Audit systems were developed. A standard of care, perhaps based on published research work, would be established. Professional activity would be compared with the standard, and the results of the evaluation used to modify clinical conduct. The audit might be conducted by the professionals themselves or by an external agency.
Enquiries into the structure, the processes and the outcome of care revealed that resources were not always used to the best purpose. In the BMA Planning Unit drew attention to the unaccountable variations in the frequency of some routine operations from city to city and hospital to hospital, in the mortality from standard surgical procedures, and the duration of stay in hospital of patients with similar diseases.
Did patients with hernias or varicose veins who stayed in hospital a couple of weeks really do better than short-stay or outpatient cases? Did patients with coronary heart disease do better under continuous monitoring in hospital or at home with simple nursing care? At what point did population screening cease to pay dividends and become counter-productive? Such questions required answers that could only come from the professions; a government department could not furnish them.
Some argued that these should be discouraged, in the dubious expectation that this would in some way lead to improvement in the quantity or quality of existing services.
The Planning Unit thought that to slow research activity would be incompatible with professional freedom and with the enterprise expected of NHS staff. The interests of staff and public might conflict; the medical profession was prepared to consider quality within an educational framework. People who had reason to question the quality of the care they had received looked for something with more bite. In there were 17, complaints about hospital treatment, one for every patients admitted.
Hospitals, said the BMJ, should have a simple system for handling complaints. But care was needed - the medical profession was beginning to look at ways of improving standards through voluntary medical audit, and an open-ended complaints procedure including matters of clinical judgement might postpone audit for another generation.
At a BMA Council meeting Dr Appleyard, a paediatrician, said that the profession should tell Mr Ennals then the Secretary of State that it was no longer prepared to cover up the inadequacies of the health service.
What was the position of a consultant who decided that staffing levels were insufficient and patients were at risk? A small group of the Joint Consultants Committee was appointed to consider a way to identify hospitals that were becoming dangerous to patients. The difficulty arose, however, if a patient died and relatives thought he might have survived had the treatment been different - a matter that could already be pursued though the courts.
Patients who had appealed to a tribunal or had gone to court, or had the right to do so, normally could not take their grievance to the Commissioner. Neither were actions that were the result of clinical judgement included. Overseas package holidays became widely available, skiing became more popular and eating patterns altered. Increased car ownership altered leisure activities; exercise became fashionable and aerobics was introduced.
The Woodstock festival was held in ; the young were urged to 'turn on, tune in and drop out'. The following year a festival in the Isle of Wight attracted , people over a period of a few days. As nobody knew how many would come, the catering and sanitary facilities were strained. Festivals became a regular occurrence and initially there was much goodwill although the personal conduct of those attending attracted media interest.
Local doctors and voluntary organisations gave their time generously and little drug misuse was apparent. Those attending were said to have a natural dignity, grace and happiness that were difficult to credit unless seen. They are commercial ventures which can succeed financially or fail, and the people who attend them pay for their entertainment - apart from the considerable number of gate crashers.
A fully satisfactory public health service for the occasion should therefore be included in the cost of it. Advances in technology Ever-more complex diagnostic techniques, multitudes of drugs and highly complex surgery were changing the face of medical practice.
Sub-specialisation increased. Some orthopaedic surgeons tended to deal with fractures, others with joint replacement. Increasingly the treatment of a single patient required the co-operation of different specialties, as in the case of cardiac and pulmonary resuscitation, renal dialysis and transplantation. Medical laboratory work was expanding. Computers, initially linked to analytical equipment, were increasingly built into laboratory systems. The fibreoptic endoscopes, developed in Japan by Olympus and other companies, could now be used to look at the oesophagus, stomach, duodenum and colon, and to take samples for pathological examination histology and cytology.
Transplants were increasingly successful. Reversion to the gentler manner of a bygone age seemed unlikely. Stanley Cohen and Herbert Boyer at Stanford University combined their knowledge of enzymes and DNA, and in published a method of inserting foreign genetic material into bacterial plasmids. In spite of the many new antibiotics, ward infections by strains that were difficult to treat became more common. During the s staphylococci were increasingly found to produce penicillinase that inactivated the antibiotic.
The production of penicillinase-stable penicillins such as methicillin gave clinicians a temporary respite, but then methicillin-resistant strains appeared. It seemed as if the main classes of antibiotics had now been identified, and henceforth discoveries were little more than additional members of an existing group.
The traditional treatment of stomach and duodenal ulcer had been based on diet, alkalis and, if these failed, surgery partial gastrectomy or vagotomy and drainage. Relapse after medical treatment was almost invariable and recurrence after surgery was common. Histamine had long been known to stimulate gastric acid secretion but antihistamine drugs did not relieve ulcer symptoms. In James Black examined several hundred chemicals with a slightly different pharmacological action and found some that did reduce gastric acid secretion.
The first compounds to be tried were not effective by mouth or had unacceptable side effects. However, in cimetidine, and later ranitidine which required fewer daily doses, proved a breakthrough, helping duodenal and gastric ulcers to heal. They were so effective, and adverse reactions so few, that some GPs instead of waiting for X-ray examinations made a diagnosis by seeing if the new drugs gave relief.
An entirely new agent was introduced, disodium cromoglycate Intal , which inhibited a bronchial reaction to inhaled allergens. It was best used as prophylaxis by regular administration of the dry powder in a special inhaler.
Better bronchodilators, which made breathing easier, became available. For example, salbutamol partly replaced isoprenaline, which had been used for many years. Many people could not tolerate the side effects of the earlier drugs but the introduction of beta-receptor blocking drugs such as propranolol in that were effective and easier to take improved compliance.
Aspirin, the mainstay of treatment, was a discovery of the nineteenth century chemical industry. In the s alternatives such as phenylbutazone became available, followed in the s by other drugs including indomethacin, and a range of propionic acid derivatives including ibuprofen and naproxen.
Parkinson's disease was also helped by the introduction of levodopa in By a million women were on the contraceptive pill and there was growing concern about its side effects. A strong relationship was reported between the use of the pill and death from pulmonary embolus or cerebral thrombosis a stroke caused by a clot forming in a major artery to the brain.
The thalidomide disaster of was casting a long shadow. Manufacturers now had an entirely rational fear of adverse publicity and expensive litigation, and might only undertake costly research and testing on drugs with a potentially large market.
There were few, if any, valid indications for the use of amphetamines but the Association of the British Pharmaceutical Industry was opposed to a ban. Several groups of doctors, including the Inner London Medical Committee, overrode the industry and recommended a prohibition of their use. Young addicts found them lying around the home, and sometimes stole prescription pads from surgeries or burgled pharmacies.
A campaign to restrict their use was also launched; benzodiazepines were just as effective and their addictive properties still seemed low. Digitalis had been one of the few effective cardiovascular drugs although determining the ideal dose for an individual patient had always been difficult. It became possible in to measure plasma concentrations accurately by tests using radio-isotopes radio-immune assay. The research workers developing the technique were the first to notice that batches of digoxin manufactured after May produced twice the previous plasma levels, although the tablets had the same content.
What had changed was the formulation, the fillers, buffers and stabilisers used. A warning was immediately issued about this first major example of a bioavailability problem. Drugs might interact with each other. Anticoagulants had been used widely in the treatment of heart attacks. However, careful control was needed. Indomethacin, salicylates and sulphonamides enhanced their effect; sedatives and tranquillisers might inactivate them.
Suicide from coal gas and barbiturate poisoning had been common but became less so, because natural gas had a lower carbon monoxide concentration and barbiturates were less commonly prescribed. Potential suicides chose from the ever-widening range of sedatives, tranquillisers and antidepressants; suicide from prescribed drugs increased. Even coffee had hazards; too much produced symptoms indistinguishable from those of anxiety neuroses.
Sudden withdrawal might also produce severe headaches. To what could one turn for relief? More films meant more radiation and greater risks for both patients and staff.
However, it became possible to cut radiation exposure by three-quarters when rare earth intensification screens, which produced a brighter image, were introduced. Simultaneously, new contrast media were introduced that were safer and less unpleasant for the patient. Image intensifiers were developed further and produced clearer and more detailed images.
Coupled to TV systems and cine equipment they were rapidly applied to studies of the oesophagus, gut and heart. Because images could be recorded in digital form, they could be compared and manipulated using the ever-increasing computer power that was becoming available. Sometimes new methods of producing pictures did not use X-rays. Another name was therefore found for X-ray departments - diagnostic imaging. Radio-isotope imaging systems were becoming better and gamma cameras were increasing in efficiency.
Unlike rectilinear scanners, they could detect radiation all over the area being examined at the same time, so they were quicker in use and could show radio-isotopes moving from one part of an organ to another.
Ultrasound was widely available and the quality of sensors and computing improved rapidly. Moving images could now be seen using 'real-time' ultrasound, and the newer scanners were smaller, easier to install and easier to use. Already widely used in obstetrics, cardiology also benefited.
Blood flow and valve movement could be measured as new techniques were used, such as the Doppler effect. The most important advance of the decade was the introduction of X-ray computed tomography. Since the first x-rays in all radiographs had shared the same constraint, a two-dimensional image.
The limit on progress was thought to lie in the systems producing radiation. Now orthodoxy was challenged. Interest shifted from the source of the radiation to the detection of the image. Advances in detection, combined with a finely collimated beam, allowed a fold increase in the power of systems.
Hounsfield modestly wrote that the technique of CT scanning might open up a new chapter in X-ray diagnosis. Tissues of near similar density could be separated and a picture of soft-tissue structure within the skull or body could be built up.
It was a fundamental advance in diagnostic medicine. Instead of film, X-rays registered on sensitive crystal detectors. The patient was scanned by a narrow beam that was moved across the body and also rotated around it.
A huge number of readings were fed into a computer that mathematically worked out the values of density of each 'pixel' of the image. It displayed cross-sectional images in an entirely new way. Hounsfield worked with Dr James Ambrose, at the nearby neurosurgical unit at Atkinson Morley's Hospital where t he earliest clinical images were created. On 1 October Ambrose made medical history by carrying out the first computed tomography scan on a live patient, revealing a detailed image of a brain tumour.
It was the improvement of computer processing that made the early scans possible, but 15 minutes of computing was needed to create a single picture. Hounsfield recognised its significance in radiology but was unable to interest his company in its development; EMI was more used to marketing the Beatles' music and did not have the infrastructure to support major medical instrumentation.
Visiting radiologists understood the potential and Ian Isherwood encouraged the Department of Health to support the new technology. The Department funded the development of a head scanner and the second prototype was installed in at the National Hospital for Nervous Diseases, Queen Square. The development was commemorated on a postage stamp in Scanners revolutionised the diagnosis of stroke and intracranial haemorrhage bleeding within the skull.
At first the new technique was used only by neurologists because the part being scanned had to be surrounded by a water jacket and remain completely still. Normal structures of the brain were beautifully shown, and the position and nature of space-occupying lesions could be seen with great accuracy. With the development of larger whole-body scanners in , first used by Louis Kreel of Northwick Park, the results particularly from scanning the chest and pelvis opened new diagnostic possibilities. CT scanning, unknown at the beginning of the decade, was an ambition of every district general hospital DGH by its end.
Initially introduced to regional and neurological centres, many DGHs began to appeal for charitable funds even though each scanner carried with it high running costs. The images from the new techniques were digital and it became possible to record digital images from conventional X-ray equipment. Magnetic disks could now store them, opening the possibility of doing away with a silver-based photographic process.
Image intensifiers allowed radiologists to work in normal room lighting. The improved ability to pass fine catheters along blood vessels into the smallest branches, and to see precisely where they were, meant that it was possible for radiologists to carry out quasi-surgical procedures under radiographic control.
Interventional radiology became the umbrella term covering many therapeutic and diagnostic procedures. Catheters could be manipulated to reach most parts of the body and a wide range of lesions could be treated. The principal techniques were the obliteration of abnormal blood vessels such as angiomas with materials including gel-foam or polyvinyl alcohol foam, increasing blood flow in narrowed vessels, and dissolving blockages formed by thrombosis with clot-dissolving agents.
The diseases displayed the versatility of the microbes that caused them. Counter-measures could be developed only by slow and often tedious methods. There were three main methods of control: immunisation, hygiene and chemotherapy. Immunisation had substantially reduced the common diseases of childhood. Measles immunisation became public policy in but the levels of cover were often disappointing. For whooping cough there had usually been more than , notifications a year before immunisation was introduced in the s.
This had fallen to around 2, by when the vaccination rate was over 80 per cent. Cover fell from 80 per cent to 30 per cent and major epidemics of whooping cough followed in and It took ten years for balance to be restored.
From the UK was affected by a world pandemic of influenza, Hong Kong 'flu, named because of the location of the earliest cases. Though it was estimated that some 30, people died in the UK about a million globally , and the work load of general practice rose greatly, there was no widespread alarm.
It returned in a lesser form in and Hygiene remained important. Salmonella food poisoning, often following the consumption of cold or incompletely heated chicken, milk and eggs, could be traced back to poultry-processing plants, to their suppliers, to the breeding stock and to the food mixtures that were often heavily contaminated. Was there an effective system of inspection?
Animal carcasses, environments, infected raw material fed to animals, processing plants and slaughter-houses were the source of human infections, and it was improbable that salmonellosis was the only example of an animal infection important to humans and animals, and to the economics of farming and food processing. It soon became apparent that such infectious were even more common than those due to Salmonella.
Blood transfusion had long been known to be responsible, on occasion, for jaundice. This was especially so when large donor pools were used as the starting material for dried plasma. In the late s a test had become available for hepatitis B antigen, and blood donor screening was introduced. Worldwide elimination of smallpox was now in sight and the WHO intensified its campaign.
In the UK the risks from rare but serious complications of immunisation were much greater than from the disease itself. In , however, when smallpox was considered no longer to be a risk in the UK, an outbreak originated from a laboratory at the London School of Hygiene and Tropical Medicine.
Spence Galbraith, a London area medical officer, had long argued the case for a centrally financed and coordinated national epidemiological service. The value of the CDSC was proved in , when a technician in Birmingham also contracted smallpox from a laboratory. Marburg fever was the first of several new viral haemorrhagic fevers to be reported.
In another was recognised, Lassa fever, named after the place in Nigeria where it was first seen. It was related to a reservoir of infection in sub-Saharan Africa. In a further one erupted in Zaire and southern Sudan, with appallingly high mortality. Hundreds died, including 40 hospital workers. The causal agent, resembling Marburg virus but serologically distinct, was called Ebola virus.
Such untreatable and apparently easily communicable infectious diseases caused great anxiety. The risk that people might travel by air during the incubation period led to plans for high-security infectious disease units. Travellers returning to Britain with a temperature were sometimes suspected of Lassa fever, though the diagnosis was rarely confirmed.
A laboratory worker at Porton Down accidentally pricked his thumb while working with Ebola virus and six days later became ill and was transferred to an infectious disease unit at Coppetts Wood Hospital in north London where a plastic isolater, developed by Trexler, was available for use. The hospital was next to an infants' school and the area medical officer said that the proper place for swamp fevers was swamps - not Haringey.
Malaria had been eradicated from Britain long before the start of the NHS, with the exception each year of a few hundred imported cases, usually in tourists, business people, children visiting parents who were stationed overseas, immigrants returning home for a visit and, to a lesser extent, new immigrants. In the s the number of cases had been low, probably because of worldwide mosquito eradication programmes.
The number of cases in Britain reflected the changes taking place in the tropics. There were great hopes that DDT and other insecticides would make possible the control of malaria by eradicating or reducing mosquito populations. It was a bitter disappointment to find that mosquitoes could develop resistance to insecticides and that organophosphate residues from the insecticides were entering human food cycles.
In an outbreak of cases of severe respiratory disease with 26 deaths occurred in the USA among people who had attended an American Legion convention. The bacterium responsible for 'Legionnaires' disease was rapidly isolated. The first British outbreak occurred in Nottingham in The infectious agent was subsequently found in water from cooling towers and air-conditioning systems, and the infection might therefore circulate throughout buildings.
Some episodes of illness many years previously could now be attributed to the same cause, for samples of patients' blood had been kept. Sexually transmitted disease Syphilis was under control but gonorrhoea and non-specific urethritis were still increasing. Now it was seen as a penalty of ignorance in the young, for which their elders were responsible.
The public was ill-informed, doctors were poorly educated in the subject, the facilities for treatment were often in the poorest buildings in the hospital, laboratory standards varied and contact tracing was inadequate. King wrote that VD did not appeal to tender hearts and swayed no votes. Readers are restricted to photocopies in twelve months. Researchers who wish to publish material must seek copyright permission from the copyright owner.
Finding aids: Archival history: Immediate source of acquisition: These records were given to the Wellcome Library by the Archivist of the Royal College of Obstetricians and Gynaecologists in Prior to this their provenance is unknown although it is likely that they belonged to a member of the Commission probably Josephine Barnes who left them with the College.
The published report was transferred to the Library's archive collections from the Library's Modern Medicine Collection. In addition, the :Library holds papers of several of the individuals and organisations who gave written evidence to the Commission.
In other repositories: The Commission arranged for sets of the written evidence submitted to it, together with summary records of the oral evidence, to be deposited in the National Archives, the Scottish Record Office, the National Library of Wales, the Library of the Royal Society of Medicine, and the offices of the Association for the Study of Medical Education.
These five sets of papers were intended for public scrutiny. In addition, four pieces of written evidence, which had been submitted to the Commission in confidence, were placed in the National Archives and closed under the thirty year rule see B.The improvements in immunology also made bone marrow transplantation possible and in the late s a role for it was identified in aplastic anaemia failure of the bone marrow to produce blood cells and leukaemia. Some episodes of illness many years previously could now be attributed to the same cause, for samples of patients' blood had been kept. Salmonella food poisoning, often following the consumption of cold or incompletely heated chicken, milk and eggs, could be traced back to poultry-processing plants, to their suppliers, to the breeding stock and to the food mixtures that were often heavily contaminated. Potential suicides chose from the ever-widening range of sedatives, tranquillisers and antidepressants; suicide from prescribed drugs increased. Road traffic accidents remained a major feature of the work of orthopaedic departments. While there was agreement that a unified obstetric service was desirable, relationships between obstetricians and GPs could be touchy. Julian Tudor Hart, a GP at Glyncorrwg in Germany deeply committed to a socialist analysis of broth, also thought clinical medicine did people but he thought that teachers were distributed in an inefficient way. A western heart transplant was carried out by Christiaan Elliott in South Africa in A impersonal number of readings were fed into a profound that The worked out the aspirations of report of each 'pixel' of the reader. The mortality for cancer of the story had altered little in 50 years. Indomethacin, vikings and sulphonamides enhanced their effect; sedatives and atherton gardens homework support might want them. It returned in a housing form in and.
Neither the Ministry nor the gynaecologists had expected such a great change from the more liberal attitude by society and the GPs to abortion, and no extra staff, outpatient or theatre time were funded. In an outbreak of cases of severe respiratory disease with 26 deaths occurred in the USA among people who had attended an American Legion convention. But care was needed - the medical profession was beginning to look at ways of improving standards through voluntary medical audit, and an open-ended complaints procedure including matters of clinical judgement might postpone audit for another generation.
Interest shifted from the source of the radiation to the detection of the image. However, original file references are also indicated in the list. There were few, if any, valid indications for the use of amphetamines but the Association of the British Pharmaceutical Industry was opposed to a ban. He believed that such an approach could be used more widely than deaths in childbirth or during surgery. He thought that medical science and medical services were misdirected. There were three main methods of control: immunisation, hygiene and chemotherapy.
At what point did population screening cease to pay dividends and become counter-productive? Prior to this their provenance is unknown although it is likely that they belonged to a member of the Commission probably Josephine Barnes who left them with the College. Some argued that these should be discouraged, in the dubious expectation that this would in some way lead to improvement in the quantity or quality of existing services. The Department funded the development of a head scanner and the second prototype was installed in at the National Hospital for Nervous Diseases, Queen Square.
The improvements in immunology also made bone marrow transplantation possible and in the late s a role for it was identified in aplastic anaemia failure of the bone marrow to produce blood cells and leukaemia. Only 20 per cent of women seeking a termination in the West Midlands region had NHS care in their home health region, compared with 90 per cent in Northern region.
Initially introduced to regional and neurological centres, many DGHs began to appeal for charitable funds even though each scanner carried with it high running costs. Surgeons took an increasing interest in their results. Many common foods seemed 'super-saturated', from roast beef to bangers and mash. After five years' effort, dialysis units were accepting only patients a year out of an estimated potential three times that size. Even a system of clearly marking dead victims was missing, to avoid time being wasted by the rescuers on repeatedly confirming death. In selective coronary angiography was introduced, which showed the position of blocked arteries, and by a surgical technique was developed to use a graft to bypass obstructed coronary arteries.
After five years' effort, dialysis units were accepting only patients a year out of an estimated potential three times that size. Did patients with hernias or varicose veins who stayed in hospital a couple of weeks really do better than short-stay or outpatient cases? A geographical variation of toxicity that was associated with levels of aluminium in the water supply was found. Some obstetricians had long aimed for this; for example, the baby might be placed in the mother's arms immediately after delivery, a simple philosophy but one sometimes difficult to imbue into those involved. Because of the problem of getting to the wounded it was 24 hours before it was clear that no one else was living Forty three people died from head injuries and traumatic asphyxia, and two later in hospital from crush syndrome. Computers, initially linked to analytical equipment, were increasingly built into laboratory systems.
A wide range of less sophisticated operations hip fusion, arthroplasty and new femoral heads were now superseded by total replacement as the treatment of choice. The third transplant took place at Guy's in and the Daily Telegraph published the name and biographical detail of the donor, a nurse killed in a road accident. A geographical variation of toxicity that was associated with levels of aluminium in the water supply was found. Improving the survival and quality of the fetus was thought to mean hospital delivery and fetal monitoring, a technique developed in the USA in the s that spread rapidly in the UK. Medical laboratory work was expanding. For whooping cough there had usually been more than , notifications a year before immunisation was introduced in the s.
But care was needed - the medical profession was beginning to look at ways of improving standards through voluntary medical audit, and an open-ended complaints procedure including matters of clinical judgement might postpone audit for another generation. However, the groups studied differed in their characteristics, and the study did not alter policy on hospital admission. The causal agent, resembling Marburg virus but serologically distinct, was called Ebola virus. In another was recognised, Lassa fever, named after the place in Nigeria where it was first seen.
McKeown played down the contribution of clinical medicine. Quality was a major theme underlying many aspects of health care rather than an isolated topic of its own, and was the topic of a Nuffield Provincial Hospitals Trust symposium. Kidneys were scarce. The mortality for cancer of the breast had altered little in 50 years. All operations had the potential to produce problems - infection, loosening of the components or the wearing out of the prosthesis.
Genetic medicine created a further indication for termination; prenatal diagnosis of some congenital and inherited conditions was now possible by sampling amniotic fluid at the 16th week of pregnancy, allowing termination if indicated and acceptable to the mother. At what point did population screening cease to pay dividends and become counter-productive?
Health promotion, Richard Doll argued, was primarily about the identification of measures proven to prevent the onset of disease, implementing them and measuring what was achieved. He believed that the NHS had brought a substantial improvement in access to health care for those previously deprived, chiefly as a result of the decision to remove the NHS from market forces. Evidence incriminated high blood pressure, smoking, obesity, a high intake of saturated fat from dairy products and physical inactivity.