMA, with Dr Ivor Jones in the chair, was established to produce a report on health service financing. The Institute of Economic Affairs considered that private health insurance might usefully supplement taxation, fees and charges in financing health care and would become increasingly popular. If people were prepared to pay more for better food, clothing, cars and holidays, it should be possible to encourage them to pay more for better health care. The administrative costs might be higher, but there were a number of alternative schemes, including the introduction of health care vouchers for hospital cover.287
However, George Godber could see that substantial progress had been made during the decade.288 The hospital development programme was under way, although because money was short much of the improvement had come from extending existing hospitals, rather than the replacement really needed. The GPs’ charter was encouraging GPs to group and rehouse themselves. Less capital investment was needed but the speed of progress depended on the independently minded GPs. The greatest achievement was probably the development of professional postgraduate education, a necessary complement to the changes in professional organisation.
In November 1967 Kenneth Robinson changed his opinion and said that a full and careful examination of the administrative structure of the medical and related services was needed, not just for the present but looking 10-12 years ahead. Other changes were in the offing, to the social services a result of the Seebohm Commission, and to local government as a result of the Royal Commission. Kenneth Robinson made it clear that such a review would relate solely to the administrative pattern. He was not considering the possibility of an alternative type of NHS, perhaps through private sector financing, as was sometimes urged. He would put forward his tentative proposals in the form of a Green Paper. The NHS was 20 years old; the question now to be asked was whether the existing structure was adequate to meet future needs.289 Many had a touching belief that altering an administrative framework, which had nothing to do with care either in the community or in the hospitals, would solve the problem that Powell had outlined of expanding demands, free access and restricted spending.
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106. Saunders C. A personal therapeutic journey. BMJ 1996; 313: 1599-601.
107. St Christopher’s Hospice. BMJ 1967; 3: 169-70.
108. Ministry of Health. Report of the Maternity Services Committee. (Chairman: Lord Cranbrook.) London: HMSO, 1959.
109. Ministry of Health, Central Health Services Council. Human relations in obstetrics. London: HMSO, 1961.
110. Gordon I, Elias-Jones TF. The place of confinement: home or hospital? BMJ 1960; 1: 52-3.
Early discharge of maternity patients [leading article]. BMJ 1967; 3: 508-9.
111. Place of delivery [leading article]. BMJ 1966; 1: 493-4.
112. DHSS. On the state of the public health. Report of the CMO for 1968. London: HMSO, 1969.
113. Maternal mortality [leading article]. BMJ 1960; 2: 123-5.
114. Williams AS. Women and childbirth. The history of the National Birthday Trust Fund 1928-1993. Gloucester: Sutton, 1997.
115. Perinatal Mortality Survey. BMJ 1962; 2: 1187; and correspondence: 1253-5.
116. Butler N, Bonham DG, editors. Perinatal Mortality. The first report of the 1958 British perinatal mortality survey. Edinburgh: E & S Livingstone, 1963.
117. Butler N, Alberman ED, editors. Perinatal Problems. The second report of the 1958 British perinatal mortality survey. Edinburgh: E & S Livingstone, 1969.
118. Williams AS. Women and childbirth. The history of the National Birthday Trust Fund 1928-1993. Gloucester: Sutton, 1997.
119. Dalton K. Menstruation and crime. BMJ 1961; 2: 1752-3.
120. Legalized abortion: report by the Council of the Royal College of Obstetricians and Gynaecologists. BMJ 1966; 1: 850-4.
Therapeutic abortion: report by BMA Special Committee; and Summary of memorandum by RMPA. BMJ 1966; 2: 40-4.
121. Jeffcoate TNA. Indications for therapeutic abortion. BMJ 1960; 1: 581-8.
BMA Committee on therapeutic abortion. Indications for termination of pregnancy. BMJ 1968, 1: 171-5.
122. New abortion Bill. BMJ 1966; 2: 247.
Majority of 194 in Abortion Bill vote [parliamentary notes]. BMJ 1966; 2: 311-12.
123. CHSC. The welfare of children in hospital. Report of a committee of the CHSC. (Chairman: Sir Harry Platt.) London: HMSO, 1959.
Children in hospital [leading article]. BMJ 1959; 1: 425-6.
124. Gunson HH, Dodsworth H. Fifty years of blood transfusion. Transfusion Medicine 1996; 6, suppl. 1: 1-88.
125. Castree BJ, Walker JH. The young adult with spina bifida. BMJ 1981; 283: 1040-2.
126. Children of short stature [leading article]. BMJ 1967; 3: 187-8.
127. Williamson J, Stokoe IH, Gray S et al. Old people at home. Their unreported needs. Lancet 1964; 1: 1117-20.
128. Kay DWK, Roth M, Hall MRP. Special problems of the aged and the organisation of hospital services. BMJ 1966; 2: 967-72.
129. Human warehouses [leading article]. BMJ 1961; 2: 100.
130. Martin JP. Hospitals in trouble. Oxford: Basil Blackwell, 1984.
131. Sargant W. Drugs in the treatment of depression. BMJ 1961; 1: 225-7.
Sargant W. Psychiatric treatment in general teaching hospitals: a plea for a mechanistic approach. BMJ 1966; 2: 257-62.
132. Psychiatry in general hospitals [leading article]. Lancet 1963; 2: 1149.
133. Ministry of Health. Report for the year 1959. Cmnd 1086. London: HMSO, 1960.
134. Barton R. Institutional neurosis. Bristol: John Wright, 1959.
135. Silverman M. A comprehensive department of psychological medicine - a 12 months review. BMJ 1961; 2: 698-701.
Smith S. Psychiatry in general hospitals. Manchester’s integrated scheme. Lancet 1961; 1: 1158-9.
136. Barton R. The psychiatric hospital. In: Freeman H, Farndale J, editors. Trends in the mental health services. Oxford: Pergamon Press, 1963.
137. Cawley RH, McKeown T. Services for the mentally-ill in a balanced hospital community. In: Freeman H, Farndale J, editors. Trends in the mental health services. Oxford: Pergamon Press, 1963.
138. Tooth GC, Brooke EM. Trends in mental hospital population and their effect on future planning. Lancet 1961; 1: 710-13.
Ministry of Health. Report for 1960. Cmnd 1418. London: HMSO, 1961.
139. Freeman H. In conversation with Enoch Powell. Psychiatric Bulletin 1988; 12: 402-6.
140. Everybody’s business. Report of the annual conference of the National Association for Mental Health. Lancet 1961; 1: 608-9.
141. Ministry of Health. On the state of the public health. Report of the CMO for 1959. London: HMSO, 1960.
142. Brooke EM. A census of patients in psychiatric beds, 1963. Ministry of Health Reports on Public Health and Medical Subjects no. 116. London: HMSO, 1967.
143. Hill Sir Denis. Psychiatry in medicine. London. Nuffield Provincial Hospitals Trust, 1969, 103-5.
144. Jones K. The role and function of the mental hospital. In: Freeman H, Farndale J, editors. Trends in mental health services. Oxford: Pergamon Press, 1963.
145. Shepherd M. Primary care of patients with mental disorder in the community. BMJ 1989 299: 666-9.
146. Future of the mental hospital [leading article]. BMJ 1962; 2: 904-5.
147. Psychiatry in general hospitals [leading article]. Lancet 1963; 2: 1149.
Does the community care? [leading article] BMJ 1966; 2: 655-6.
Future of mental hospitals [leading article]. BMJ 1967; 2: 781-2.
148. Ministry of Health. On the state of the public health. Report of the CMO for 1962. London: HMSO, 1963.
149. Smith S. Psychiatry in general hospitals. Lancet 1961; 1: 1158-9.
150. Marinker M. Changing patterns in general practice education. In: Teeling Smith G, editor. Health, education and general practice. London: Office of Health Economics, 1965.
151. Balint M. The doctor, his patient and the illness. London: Tavistock, 1957.
Balint M. The other part of medicine. Lancet 1961; 1: 41-3.
152. Cartwright A. Patients and their doctors. London: Routledge & Kegan Paul, 1967.
153. Fry J. General practice tomorrow. BMJ 1964; 2: 1064-7.
154. Fry J. Why patients go to hospital. BMJ 1959; 2: 1323-7.
155. Professor Michael Shepherd [obituary]. The Times 1995: Sep 13.
156. The British National Health Service. Conversations with Sir George Godber. JE Fogarty International Center. Washington DC: US Department of Health, Education and Welfare, 1976.
157. Lord Moran. Evidence to the Royal Commission on Doctors’ and Dentists’ Remuneration. BMJ 1958; 1, suppl: 27-30.
158. Moran C. The ‘Ladder’. Lancet 1959; 1: 216.
159. Horder JP. Training for general practice. Journal of the College of General Practitioners 1964; 7: 303-4.
160. Whitfield MJ. Training for general practice: result of a survey. BMJ 1966; 1: 663-7.
161. Horder JP, Swift G. The history of vocational training for general practice. Journal of the Royal College of General Practitioners 1979; 29: 24-32.
162. Vocational training for general practice [leading article]. BMJ 1966; 2: 251-2.
Swift G. The Wessex scheme. Conference on vocational training for GPs. BMJ 1968; 2: 759.
163. College of General Practitioners. Reports from general practice, no. 5. Evidence to the Royal Commission on medical education. London: CGP, 1966.
164. Good general practice [leading article]. BMJ 1967; 3: 754.
165. Marinker M. Should general practice be represented in the university medical school? BMJ 1983; 286: 855-9.
166. Fry J, Dillane JB, Lester A. Towards better general practice. BMJ 1962; 2: 1311-15.
167. Medical Practitioners’ Union. Health centre report. London: MPU, 1960.
Health centres or medical centres [leading article]. Lancet 1961; 1: 149-50.
168. Warin JF. Evolution of a health team. BMJ 1965; 1: 525.
Warin JF. GPs and nursing staff: a complete attachment scheme in retrospect and prospect. BMJ 1968; 2: 41-5.
169. Fry J, Dillane JB, Connolly MM. The evolution of a health team: a successful general practitioner health visitor association. BMJ 1965; 1: 181.
170. Baly ME. A history of the Queen’s Nursing Institute. London: Croom Helm, 1987.
171. Wolfinden RC. Health centres and the general medical practitioner. BMJ 1967; 2: 565-7.
172. Hasler J. The primary health care team. London: RSM Press, 1994.
173. Cardew B. An appointment system service for general practitioners. BMJ 1967; 4: 542-3.
Appointment systems in general practice [leading article]. BMJ 1967; 4: 500-1.
174. Reedy BIEC. Changing face of general practice. BMJ 1967; 1: 54.
175. Marsh GN Group practice nurse: an analysis and comment on six months’ work. BMJ 1967; 1: 489-91.
176. Dopson L. The changing scene in general practice. London: Johnson, 1971.
177. Rivett GC. Use of radio communication in general practice, BMJ 1965; 2: 530-1.
Rivett GC Miniature radiotelephones in general practice. Practitioner 1966; 196: 838-42.
178. Ministry of Health. Final report of the committee on cost of prescribing. (Chairman: Sir Henry Hinchcliffe.) London: HMSO, 1959.
179. Fraser B. The doctor and the administrator. BMJ 1968; 2: 553-4.
180. Ministry of Health. Report for 1962. Cmnd 2062. London: HMSO, 1963, 47.
181. Merit awards for GPs [leading article]. BMJ 1962; 1: 1125-6.
General practitioners in conference [leading article]. BMJ 1962; 1: 1675-6.
182. Standing Medical Advisory Committee. Subcommittee report on the field of work of the family doctor. (Chairman: Annis Gillie.) London: HMSO, 1963.
General practice in the future [leading article]. BMJ 1963; 2: 817-18.
183. Present state of medicine. Diagnosis and treatment [leading article]. BMJ 1963; 2: 453-6.
184. Discontent with the pool [leading article]. BMJ 1963; 2: 1143-4.
The basis of unity [leading article]. BMJ 1964; 1: 253-4.
185. Crisis in general practice [leading article]. BMJ 1964; 1: 851-2.
Timmins N. The five giants. London: HarperCollins, 1995.
186. Conference on general practice. Planning for the future. BMJ 1964; 1: 1502-4.
187. General practitioners in the NHS [leading article]. BMJ 1965; 1: 264-5.
188. Encouraging general practice [leading article]. BMJ 1964; 2: 463.
Practice expenses: Minister’s proposals. BMJ 1964; 2, suppl: 121.
Ministry of Health. Annual report for 1964. Cmnd 2688. London: HMSO, 1965.
189. Fraser B. The doctor and the administrator. BMJ 1968; 2: 553-4.
Fifth report of the Review Body on the remuneration of general medical practitioners. Cmnd 2585. London: HMSO, 1965.
190. The current turmoil [parliamentary notes]. BMJ 1965; 1: 957-6.
191. The Review Body’s award [leading article]. BMJ 1965; 1: 397.
192. Macpherson G. Reviving the fortunes of general practice: James Cameron and Kenneth Robinson. BMJ 150th anniversary issue, 1982; Jul 5: A26-9.
193. Step by step [leading article]. BMJ 1965; 2: 1.
194. Charter for general practice [leading article]. BMJ 1965; 1: 669.
Towards a better family doctor service [leading article]. BMJ 1965; 1: 875.
195. Discussions must continue [leading article]. BMJ 1965; 2: 181.
196. Towards a new contract [leading article]. BMJ 1965; 2: 889.
The majority say yes [leading article]. BMJ 1965; 2: 1075.
197. A fresh start [leading article]. BMJ 1966; 1: 1183-5.
Government’s decision on Report [leading article]. BMJ 1966; 1: 1225.
198. Independent Medical Services [leading article]. BMJ 1966; 2: 4.
199. Timmins N. The five giants. London: HarperCollins, 1995.
200. Merit awards in general practice [letter] BMJ 1967; 1: 175.
Special experience and service [leading article]. BMJ 1967; 1: 318-19.
Merit awards ballot. BMJ 1967; 2, suppl: 25.
201. The British National Health Service. Conversations with Sir George Godber. JE Fogarty International Center. Washington DC: US Department of Health, Education and Welfare, 1976.
202. Ministry of Health. Annual report for the year 1967. Cmnd 3702. London: HMSO, 1968.
Health centre explosion. BMJ 1967; 4: 759-60.
203. Godber GE. Medical officers of health and health services. Community Medicine 1986; no 1: 12.
204. Higgins PM. Thamesmead: dream to reality. BMJ 1982; 285: 1264-6.
Thamesmead: the first phase of community health service. BMJ 1967; 4: 676-8.
205. Ministry of Health. On the state of the public health. Report of the CMO for 1965. London: HMSO, 1965.
Ministry of Health. On the state of the public health. Report of the CMO for 1967. London: HMSO, 1968
206. Smith RE. Teaching in a non-teaching hospital. Lancet 1958; 1: 311-13.
207. Registering medical auxiliaries [leading article]. BMJ 1959; 2: 1164-5.
208. The new St Thomas’. BMJ 1958; 1: 115; and BMJ 1966; 2: 356.
209. Hospital and research centre [annotation]. Lancet 1961; 1: 600.
DHSS. On the state of the public health. Annual report of the CMO for 1969. London: HMSO, 1970.
210. Godber GE. Health services past, present and future. Lancet 1958; 2: 1-6.
211. McKeown T. The concept of a balanced hospital community. Lancet 1958; 1: 701-4.
212. Central Health Services Council. The welfare of children in hospital. Report of a committee of the CHSC. (Chairman: Sir Harry Platt.) London: HMSO, 1959.
213. Farrer-Brown L. Hospitals for today and tomorrow. BMJ 1959; 1, suppl: 118-22.
214. Abel AL, Lewin W. Report on hospital building. BMJ 1959; 1, suppl: 108-14.
215. Davies JOF. A visit to the USA. BMJ 1960; 1: 1879-84.
Davies JOF, Lewin W. Observations on hospital planning. BMJ 1960; 2: 763-8.
216. Ministry of Health. On the state of the public health. Report of the CMO for 1960. Cmnd 1550. London: HMSO, 1961.
217. Llewelyn Davies R. Architectural problems of new hospitals. BMJ 1960; 2: 768-72.
218. Ministry of Health. Report for the year 1960. Cmnd 1418. London: HMSO, 1961, 23.
Nuffield Provincial Hospitals Trust. Studies in the function and design of hospitals. London: Oxford University Press, 1955.
219. Ministry of Health. The district general hospital. Building Note no. 3. London: HMSO, 1961.
220. The British National Health Service. Conversations with Sir George Godber. JE Fogarty International Center. Washington DC: US Department of Health, Education and Welfare. 1976, 18.
221. Allen D. Hospital planning. London: Pitman Medical, 1979.
222. National Health Service. A hospital plan for England and Wales. Cmnd 1604. London: HMSO, 1962.
223. Ministry of Health. On the state of the public health. Report of the CMO for 1962. London: HMSO, 1963.
224. Ten-year hospital plan [leading article]. BMJ 1962; 1: 238-9.
225. Barr A. The population served by a hospital group. Lancet 1957; 2: 1105-8.
226. Smith J. Hospital building in the NHS. BMJ 1984; 289: 1298-300.
227. Parliament. The National Health Service. Hospital building programme. Cmnd 3000. London: HMSO, 1966.
228. Teaching hospitals and the community [leading article]. Lancet 1971; 1: 584-5.
Rivett GC The development of the London hospital system, 1823-1982. London: King’s Fund, 1986.
229. Postgraduate centres for London [leading article]. BMJ 1961; 2: 40.
230. Ministry of Health. Postgraduate medical education and the specialties. (Chairman: Sir George Pickering.) Reports on Public Health and Medical Subjects no. 106. London: HMSO, 1962.
231. Chelsea Postgraduate Medical Centre. BMJ 1966; 1: 1289-91.
232. Waiting for doctor [leading article]. BMJ 1958; 2: 901-2.
233. Ministry of Health. First report of the joint working party on the organisation of medical work in hospitals. London: HMSO, 1967.
234. DHSS. On the state of the public health. Report of the CMO for 1970. London: HMSO, 1971.
235. Modernizing hospital medicine [leading article]. BMJ 1967; 4: 252-3.
236. Robinson K. Partnership in medical care. Maurice Bloch lecture. Glasgow: Jackson, 1968.
237. Partnership in medical care [leading article]. BMJ 1967; 4: 634-5.
Medical partnership: Minister’s lecture at Glasgow. BMJ 1967; 4: 675-6.
238. Ministry of Health. Report for 1967. Cmnd 3702. London: HMSO, 1968.
Rowe RG, Brewer W. Hospital activity analysis. London: Butterworths, 1972.
239. Acheson ED. Medical record linkage. Oxford: Oxford University Press, 1967.
Record linkage. BMJ 1968; 3: 116-17.
240. Ministry of Health. Report for the year 1960. Cmnd 1418. London: HMSO, 1961.
241. Computers in medicine. BMJ 1965; 2: 1427-8.
242. Ministry of Health. Report for the year 1959. Cmnd 1086. London: HMSO, 1960.
243. Ministry of Health. Report for the year 1967. Cmnd 3702. London: HMSO, 1968.
244. Commission on education [leading article]. BMJ 1965; 2: 57-8.
245. Nuffield Provincial Hospitals Trust: conference on postgraduate medical education. BMJ 1962; 1: 466-7.
246. Pickering Sir George. Postgraduate medical education. BMJ 1962; 1: 421-5.
247. Lister J. Reflections on building a postgraduate medical centre. BMJ 1966; 1: 228-30.
248. Royal Commission. Evidence from Medical Practitioners’ Union [leading article]. BMJ 1958; 1, suppl: 30-2.
249. Ministry of Health. Report for 1960. Cmnd 1418. London: HMSO, 1961.
250. Klein R. The tale of two committees or the perils of prediction. BMJ 1976; 1: 25-6.
251. Seale J. Supply of doctors. BMJ 1961; 2: 1554-5.
Seale J. The health service in an affluent society. BMJ 1962; 2: 598-602.
Seale J. Medical emigration from Great Britain and Ireland. BMJ 1964; 1: 1173.
252. Hospitals year book 1965. London: IHSA, 1965.
253. ‘A pretty ghastly, awful picture’ [leading article]. BMJ 1961; 2: 1548-9.
254. Emigration of doctors. BMJ 1964; 2: 50-1.
Campbell AGM. Dangerous trends in medical care. BMJ 1965; 1: 507.
255. Pappworth MH. Emigration of British doctors [letter]. BMJ 1962; 1: 1075.
256. Emigration of British doctors to the United States of America and Canada. BMJ 1968; 1: 45-8.
Return to Britain? [leading article] BMJ 1968; 1: 1-2.
257. Lawrie J, Newhouse M, Elliott P. Working capacity of women doctors. BMJ 1966; 1: 409-12.
258. Ministry of Health. Report for 1967. Cmnd 3702. London: HMSO, 1968.
259. Ministry of Health. Medical staffing structure in the hospital service. Report of the Joint Working Party. (Chairman: Sir Robert Platt.) London: HMSO, 1961.
Ministry of Health. On the state of the public health. Report of the CMO for 1960. London: HMSO, 1961.
260. Time for nursing [leading article]. Nursing Times 1958; Sep 26: 1111.
261. The overtaxed nurse. Conference organised by the Association of Hospital Matrons. Nursing Times 1958; Feb 7: 159-160.
262. From student to nurse [leading article]. BMJ 1961; 2: 1008-9.
263. RCN/National Council of Nurses. A reform of nursing education. (Chairman: Sir Harry Platt.) London: RCN, 1964.
Nursing in the future [leading article]. BMJ 1964; 1: 1585-6.
264. Smith RE. Teaching in non teaching hospitals. Lancet 1958; 1: 311-13.
265. Ministry of Health. On the state of the public health. Report of the CMO for 1960. London: HMSO, 1961.
266. Ministry of Health. On the state of the public health. Report of the CMO for 1967. London: HMSO, 1968.
267. Newman C. University education for nurses. Nursing Times 1958; Aug 25: 1002-3.
268. Girdwood RH. Some problems of nursing today. BMJ 1966; 1: 1411-13.
269. Davies JOH. Observations on hospital planning. BMJ 1960; 2: 767.
270. Ministry of Health. On the state of the public health. Report of the CMO for 1961. London: HMSO, 1962.
271. NHS Staffing in the context of a strained economy [parliamentary notes]. BMJ 1962; 1: 1018-20.
272. Ministry of Health. On the state of the public health. Report of the CMO for 1967. London: HMSO, 1968.
273. Raven RW. Progressive patient care. BMJ 1962; 1: 43-4.
274. Standing Nursing Advisory Committee. The pattern of the in-patient’s day. London: HMSO, 1961.
Standing Nursing Advisory Committee. Control of noise in hospitals. London: HMSO, 1961.
Standing Maternity and Midwifery Advisory Committee. Human relationships in obstetrics. London: HMSO, 1961.
275. Nursing administration [leading article]. BMJ 1964; 2: 892-3.
276. Ministry of Health and Scottish Home and Health Department. Report of the committee on senior nursing staff structure. (Chairman: Brian Salmon.) London: HMSO, 1966.
277. Hospitals year book 1965. London: IHSA, 1965.
278. Ministry of Health and Scottish Home and Health Department. Report of the committee on senior nursing staff structure. (Chairman: Brian Salmon.) London: HMSO, 1966.
279. Hector W. Nursing in the UK. In: Walton J, Barondess JA, Lock S, editors. The Oxford medical companion. Oxford: Oxford University Press, 1994.
280. Teeling Smith G, editor. The evolution of the NHS debate. In: A new NHS act for 1996? London: Office for Health Economics, 1984.
281. Report of the Medical Services Review Committee. Summary of conclusions and recommendations. BMJ 1962; 2: 1178-86.
282. Institute of Hospital Administrators and the King’s Fund. The shape of hospital management in 1980? London: King’s Fund, 1967.
283. Integration of health services [parliamentary notes]. BMJ 1966; 2: 477.
284. Royal Commission. BMJ 1966; 2, suppl: 75-6.
New look at the NHS [leading article]. BMJ 1967; 1: 6.
285. Powell JE. A new look at medicine and politics. London: Pitman Medical, 1966.
A new look at medicine and politics. BMJ 1966; 2: 1315-19.
Powell E, Miller H. Medicine and politics. BMJ 1967; 1: 555-9.
286. The North looks ahead [leading article]. BMJ 1967; 1: 647-8.
Future of British medicine. BMJ 1967; 1: 693-4.
287. Seldon A. Prospects for private health insurance. BMJ 1967; 3: 166-8.
288. DHSS. On the state of the public health. Report of the CMO for 1969. London: HMSO, 1970
289. Minister to review structure of NHS [parliamentary notes]. BMJ 1967; 4: 367.