Delay, Denial and Dilution

8/9/2019 Delay, Denial and Dilution

1/55

Delay, Denial and Dilu t ion

The Im pact of NH S Ra tioning on

Hear t Disease an d Cancer


2/55


3/55

IEA Hea lth a nd Welfar e Unit

Choice in Welfa re No. 55

Delay, Denia l and Dilu t ion:

The Impact of NH S Ra t ion ing onHear t Disease a nd Cancer

David G. Green

Lau ra Casper

IEA Hea lth a nd Welfar e UnitLondon


4/55

First published J an ua ry 2000

IEA Hea lth a nd Welfar e Unit

2 Lord N ort h StLondon SW1P 3LB

IEA Health an d Welfar e Unit 2000

All rights reserved

ISBN 0-255 36459-8ISSN 1362-9565

Typeset by the IE A Hea lth a nd Welfar e Unit

in New Century Schoolbook

Pr inted in Great Britain by

St Edmu ndsbury Press

Bury St E dmu nds, Su ffolk


5/55

ContentsPage

The Au thors vi

Foreword

Terence Kealey vii

Preface ix

In t roduct ion 1

Diseases of the Circula tory System 5

Cancer 21

Conclusions 33

Figures

1. Coronary Hear t Disease Dea th Ra tes for MenAged 35-74 per 100,000 Populat ion (1993 or 1994)

Selected Count r ies 6

2. Isch a em ic H ea r t Disea se,

Dea ths Per 100,000 Popula t ion , 1995 7

3. F ive-yea r Sur viva l Ra tes for Lun g Ca ncer Pa tien ts 24

4. One-yea r Surviva l Ra tes for Lung Cancer Pa t ients 24

5. F ive-yea r Surviva l for Breast Cancer Pa t ient s 266. F ive-yea r Surviva l for Recta l Cancer Pa t ien ts 27

7. F ive-yea r Surviva l for Colon Cancer Pa t ients 27

8. F ive-yea r Surviva l for Ovar ian Cancer Pa t ient s 30

Notes 36


6/55

vi

The Aut hors

David G. Gree n is the Director of th e Hea lth an d Welfar e Un it

a t the In st itu te of Economic Affa irs. His books include Power and

Party in an English City, Allen & Unwin, 1980; Mutual Aid orWelfare S tate, Allen & Unwin, 1984 (with L. Cromwell); Working-

Class Patients and the Medical Establishment, Temple Smith/

Gower , 1985; T he N ew Right: The Counter R evolution in Political,

Economic and Social Thought, Wheatsheaf, 1987; Reinventing

Civil S ociety, IEA, 1993; Com m un ity Without Politics, IEA, 1996;

Benefit Dependency, IEA, 1998; and An End to Welfare Rights,

IE A, 1999.

He wrote th e chapter on The Neo-Libera l Per spective in TheS tu dents Com pan ion to S ocial Policy, Blackwell, 1998.

Laura Casper lives in Wisconsin a nd is cur ren tly stu dying a t

Trin ity College, Hart ford, Conn ecticut . She worked a s a resear ch

assistant at th e IEA Health an d Welfare Un it dur ing the summ er

of 1999.

Terenc e Kealey lectu res in clinica l biochem istr y a t Ca mbridgeUniversity a nd is an honora ry consu ltan t chem ical pat hologist at

Adden brookes H ospit a l.


7/55

vii

Foreword

When in 1987 I toured t he un iversity teaching hospital in Aachen,

Germa ny, th e Director boast ed of h is 80 per cent bed occupa ncy

ra te. I wa s su rprised. But my hospita l I sa id has a 100 per centbed occupa ncy ra te.

You do not u nder st and he sa id. We ha ve two other big hosp-

itals in Aachen, one ha s a bed occupa ncy of 70 per cent an d t he

other of only 60 per cen t .

In Germ an y, as in m ost coun tr ies of western E ur ope, th ere a re

no waiting lists. Hospita ls compete for pa tien t s, the pr ofessiona l

sta ff is cont ent , and facilities are modern . In Br ita in, on t he oth er

ha nd, as Ca sper and Green demonstr at e in th is rema rka ble book,th ere a re wait ing list s for th e wait ing lists. Moreover, neither our

doctors nor our nu rses ar e cont ent , and t he facilities ar e poor.

Brita ins health service is almost u nique. Whereas th e coun tr ies

of western Eu rope ha ve crea ted system s of hea lth car e based on

privat e insu ra ncebut un derpinn ed by th e stat e to ensur e tha t

th e poor a re n ot n eglectedwe in Brita in u se a system modelled

on Lenins dr eam of universa l free provision , an d so, in t he midst

of an expanding and prosperous economy, we in Britain have

nu r tu red an island of Soviet socialism. How well does it work?Not very well. For decades, the faults of the NHS have been

obscured by the general improvements in health that our in-

crea sed prosperity, impr oved nu tr ition a nd bett er housing have

crea ted , but n ow tha t we are prosperousnow tha t life and dea th

depend on h ospita ls, doctors a nd n ur ses ra th er t ha n on sewers,

agricultu re a nd accomm odat ionthe ina dequa cies of our hea lth

delivery are increasingly being exposed. For years, people have

been reluctan t to sha tt er our faith in t he envy of th e world (a nenvy so envious th a t p ractically nobody has copied u s) but in t his

courageous book Casper and Green have chronicled how poorly

the NHS does, in fact, serve the sufferers from the common

diseases of our time. Nationalisation works no better in health

th an in telephones.

Beveridge didnt m ean it to be this way. In h is fam ous Report ,

published in December 1942, he a pplaude d t he phen omen al

growth of volunt ar y insu ra nce against sickn ess, an d indeed, by


8/55

DELAY, DEN IAL AND DILUTIONviii

1938, th e 1,334 volunta ry hospita ls of Brita in r eceived 59 per cent

of their income from pa t ient s fees, pa id either directly or via

private health insurance organised by institutions such as the

Brit ish P roviden t Associat ion.

Beveridge wanted to foster the growth of private medical

insurance, and he wanted to restrict the state only to under-

pinn ing pr ovision for th e poor, bu t Nye Bevan (a squa lid n ui-

san ce as Winston Ch ur ch ill once described him) was determin ed

on nationalisation on the Soviet modeland in a classic case of

crowding out, his universal free provision destroyed private

hea lth car e for m ost people.

Of cour se, UK hea lth car e is cheap . We spend less on h ealth car eth an does an y compa ra ble na tion, but th e cheapn ess of th e NHS

is subsidised by the exhaustion and demoralisation of the staff

and by the second-rate service it so often provides. It is the

chea pness of th e miser who knows the price of everyth ing and t he

value of noth ing. And it is a cheapness t ha t dem eans pat ient s a s

supplicants and which hides the medical realities of rationing

from th em.

Nobody wants to be told to pay more for anything, so thepolitica l par ties now collude with th e people of Brita in in pr eten d-

ing they ha ve crea ted a perpetua l motion ma chinea ma gical

inst rum ent for conjur ing truly free h ealth care out of a politician s

fiat. But th e rea lity is that , after rea ding th is book, people will

want better t reat ment , and t hey will wan t t o find the m oney.

Yet, and th is ha s emerged a s a n iron law of our time, people will

not pay h igher ta xes. They will, however, pa y for pr ivat e goods, so

we must now invent a system th at lowers the bar riers between

the private and public sectors, to reward private payers for, inBeveridges words , the du ty an d plea su re of th r ift .

Put simply, we should copy the German system, but if that

policy appea rs t oo eur oph iliac for some, we sh ould copy the Swiss

system inst ead (its a lmost iden t ica l). Nobody would want to copy

th e Amer ican s, so let u s recognise tha t h ealth is one a rea where

th e Cont inent als do better t ha n th e Anglophones.

In rea lity, it is the Germa n h ealth care system t ha t is the envy

of the worldor it would be, if th e world were bet ter inform ed.Than ks t o Casper a nd Green, it now is.

Terence Kealey


9/55

ix

Preface

It is often s aid th at , despite the fact th at British expenditur e on

health care is low by international standards, the British

National Health Service produces good medical outcomes. Inrecent year s it ha s become obvious t ha t t here is r a tioning, but t he

examples which h ave received most public a tt ent ion h ave affected

relatively small groups, such as people suffering from multiple

sclerosis or male impotence. The NHS could conceivably be

st ruggling to meet th e needs of such specia l groups with ou t being

fun dam ent ally flawed, and a fa irer m easu re of its su ccess would

be to look a t th e impa ct of th e NHS on th e killer diseases which

affect the most people. We therefore looked at the two maincauses of premature death: diseases of the circulatory system

(responsible for 40 per cent of prem a tu re dea th s in men a nd 30

per cent in women) an d cancer (the second biggest killer). J ust

how well does t he N HS do compa red with similar coun tr ies?

Than ks a re due to Laur a Ca sper, who worked a t t he IEA as a

research assistan t du ring the sum mer of 1999 an d produced such

good work th at I felt it only right to ma ke h er a co-au th or. I h a ve

also benefited from t he resea rch a ssista nce of Selina J ones, BenBrowning a nd Kat her ine Russell, all of whom did a fine job. Ben

Browning deserves to be singled ou t for h is invalua ble help.

The finished product was mu ch improved by th e comm ent s of

Lord McColl, J im Th orn ton, Robert Whelan an d t wo an onymous

referees. Needless to say, any remaining errors, omissions or

oversight s a re en tirely my fau lt.

David G. Green


10/55

1

Introduction

T he NHS is efficient . We spend less on h ea lth a s a p roport ionof GDP th an ma ny oth er coun tr ies, but th e results a re justas good. Such claims a re comm on, but is it tr ue t o sa y tha t t he

NHS produces good resu lts for pa tien ts? This st udy exam ines the

impa ct of th e NH S on th e two ma in killer diseases. Among both

men and women the biggest cause of death is diseases of the

circulatory system, followed by cancer. Among diseases of the

circula tory system, we focus on corona ry hea rt disease and st roke.

We look a t four cancers : brea st cancer, th e most common cancer

for females; lung cancer, the most common for men; colorectal

ca ncer, th e second most comm on fat al m aligna ncy in both sexes

combined; and ovaria n can cer, th e four th most comm on am ongst

women . Does t he NH S r a tion pr ovision for people su ffering from

these conditions? And if so, does it make any difference to the

resu lts for pa tient s?Until recently, the existence of explicit rationing by the NHS

was consist ently den ied. All decisions were supposed to be clinica l

ra th er t ha n fina ncial. There was priority setting but not ra tion-

ing. Such claims h ave become increasingly implau sible, however,

as the number of doctors complaining about rationing has

increased.

J ust as th e out right denial of ra tioning has become less tena ble,

so defenders of the NHS have tried to offer a more positivedefence. Instead of claiming that all decisions are clinical, they

ar gue th at medical r at ioning is a virt ue, so long a s decisions ar e

based on legitima te grounds. Typically they asser t, not only th at

ra tioning exists, but also th at it is una voidable. Invar iably th ey

object to medical paternalism and suggest one of four main

alter na tive (somet imes overlapping) ra tiona les.

One group argues that rationing should be given democratic

legitimacy, through devices such as opinion surveys and citizen


11/55

DELAY, DEN IAL AND DILUTION2

juries.1 A second group dem ands evidence-based m edicine. Only

medical procedures based on scientific evidence should be

provided by the NH S. The Na tiona l Inst itut e for Clinical E xcel-

lence (NICE ) is a consequen ce of th is line of r easoning. A third

group em phasises cost -effectiveness.2 In pra ctice, th ey ar e closely

linked to enthusiasts for evidence-based medicine, but not all

champions of scientific evidence attach the same weight to cost

minimisation. And a fourth group has urged that treatment

should be m ade available according to the qu a lity of life gained by

patients. The Quality Adjusted Life Year (QALY) has probably

been t he most debat ed of such a ppar ent ly technical devices.3

These enthusiasts for openness and explicit rationing have inth eir tu rn come u nder str ong criticism by writer s such as Da vid

Hunter 4 and Rudolf Klein,5 who have t ended t o debun k ra tiona l

ra tioning. The pu rpose of th e present study, however, is not to

enter int o that debat e, but t o form a clearer view about the extent

of ra tioning on t he t wo biggest cau ses of dea th in the UK, diseases

of the circulat ory system an d cancer.

Before going an y fu rt her it may be advisable to clar ify wha t we

mean by rationing. It is inevitable that words will take onalternative meanings in different contexts, but it is rather

import an t t ha t a ny one word should mean th e sam e thing dur ing

the course of any single argument. We follow Rudolf Klein in

distinguishing between pr iority sett ing and rat ioning.6 If a service

is fina nced from t axes, t he government will inevita bly be gu ided

by pr iorit ies when it a ppor tions some of th e na tional budget to th e

NH S or elemen ts with in it. We do not call th is process r at ioning,

but when individual doctors, working within their assignedbudgets, make decisions about the treatment of individual

pat ient s, th en we speak of ra tioning.

Measur es of Ra t ioning: Denia l , Dela y a nd Di lut i on

One example which has received attention in the press and

specia list jour na ls is the denial of cancer care, so much so th a t t he

Pr ime Minister himself becam e involved. The most au th orita tive

estimate has been made by Professor Sikora, head of the WHOcan cer program me, who calculat ed that th ere could be as ma ny as


12/55

INTRODUCTION 3

25,000 unnecessary deaths in the UK every year because of

under -provision. We can also compa re t he r at e at which ca r e is

den ied t o people su ffering from kidney fa ilu re. A recent su rvey of

rena l specialists in Can a da, th e US a nd t he UK found tha t 12 per

cent of UK specialists sa id th ey had refused tr eatmen t to patient s

because of limited resources. The rate of provision between the

three countries varied substantially. In 1992, 65 patients per

million population (pmp) were accepted for dialysis in the UK,

compared with 98 pmp in Canada and 212 pmp in the US.7

According to another study, by 1995 th e figur e for En glan d was 82

pmp, significantly less than the rate in comparable European

coun t ries, where a ccepta nce rat es of over 100 pm p were common.The authors estimated that the rate in England should exceed

100 pmp t o meet esta blished need.8

Often tr eatm ent is n ot with held altogeth er, but it is delayed,

somet imes with th e resu lt th at th e pat ients condition worsens.

There ar e measu res of delay, not least th e waiting lists , although

th eir impact on outcomes is not a lways clear cut . The National

S urvey of NHS Patients, published by th e Depar tm ent of Hea lth,

is also a useful guide. It foun d th at one in t en pa tient s were seenby a specialist on th e sa me day a s t hey were referred by their GP.

About 50 per cent h ad to wait over a mont h a nd 20 per cent m ore

th an th ree months. Over one in t hr ee of th ose waiting said tha t

th eir condition had got worse while th ey were waiting an d 14 per

cent claim ed t o be in a lot of pa in. Over 50 per cent report ed th a t

their condition limited their daily activities and ability to work

and, not surprisingly, of the men of working age (16-64), half

th ought th ey should ha ve been seen sooner .9

The wa iting list h as been t he focus of mu ch political a tt ent ion

since th e Government s election pledge to cut it. It s effort s have,

however, led to continuing claims tha t it wa s fiddling the figur es.

One ploy used by some hospitals to avoid going over the 18-

month s th reshold is t o call in pat ient s who ha ve been wa iting for

nearly 18 months for a check-up. If they are put back on the

wait ing list t he clock st ar ts ticking from zero, th us concealing t he

rea l waiting time. Moreover, the Govern men t wa s forced in th esum mer of 1999 to acknowledge tha t its r eduction in th e waiting

list had been achieved by increasing the time it took to see a


13/55


consult ant in t he first place. Ther e was now a waiting list for t he

wa iting list .

Care may also be diluted by not providing the optimal treat-

ment. This often happens when new but expensive remedies

become a vailable. Again, demons tr a ting the impa ct of diluted care

on out comes is not easy a nd systema tic evidence is n ot rea dily

available. Moreover, there is invariably no clear-cut agreement

am ong doctors a bout which tr eat men ts ar e appr opr iat e or

opt ima l. We ar e not , however, wholly un able to judge between

rival t rea tm ent s. A variety of organ isat ions have produced clinical

guidelines, protocols and recommendations which enjoy wide

respect, eith er in t he U K or oversea s. If a given doctor or h ospit alor system (such as the NHS) fa lls sh ort of a well-respected clinical

guideline this const itut es at leastprim a facie eviden ce of dilu t ion

and calls for further investigation. Among the official organisa-

tions laying down benchmarks in the UK are the Clinical

Sta nda rds Advisory Group10 an d t he St an ding Medical Advisory

Committee,11 and such work is to be stepped up through the

Commission for Health Improvement and the National Service

Frameworks.


14/55

5

1

Dise ase s of the Circu latory Syste m

Over 40 per cent of all deat hs ar e th e resu lt of car diovasculardisease (CVD). The two main forms of CVD are coronaryhea rt disease (including hear t a tt acks and an gina ) an d cerebro-

vascu lar disea se (st roke). In 1996 just over half of all dea ths from

CVD were from coronar y hear t disease an d a bout a quar ter from

stroke.1

However, we must all die of somet hin g an d t he more rele-van t figur e is for pr ema tu re dea th s, na mely th ose occur r ing

before age 75. In 1996 ca rdiovascula r disease wa s r esponsible for

over 40 per cent of prema tu re dea th s in men an d 30 per cent in

women.2

The Governm ent adm its th at th e UK record is un sat isfactory.

After allowing for the different age structure of each country,

Saving Lives: Our Healthier Nation compa res dea th ra tes from

circulatory disease for persons aged under 65 throughout the

European Union. Out of the 15 countries studied, the UK was

thirteenth.3

Corona ry Heart D isea se

Coronary heart disease (CHD) is the most common cause of

prem at ur e (un der t he a ge of 75) deat h in th e UK, accoun ting for

28 per cent of prema tu re deat hs in m en a nd 17 per cent in women

in 1996nea rly 60,000 prem at ur e deat hs in t ota l.4

For some year s now UK government s have officially sought toreduce death s from coronar y hea rt disease,5 but CHD death r at es

rem ain a mong the h ighest in th e world. The form er comm un ist

countries tend to be the worst. As Figure 1 shows, the rate for

men a ged 35-74 in La tvia in 1994 was 919 per 100,000 popu lat ion

(age-standardised). In the Russian Federation it was 812 per

100,000; in Estonia, 744; Lithuania, 663; and Bulgaria, 352.

Compa red only with OECD count ries t he UK r ecord is also poor

(Figure 2).


15/55


Figu r e 1

Corona ry Hea rt D isease Deat h Ra tes for Men Aged 35-74

p er 100,000 Pop ula t ion (1993 or 1994) Selected Count ries

Japan

France

Australia

Germany

US

UKBulgaria

Lithuania

Estonia

Russian Federa tion

Latvia

Source: Coronary Heart Disease S tatistics, British H ear t F oun dat ion, 1998,

p. 19.

Western coun tr ies an d J apa n t end to have lower ra tes. J apa ns

figure is 49 per 100,000; Fra nce, 94; Canada , 212; Aus tr a lia , 217;

German y, 237; an d th e US, 248 (in 1993). In t he U K th e r at e of

325 per 100,000 in 1994 is closer t o the Bu lga ria n figur e. Deat hra tes from CHD ha ve been falling in th e UK, but not as r apidly a s

in some other countries like Australia, Sweden and the US.

Between 1983 and 1993 th e deat h r at e for m en in th e UK fell by

30 per cent , compa red with 43 per cent in Aust ra lia , 41 per cent

in Sweden an d 34 per cent in t he USA.6

However, the Health Survey for England and the General

Household S urvey suggest th at while deat h from CHD is falling,

th e incidence ofill-health due t o CHD is n ot falling and ma y in

fact be rising. Dra wing on a variety of sour ces, the British Hea rtFounda tion (BHF ) estima tes th at appr oxima tely 300,000 people


16/55

DISEASES OF TH E CIRCULATORY SYSTEM 7

in the UK have a heart at tack each year and that about 1.4

million people have angina .7

Figu r e 2

Ischa emic Hear t Disease ,

Dea th s P er 100,000 Pop ula t ion, 1995

Source: OECD Health Data 1999 (CD)

Heart disease has major economic consequences as well ashu ma n costs. CHD alone cost t he health car e system about 1.6

billion in 1996, with a bout 55 per cent going to hospita l ca re a nd


17/55


32 per cent on th e cost of drugs. Only abou t one per cent of such

costs were spent on the prevention of CHD. The British Heart

Foundation has estimated the total impact of CHD on the UK

economy t o be a bout 10 billion a year .8

The Adequa cy of CHD Treatm ent

CHD leads to the obstruction of the blood flow through the

coronary arteries to the heart muscle, due to fatty deposits and

associated blood clots. An inadequate supply of oxygen-enriched

blood to the h eart can dam age th e hea rt mu scle leading to hear t

pain (angina) or to a heart attack (myocardial infarction) that

may be fatal. CHD is influenced by several factors, not all of

which can be altered. The genetic risk cannot be changed by

medical int ervent ion but cigar ette smoking, h igh blood cholester ol

levels, ra ised blood pr essu re, obesity and lack of exercise can a ll

be modified by lifestyle choices a nd /or medica l tr ea tm ent .

The m ost comm on tr eatm ent is to take dru gs, although an gina

can also be treated surgically, in the form of coronary artery

bypass grafts (CABGs) or angioplasty.9 CABGs usu a lly involve

grafting veins or ar ter ies (ta ken from th e leg) from t he a ort a (amajor artery that takes blood from the heart to the rest of the

body) to the corona ry a rt ery, th us bypassing th e obstructed a rea .

Government targets have been set for CABGs. In 1986 the UK

target was 300 per million population (pmp). The number had

risen bet ween 1978 a nd 1985 from 57 pmp t o 225 pmp in 1987.

TheHealth of the N ation report of 1991 conceded t ha t th e t ar get

of 300 pmp wa s significan tly below most ta rgets a dopted by oth er

countries,10 and noted tha t even t his inadequate t arget had not

been achieved. In 1990 the rate was only 278 pmp (15,967

operations) but by 1996 it had increased to 412 pmp (24,238

operations).11 At t he t ime, the British Car diac Society ta rget was

600 per million popu lat ion.12

The UK rate compares very unfavourably with the US, where

598,000 CABGs were performed in 1996, at a rate of 2,255 per

million popu lat ion .13 The ra te for Austra lia was a bout 870 pm p;

Cana da, 582 pmp a nd Sweden, 736 pmp.14

Not only is t he overa ll ra te low, the Depa rt men t of Hea lth alsoconcedes th at th ere ar e lar ge varia tions bet ween differen t pa rt s


18/55


of the country. Adjusting for age, the lowest figure was for the

Nott ingha m H ealth Aut hority wher e only 40 bypa ss operat ions

and angioplasties per million population were carried out. The

highest rate was found in Brent and Harrow with 1,400 per

million.15 These local dispar ities ha d been ident ified by the Aud it

Comm ission report of 1995, which ur ged health au th orities with

rates below 300 pmp to give priority to increasing supply.16

Pr ogress h as been very slow.

The consequences ar e serious. A stu dy of Pa pwort h Hospita l

found that deaths occur while patients are on waiting lists for

CABGs. Moreover, for every one death on the waiting list there

were between t wo an d th ree adverse car diac event s. The au th orsconcluded th at th e high mort a lity an d complicat ion r at es while

waiting were becau se resour ce limits mean t that pa tient s tended

to be put on waiting lists only when th eir condition ha d become

ur gent. They concluded t ha t ma ny UK pat ient s ar e referr ed an d

investigated a t a critical sta ge in th eir disease a nd ar e th erefore

at high r isk at th e time of invasive inter vention . This t enden cy

suggested to the a ut hors t ha t t he su rgical t reat ment of corona ry

hea rt disease in t he UK was more a form of crisis ma na gementth an plann ed car e.17

Moreover , because of th e pr evalence of ra t ioning, doctors ha ve

fallen into the habit of withholding treatment on non-clinical

groun ds. In th eir 1993 report ,18 th e Clinical St an dar ds Advisory

Group drew attention to the lack of clear criteria for giving

priority to patient s waiting for coronar y ar ter y bypa ss su rgery. In

response to this report, a regional workshop sponsored by the

Northern Ireland Clinical Resource Efficiency Support Team

convened in t he spr ing of 1996 to gain a better un derst an ding ofthe criteria used by doctors to assign priority to particular

pat ient s. Many doctors made judgement s a bout the u rgency of th e

pa tien ts cond ition, t ha t is th ey form ed a view about how quickly

each pat ient should be tr eat ed in order to achieve a given m edical

outcome. However, the study also found that demographic and

lifestyle cha ra cter isticssuch a s smoking, age, gender and body

weightoften influenced doctors judgements on priority inde-

pendently of their beliefs about the probable effectiveness ofsurgery.19 These findings are consistent with the long-standing


19/55


practice of discrimina ting again st elder ly pa tien ts20 becau se t hey

ha ve ha d a good inn ings, an d with th e a ckn owledged pr actice of

discriminating against smokers, which is publicly defended by

some doctors.21

High Blood Pr essure

The two main risk factors for CHD which are susceptible to

medical intervention are high blood pressure and the blood

cholesterol level. (Smoking is a personal choice and obesity is

cont rollable in most cases th rough chan ges in diet a nd exercise.)

How effectively is high blood pressure being dealt with by the

NHS? High blood pressure or hypertension is usually a

symptomless condition which increa ses t he risk of stroke, hea rt

failur e, hear t a tt ack and kidney failur e. It is th e most import an t

risk factor for stroke. Because there are no symptoms in the

majorit y of cases, h igh blood pr essu re often goes u ndetected.

When blood pr essur e is mea sur ed two figur es ar e recorded: the

highest occur s when th e hea rt cont racts (systolic); and t he lowest

when th e hea rt relaxes between beat s (diast olic). Blood pr essur e

is usually written with the higher number first, for example

160/95 mmHg. The mean systolic blood pressure for men in

England is about 139 mmHg and for women 134mmHg. The

British Hear t Foundat ion defines individua ls as h yperten sive if

th eir systolic blood pr essur e is more th an 160 mm Hg an d th eir

diastolic blood pressure is more than 95 mmHg.22 There is no

clear m edical consen sus about t he point at which blood pr essur e

is high enough to warrant intervention, although it is accepted

th at th e higher t he blood pressure th e great er th e risk.Trea tm ent involves a combina tion of lifestyle changes an d dru g

therapies.23 Lifest yle changes genera lly come first . People who ar e

overweight are strongly advised to lose weight and smokers to

give up. Changes in diet, especially for those with high blood

cholesterol levels or complications such as diabetes, are also

str ongly recomm ended. Reducing sodium an d sa lt int ake, with out

redu cing th e consu mpt ion of calcium, m agnesium or pot a ssium,

and reducing alcohol int ake a re a lso highly beneficial.Medically, a comm on first step is a th iazide diur etic. This gr oup


20/55


of dru gs works by helping th e kidneys to elimina te sa lt a nd water,

which decrea ses fluid in th e body th us lowering blood pr essur e.

Thiazide diuretics also cause blood vessels to dilate, increasing

their capacity and lowering blood pressure.

Another appr oach is to block some of the bodys na tu ra l defence

mecha nisms. Under str ess, or in moment s of dan ger, th e sympa-

thetic nervous system temporarily increases blood pressure to

cope with threats and releases hormones, such as adrenalin,

which stimu lat e t he hear t an d blood vessels. Adrenergic blockers,

the most common of which are the beta-blockers, reduce the

effects of th e sympa th etic ner vous system .

A th ird approach is to use angioten sin conver ting enzyme (ACE)inh ibitors, which lower blood pressu re by dilat ing the ar ter ies.24

It is now widely acknowledged th a t ACE inhibitors ar e effective

an d safe remedies when u sed appr opriat ely. For exam ple, it is the

recomm endation of the North of England ACE-inhibitor Guideline

Developmen t Group th at all patient s with symp tomat ic hea rt

fa ilur e a nd evidence of impa ired left vent ricula r function a s well

a s those with a r ecent myocardia l infa rct ion and evidence of left

ventr icular dysfunct ion should be t reated with an ACEinhibitor.25 The great majority of adults with heart failure have

left vent ricular dysfun ction. H owever, a stu dy car ried out by the

group foun d th at only 20-30 per cent of pat ient s with hea rt failure

were being prescribed an ACE inh ibitor.26

This finding is similar to th ose of two Scott ish studies. The fir st ,

by the Scotland Health Purchasing Information Centre, found

th at an ACE inhibitor wa s being pr escribed for only ar oun d one-

th ird of pat ient s diagnosed with hear t failur e in gener al pra ctice

in Scotland and that, even when prescribed, patients often

received su b-opt ima l doses.27 The second st udy looked a t pa tien ts

in the Gra mpian r egion an d found tha t , under t he m ana gement

of general practitioners, less than half the patients diagnosed

with heart failure took ACE inhibitors. Indeed, less than one-

third of patients with a recent myocardial infarction took beta

blockers, despite the fact that their use has achieved mortality

reductions of 20 per cent following hea rt a tt ack.28

These pr actices compa re ba dly with th ose pr evalent oversea s.One st udy of US pr actice between 1986 an d 1994 exam ined th e


21/55


use of ACE inhibitors in combina tion with a d iuretic and d igitalis.

Since 1987 it had been widely accepted that ACE inhibitors

improved survival for pa tient s with hea rt failure a nd sympt om-

at ic left ventr icular dysfun ction. Of pa tient s who were h ospita -

lised for heart failure in 1986 and 1987, 43 per cent were pre-

scribed a n ACE inh ibitor, wherea s of th ose h ospita lised in 1992

an d 1993, 71 per cent were pr escribed an ACE inh ibitor.29

Not on ly is t her e evidence of under -use of valua ble t her ap ies,

there is also evidence of inadequate diagnosis. There are some

less common cau ses of hea rt failure, such as a or tic va lve obstr uc-

tion, where ACE inhibitors are unhelpful or harmful, and

therefore accurate diagnosis is essential. Diagnosis is greatlyaided by the ultrasound technique known as echocardiography,

which can produce images of the heart and show how well the

mu scle is cont ra cting. It can u sua lly esta blish th e cau se, an d

confirm th e pr esence of hea rt failure an d t hu s a llow th e corr ect

use of drugs.30

However, a s tu dy of th e NHS in Scotlan d showed that only 30

per cent of hea rt failur e pat ient s in general pr actice were given

echocardiography scans despite evidence from areas whereechoca rdiogra phy wa s freely available th at import an t cha nges in

tr eat men t were required in 69 per cent of pat ients r eferr ed.31

Moreover, echocardiography was not expensiveabout 45 per

scan in Glasgow. The Scotland Health Purchasing Information

Cent re (SHPIC) recommen ded provision of a one-st op car diology

service, but in deference to th e NHS tr a dition of ra tion ing, even

th ough such a service would be cheap a nd cost -effective, the group

recommended a second-best option of a GP echocardiography

service in the hope of reducing by about two-thirds the casesrequiring referr al to a hospita l.32

A second stu dy by t he North of England ACE-inh ibitor Guide-

line Development Group dr ew similar conclusions. It foun d th a t

most pa tients who were investiga ted for h ear t failur e ha d a chest

X-ray and electr oca rdiogra m, while on ly a t hird ha d echoca rdio-

graph y. Diagnosis by clinical assessm ent h ad been estima ted to

be correct in only about half of cases when confirmed by

echocardiography.33

It recommended that diagnosis should bebased on either echocar diograph y or ra dionu clide mea sur ement.34


22/55


To sum up: the NHS does not have a very good record of

providing these tried and tested remedies. According to the

British H ear t F oun dat ion, based on t he 1996 Hea lth Su rvey for

En glan d, over four out of ten men an d over one in th ree women

with hypert ension were not r eceiving tr eat men t a nd, of th ose th at

are treated, about a third remain hypertensive.35 Even the

Government has acknowledged that fewer than half of people

with high blood pr essu re a re tr eat ed successfully. In 1997, 42 per

cent of people with hyper ten sion were being trea ted su ccessfully,

21 per cent were being t rea ted inadequa tely and 37 per cent were

not being treat ed at all.36

Cholesterol

A second CH D risk factor is the blood cholest erol level. Accord ing

to the Br itish Hear t F ounda tion, lowering blood cholesterol levels

by one per cent r educes the r isk of CHD by about two to thr ee per

cent.37

Cholesterol is a fat ty substa nce which can be foun d in severa l

forms in the human body. When bound to proteins it forms

lipoprotein. Cholesterol and other fatty blood components are

often called blood lipids a nd can be d ivided in to two groups: low-

density lipoprotein (LDL) cholesterol and high-density lipoprotein

(HDL) cholest erol. High levels of LDL cholest erol an d low levels

of HDL cholester ol ar e a ssociat ed with an increa sed risk of CHD.

A new class of cholesterol-lowering drugs, the st a t ins (HMG CoA

reducta se inhibitors), a re able to reduce LDL cholester ol levels by

more th an 20 per cent .38 The first tr ial to show tha t CHD patients

treated with lipid-lowering drugs gained a survival advantagewas the Scandinavian trial, published in November 1994.39 A

Scott ish t rial confirm ed th is resu lt40 an d subsequent ly a t ota l of

22 pu blished randomised cont rolled tr ials of cholesterol lowering

with statins have been pooled. Overall, they show that statins

redu ce t he risk of CHD mort ality by about 25 per cent an d th at

sta tin tr eat men t in older people is just as effective as in m iddle-

aged adults.41

These findings have led to increased expenditure on statindrugs. In 1993 expenditure was over 20m and by 1997 it had


23/55


risen to over 113m.42 Ent hu sias ts for cost -effectiveness h ave a lso

found in favour of st a tin s. The net cost per life-year gained with

sta tins of ar oun d 7,000, though qu ite h igh , compa res favoura bly

with oth er int ervent ions curr ent ly provided by th e NHS.43

To wha t extent ha s th e NHS a cted on t he kn own evidence? The

British Cardiac Society conducted a national sample survey to

assess the adequacy of hear t disea se tr eat men t. It foun d th at the

recording and management of risk factorslifestyle, blood

pressu re, cholester ol, glucosea nd th e use of prophylactic dru g

tr eat men t were less t ha n optima l. For exam ple, according t o th e

Brit ish Hyper lipidaem ia Associat ions (BHA) guidelines, most of

th e pat ients in th e sur vey should ha ve been at tempt ing to lowerth eir LDL cholesterol eith er by dieta ry cha nge or drug trea tm ent .

Of th e m inority of pat ients on lipid lowering tr eat men t, over ha lf

wer e not a dequ a t ely cont r olled a ccor din g to t h e BHA

guidelines.44

Anoth er st udy of th e prescr ibing of lipid lowering dru gs in t he

Sout h E as t Tha mes Region foun d dra ma tic var iations. With in a

single health authority, prescribing varied by 60-fold between

practices, and across the region the variation was 98-fold.45 AScott ish st udy concluded t ha t lipid mana gemen t was lar gely

neglected, despite the existence of local guidelines advocating

cholesterol lowering for pa t ient s with CHD. The blood pr essure of

93 per cent of pat ient s in th e survey ha d been m easur ed in t he

previous th ree year s, wherea s t heir blood cholest erol level ha d

been checked in only 26 per cent of cases during the same

period.46

Is th e err a tic provision t he resu lt of ra tioning or is it bad clinica lpractice? Recent discus sion in t he m edical jour na ls provides some

insights. In August 1997, the Sta nd ing Medica l Advisory Comm it-

tee (SMAC) issued a dvice to health au th orities a nd GP s on t he

use of sta tins. It recomm ended tha t an yone with a th ree per cent

an nual risk of a heart at ta ck should be trea ted.47 This meant that

about 3.4 per cent of those aged 35-69 in England were eligible for

sta tins in addition t o th ose who ha d alrea dy experienced a CH D

event.

48

However, Nick Fr eema ntle, Senior Resea rch Fellow at th eCentr e for Hea lth Economics, subsequent ly at ta cked th e modest

SMAC guidelines in a n editoria l in th eBritish Medical Journal


24/55


as financially unsustainable. He pointed out that the SMAC

guidelines would mea n t ha t 8.2 per cent of th e populat ion of th ose

aged 35-69 would h ave to be tr ea ted to fu lfil a ll th e pr ior ities. In

th e War wicksh ire Health Aut hor ity alone, adh ering to th e SMAC

guidelines would involve tr eat ing a bout 17,000 pa tien t s. The cost

in Warwicksh ire would be a bout 8m, representing 20 per cent of

its drug budget.49 Such concerns have not been confined to

Warwickshire, and t he resu lt ha s been substa nt ial un der-use of

sta tins. As th e 1999 report of th e Audit Commission r ema rk ed,

th ere wa s evidence th at dru g thera pies for pr event ing CHD were

not being u sed a s m uch a s t hey u sefully could be.50

Hea rt At ta cks

The Audit Commission in 1995 suggested some performance

indicators for patients arriving at a hospital with chest pain

and/or other symptoms of a heart attack. The ideal to aim for

would be to carry out an electrocardiogram (ECG) within 15

minut es of ar rival and, when a myocardial infar ction is suspected,

to administer th rombolytic th era py within 30 minu tes of ar rival

(often ca lled th e door -to-needle t ime).51 These recommendations

are often not achieved. Moreover, one survey found that a

significant minorit y of key hospita l ma na gers did not even kn ow

wha t t heir a chievemen ts were. A sur vey of 500 tr ust cha irmen ,

chief execu t ives, medica l directors and chief nur ses carr ied out by

theHealth S ervice Journal an d the Health Qua lity Service ask ed

respondents to give a yes or no response to the following

sta tem ent : At least 80 per cent of A&E pat ient s with chest pains

ha d a car e plan initiated with in 30 minut es of ar rival. Only 60per cent of cha irm en a nswered Yes, compa red with 47 per cent

of chief executives, 57 per cent of medical directors and 70 per

cent of ch ief nu rses. The rema inder typica lly answered Dont

kn ow ra ther than No.52

Car diac reh abilitat ion a fter h ear t a tt ack can also significan tly

improve the quality of life and reduce mortality. The most

appropriate forms of rehabilitation combine exercise with

psychologica l and educat iona l services. Evidence from th ree meta -an alyses involving over 4,000 patient s who ha d su ffered a hea rt


25/55


attack suggests that cardiac mortality can be reduced by 20-25

per cent. However, many patients who might benefit do not

receive rehabilitation under the NHS. The York Centre for

Reviews and Dissemination found that, despite increases in

reh abilita tion in recent year s, service provision in 1998 fa iled to

meet national guidelines for cardiac rehabilitation. Moreover,

th ere were wide var iat ions in th e sta nda rd of provision, reflected

in staffing costs which ranged from about 10,000 per year to

62,000 per year .53

St roke

St roke is the na tions th ird biggest k iller a nd lar gest single cause

of severe disa bility.54 TheHealth S urvey for England 1996found

that 1.8 per cent of men and 1.6 per cent of women reported a

history of stroke an d t ha t 8.6 per cent of men over th e a ge of 75

and 7.5 per cent of women over 75 report ed a h istory of st roke.55

However, theHealth S urvey for En gland relies on self-report ing,

an d a m ore reliable estimat e ha s been m ade by Geddes an d her

colleagues based on a survey of the North Yorkshire Health

Aut hority. The t eam est ima ted th a t 4.7 per cent of people aged 55or more ha d su rvived a str oke: 80 per cent ha d su ffered a single

st roke, 13 per cent , two str okes an d seven per cent , three or m ore.

Some 23 per cent reported a full recovery and the remainder

experienced subsequent impairmen ts. The m ost prevalent were

cognit ive (33 per cent ), problems with th e right limb (33 per cen t ),

th e left limb (27 per cent ) and speech (27 per cent ). Some 55 per

cent sa id they needed help t o fu lfil one or more of ten activities of

daily living. Overa ll th e st udy est ima ted th e prevalence of stroke

in th e whole popula tion to be 1.47 per cent , more th an double th e

estima te norma lly used by health au th orities (0.6 per cent). They

estimat ed tha t 1.13 per cent of people ha d impairm ents an d th at

0.62 per cent were dependent as a resu lt of th eir st roke.56

Using da ta from t he Geddes su rvey, th e Str oke Association h as

estima ted th at 82,000 people aged 55-64 ha ve a h istory of st roke.

Overa ll, it th ought th at 764,000 people of all ages in th e UK h ad

a h istory of st roke, of which some 53,000 ha d severe disabilities

as a consequence.57

Str oke car e costs ar e considera ble. At presen t, expenditu re on


26/55


st roke ca re is concent ra ted on th e immediat e episode of in-pa tient

tr eat men t a nd not on long-ter m car e. Overall, th e costs of str oke

ca re were 2.3 billion in E ngland in 1995-96. This amount s to 5.8

per cent of NHS and social services expenditure. The cost of

longer-term care for surviving stroke patients is also high and

likely to rise fur th er a s a resu lt of demogra phic cha nge.58

Stroke care already has a strong evidence base. Over the last

two decades a nu mber of small, ra ndomised cont rolled t rials of

specialised stroke units have been conducted. They found that

stroke units reduce mortality and disability compared with

management in acute general wards. No other treatment for

str oke h as demonstr at ed such large benefits.For example, a stu dy published in 1994 compa red a str oke un it

and a general ward. Patients within the stroke unit recovered

more quickly as determined by their activities of daily living

scores. Patients were also discharged more rapidly from the

str oke u nit. About ha lf were discha rged from th e str oke unit in

about six weeks compared with over 12 weeks in the general

ward. In the stroke unit, all patients were discharged after 12

weeks, whereas it t ook 32 weeks in t he genera l war d.

59

In 1993 Peter Langhorne and his colleagues assessed the

conclusions that could be drawn from ten randomised clinical

tr ials then a vailable for st udy. They compa red a stroke un it with

alternatives such as a general hospital ward. By a stroke unit

th ey meant a m ult i-disciplina ry tea m of specia list s, which could

be geogra phically based or mobile. They foun d t ha t th e ma na ge-

ment of patients in a stroke unit was associated with lower

morta lity after 17 weeks a nd a fter 12 mont hs . After 12 mont hs,

th e redu ction in mort ality was 21 per cent , or 25 per cent if th etr ials based on inform al ra ndomisat ion were excluded. The s tu dy

also found evidence that patients treated in units had an im-

proved a bility t o fun ction .60

Special str oke u nits not only reduce morta lity but also reduce

th e length of hospita l sta ys. The Str oke Un it Tria lists Collabora-

tion studied 11 trials comparing a dedicated stroke unit with a

general medical ward; six trials comparing mixed assessment/

reh abilita tion u nits with a genera l medical war d; a nd four tr ialscomparing a mixed assessment/rehabil i tat ion unit with a


27/55


dedicated unit. Dedicated units dealt with stroke cases only.

Mixed assessment /reha bilita tion un its were eith er a ward or a

team with an interest and expertise in the assessment and

reh abilita tion of disablin g illness but not exclusive to str oke. The

rate of death after one year was found to be 20.9 per cent for

str oke units an d 25.4 per cent for alter na tives. The proport ion of

pat ient s u na ble to live at home was 40.1 per cent for str oke un its

and 47.2 per cen t for t he a lterna tives. Benefits did not depend on

increased hospita ls sta ys a nd ma y even h ave reduced th em. The

team concluded that stroke unit care was unlikely to be more

expensive tha n conventiona l car e in a genera l war d a nd m ay be

less cost ly.61

However, despite clear evidence th at str oke u nits ar e effective,

th ey ar e un der-used. The m ost systema tic evidence comes from

th e 1998 Stroke Association sur vey. It carr ied out two nat iona l

surveys: one covering a ll consultant s in th e UK r esponsible for the

care of stroke patients; and one covering all health authorities

an d boar ds in t he U K. The findings were distu rbing. The ea rlier

St roke Associat ion su rvey of 1992/93 had foun d th a t u nder ha lf of

consu ltan ts h a d access to a st roke un it. Despite th e appea l of theStr oke Associat ion for the collect ion of informa t ion , in 1999 th ere

was still no national information about the number of stroke

units, the treatment policies they followed, or the number of

patients treat ed by them.

Neverth eless, the 1998 sur vey foun d t hat about 75 per cent of

consu lta nts had a ccess t o some form of specialist st roke service,

either a defined unit with beds or an interdisciplinary team.

However, of those with access to a specialist service, in 46 per centof cases it was to a rehabilitation unit. Acute-only units were

available to 17 per cent of consultants and combined acute/

reh abilita tion u nits t o 16 per cent.62

Consult ant s wer e sa id to be fairly happy with th eir a ccess, but

a significan t minority report ed inadequat e a ccess: 18 per cent ha d

inadequat e a ccess t o acut e str oke u nits; 20 per cent to rehabilita-

tion units; 25 per cent to acute/rehabilitation units; and 13 per

cent to a str oke tea m.In practice, however, only one-third of consultants said that

patients were usually managed by a stroke unit team or in a


28/55


str oke un it. Moreover, t her e were significan t regiona l var iations

an d, in th e worst cases of the West Midlan ds an d th e North West,

40 per cent of consu ltan ts did not m an age their pat ient s in str oke

units or teams.63

Despite an overall improvement in access since 1992/93, the

1998 survey foun d wide and un accepta ble variat ions a round t he

coun tr y in t he chan ces of being ma na ged in a n organ ised stroke

service. Consu ltan ts from England (29 per cent) a nd Wa les (21

per cent ) had poorer a ccess to acute st roke unit car e tha n t hose

from Scotland (41 per cent) or Northern Ireland (52 per cent).

Patients in Northern Ireland had the best chance of being

admitted or transferred to a stroke unit, followed by Scotland,Tren t, Wales and London. Those a dmitt ed to hospitals in Wales,

Scotlan d or Nort her n Ir elan d were a pproxima tely twice as likely

to be cared for in a stroke unit as those admitted to English

hospitals.64

Of th ose consu ltan ts who trea ted st roke, only 3 per cent were

specialists in stroke medicine. The others were specialists in

general medicine (55 per cent), geriatric medicine (27 per cent)

and neurology (6 per cent). Most were part of a team, but thesurvey found that many consultants felt the time available for

th eir st roke pa tient s wa s eith er fairly or very ina dequa te.65

At t he t ime of th e survey it was estima ted tha t on an y single day

th ere would be about 10,500 str oke pa tient s in U K hospita l beds.

On t he da y of th e survey about 52 per cent were ma na ged by an

organ ised st roke service. Tha t is, nea rly ha lf were depr ived of th e

established a dvan ta ges of a str oke un it, nam ely a su bstan tially

reduced risk of dea th or severe d isability. The St roke Associationcalcula ted t ha t, of th e estim a ted 116,000 acute st roke admissions

in a year , about 55,000 were not ma na ged in a str oke un it, which

would ha ve reduced t he chan ces of deat h or being instit u tiona l-

ised by 25 per cent . The Str oke Association estima ted t ha t t his

mea nt th ere were between 4,500 an d 7,000 avoidable deat hs a nd

institutional placements each year. Or, counting only deaths,

between 2,000 an d 3,000 avoidable deat hs per yea r. All told, th e

Stroke Association concluded that only about half of all strokepa tien ts were receiving opt ima l specia list st roke car e.66

The Stroke Association also found that other treatment tech-


29/55


niques of proven efficacy were not being applied. There was

evidence t ha t some consu ltan ts were not well informed about th e

benefits of some drug treatments, including even aspirin and

hepa rin, which h ad been th e subject of two ma jor int ern at iona l

tr ials the year before th e survey. When pa tient s were tr eat ed in

th e comm un ity, th e Stroke Association foun d th at fewer t han h a lf

of th e pat ient s who would benefit from t aking aspirin were in fact

taking it. And, even following hospita l discha rge, only 80 per cen t

were tak ing it .67


30/55

21

2

Cancer

I n S aving Lives: Our H ealth ier N ation th e Govern ment report sthat overall death rates from cancer in England for peopleun der 65 are slightly better t ha n th e EU average, but goes on to

sa y tha t t his figure conceals some import an t differen ces. The UK

ra te of deat h from brea st cancer is am ongst t he worst in Eu rope,

twelfth out of 15, and for cervica l cancer t he UK is th irt eent h out

of 15.1 The report ma kes the fur th er adm ission t ha t t he cha nces

of sur viving ar e poorer in th e UK th an in some other coun tr ies

and goes on to concede tha t pa rt of th e differen ce ma y reflect the

fact that there are cancer services in other countries which are

better th an we are in th is coun tr y at t rea ting can cer. This

admission is then followed by a fur ther confession. People in more

depr ived a rea s, it sa ys, ten d t o have lower su rvival ra tes .2

The E uroca re I I st udy, based on over 3.4 million cancer r ecordsin 17 coun tr ies, allows us t o compar e sur vival ra tes in E ngland

an d Scotla nd with th ose for other Eu ropean coun tr ies.3 It sh owed

that in England and Scotland the five-year survival rate from

1985 to 1989 was below th e Eu ropean avera ge for both m en a nd

women suffering cancer of the colon and rectum,4 lung,5 and

breast .6 The gap wa s often subst an tial. For inst an ce, five year s

after t rea tm ent , the cha nces of sur vival for men with colorectal

can cer were 59 per cent in t he N eth erlan ds compa red with 41 percent in En glan d a nd Scotland. In F ra nce men with lung can cer

ha d a 40 per cent cha nce of being alive one year a fter t rea tm ent ,

compa red with 23 per cent in En glan d.

Since the report of the Expert Advisory Group on Cancer

(Calman-Hine) in 19957 more attention has been devoted to

deficiencies in cancer care. However, despite the widespread

criticism, inadequacies remain. According to WHO cancer

progra mm e director a nd NHS consu ltan t, Professor Ka rol Sikora ,


31/55


no ma jor resources ha ve been allocat ed t o sett ing up specialist

team s, as r ecomm ended by Calma n-Hine, and th e UK h as fewer

oncologists per pa tient th an compa ra ble Eu ropea n coun tr ies. A

Royal College of Radiologists su rvey found t ha t the workload of

UK oncologists was far higher than in similar European coun-

tr ies. Some U K consu ltan ts were seeing over 1,000 new pat ient s

a year. The average was 550 a year , compa red with 250 in F ra nce

and Germany. To match German and French figures would

require t he n um ber of UK consu ltan ts to be doubled.8

The shortage of specialists means, not only the denial of

treatment, but also delays even in emergencies. For instance,

meta sta tic maligna nt spina l cord compression is a ma jor cau se ofmorbidity in patients with cancer and often means that a

previous ly-fun ctioning pa tien t becomes bedr idden or confined t o

hospita l for th e rest of his or her life.

D.J. Husband, consultant in clinical oncology in Bebington,

car ried ou t a st udy of 301 pa tient s referr ed to th e Clat ter bridge

Cent re for Oncology for tr ea tm ent of a first episode of ma ligna nt

spina l cord compression du ring a th ree-yea r period. It is widely

accepted t ha t m aligna nt spina l cord compr ession is a medical orsurgical emergency, requiring urgent diagnosis and treatment

becau se dely can resu lt in irr eversible par a lysis or loss of bladder

function.

However, the study found that delay in the diagnosis and

treatment of malignant spinal cord compression remained a

common problem and resulted in preventable deterioration in

neurological function before treatment in most patients. It is

rea sona ble to expect r eferr al a nd t rea tm ent of th is condition in

less th an 24 hour s but t he st udy foun d tha t t his tar get was notachieved for 70 per cent of pat ient s a t gener al pr actitioner sta ge,

79 per cent a t t he distr ict genera l hospita l sta ge, an d 33 per cent

at the treatment unit stage. Delays of more than seven days

occurred in 33 per cent of patients at the general practitioner

sta ge, 34 per cent at th e district genera l hospital sta ge an d six per

cent at th e tr eatm ent u nit st age. Failur e to diagnose spina l cord

compress ion and fa ilur e to investigat e, refer, and t rea t su fficient ly

urgently were the main causes of delay and the consequentfunctional deterioration.9


32/55

CANCER 23

The Calma n-Hine report advocat ed an improved network of care

based on some 30 specialist can cer cent res, each link ed t o 10-12

can cer u nits. In th e yea r a fter th e Calman -Hine report, Pr ofessor

Richa rds an d colleagues10 condu cted a sur vey based on 12 tr ust sproviding for 24 million people. The study looked at current

activity levels, changes in activity over time, and facilities for

can cer care. They foun d tha t t he r ecomm enda tions of the Calman-

Hine report had not been implemented. Five out of the twelve

centres did not provide a full haemato-oncology service and the

sam e num ber did n ot employ specialists in pa lliative medicine.

Furthermore, considerable inequalities were evident in the

provision of h igh t echn ology equipm ent, th e referra l r a te a nd theprovision of cancer beds between th e cent res.11 Three year s lat er,

in 1999, Professor Kar ol Sikora described t he implemen ta tion of

Calma n-Hine as a saga of un der-resou rcing and bu rea ucra tic

muddle. Whole forest s had been felled, he sa id, to gener a t e t he

paper consu med by report s, stra tegic an alyses an d focus groups,

but progress h ad been inadequa te. A ma jor problem h ad been th e

lack of new resour ces t o implemen t change.12

If th e UK were a s effective in tr ea ting each cancer a s t he bes t in

Eur ope, ar gued P rofessor Sikora , it cou ld save up to 25,000 lives

a year. And if it merely hit the average, this figure would be

10,000 lives.13 He conceded that there had been some improve-

ments, but because the Calman-Hine report had not been

accompa nied by any promise of new fun ding, a ny impr ovemen t s

implied a r eduction in other ser vices. He th ought t ha t th e limited

improvemen ts following Calman-Hin e ha d been at th e expense of

patients with cardiovascular disease, diabetes and the chronic

problems of old a ge.14

The Main Kinds of Canc er

Lun g Can cer

Surgical resection is the recognised treatment of choice for

pat ient s with sta ge I or II non-sma ll cell lung can cer. In t he UK

surgical resection rates have remained at about 10 per cent,

wherea s in t he USA one su rvey report ed a ra te of 28 per cent a nd

in Europe rates have been found to be higher still. In reality,ma ny UK pat ients with operable tumours h ave been denied the

cha nce of cur a tive sur gery.15


33/55


Figu r e 3

Figu r e 4

Note: All rat es ar e rela tive an d age-sta nda rdised. They reflect findin gs from

th e Eu rocar e II st udy for 1985-1989.


34/55

CANCER 25

The one-year sur vival rat es in E ngland an d Scotla nd were not

only below th e Eur opean avera ge, but th e a bsolute lowest out of

th e 17 coun t r ieswhich included E stonia , Slovakia, Slovenia a nd

th e oth er 14 coun tr ies in the E ur oca re II stu dy (see Figure 4). The

five-year sur vival ra tes for En glan d a nd Scotlan d were a lso well

below the European average but were not the absolute lowest.

Est onia ha d a five per cent sur vival ra te for m en compa red with

Scotla nds six per cent and Englan ds seven per cent (see F igur e

3). The Eur ocar e II au th ors believed th at th e lower su rvival ra tes

for pa tient s with lun g can cer in E ngland an d Scotlan d were partly

expla ined by rest ricted a ccess t o specia lised care.16

Hilary Pickles, Director of Public Health in Hillingdon, hasar gued t ha t lung cancer is often given low pr iorit y becau se it is

seen a s self-inflict ed. Pickles fur th er a rgued tha t on ly so mu ch

can be done within existing resources and that the outlook for

lung cancer compared with alternatives such as care of the

elderly, asthma, breast cancer and cardiothoracic surgery was

bleak.17

Breast Can cerEa ch yea r a round 30,000 new cases of breast can cer a re diagnosed

in th e UK an d ar oun d 15,000 die from th e disease. The Eu rocar e

st udy, based on 30 can cer r egistries in 12 coun tr ies between 1978

and 1985, foun d relat ively low survival for UK women with brea st

cancer. England and Scotland, along with Spain, Estonia and

Poland, had the lowest rates of breast cancer survival.18 The

Eur oca re I I st udy from 1985 to 1989, based on 42 r egistr ies in 17

countries, found that Scotland, England and Slovenia had one-

year su rvival some 3-4 per cent below th e avera ge, and five-year

su rvival 6-9 per cent below avera ge (see F igur e 5).19

How can th ese differences be explained? The E ur oca re a ut hors

concluded th at low sur vival in t he UK may be a tt ribut ed t o poor

compliance on the part of health authorities and doctors with

consensu s t rea tm ent guidelines a s well as great er var iat ions in

treatment .20

There is no evidence tha t brea st can cer in UK women differs in

histology or grade from that in similar countries. Nor is there

evidence that women in the UK who have symptomatic breast


35/55


disease delay any longer in seeking diagnosis.21 Consequently,

according to Professor Richa rds of Guys a nd St Thoma s, th e chief

rea son for poor UK resu lts is th a t a significan t n um ber of women

who ar e diagnosed with brea st cancer r eceive su b-opt ima l ca re.22

A study of women aged under 50 in the South East Thames

Region by Pr ofessor Richa rds foun d that th e trea tment s provided

were frequ ent ly at var ian ce with well-respected gu idelines.23

Figu r e 5

Note: Rates a re a ge stan dar dised a nd relat ive. 1985-1989 Eu rocar e II

A study by C.J. Twelves and colleagues found that, althoughgeographical variations in the selection of patients for surgery

account for some of the differences in survival, the health

au th ority in which t he pa tient was first t rea ted had a n effect on

the outcome. In fact, across health boards, estimated five-year

survival rates ranged from 67 per cent to 84 per cent. One

possible explana tion was differen ces between health boards in th e

proportion of patients receiving adjuvant systemic therapy

(usually tamoxifen). Analysis clearly showed that the healthboa rd of first t rea tm ent predicted independen tly whet her or not

pat ient s would receive adjuvan t systemic tr eat men t.24


36/55

CANCER 27

Figu r e 6


37/55


Figu r e 7

Not

e :

Ra t

e s

a r e

r e l

a t i

v e

and

a ge -

s t a

n d

a r d

ise-

d .

198

5 -

198

9 ,

Eu rocar e II


38/55

CANCER 29

Other studies have also found unexplained variations in

diagnosis an d tr eat men t. Chouillet a nd colleagues assessed 334

cases of breast cancer diagnosed in South East England. It is

fundamental to effective treatment that the stage of the cancershou ld be kn own, but it was r ecorded in only 24 per cent of cases.

Liver and bone scan ning an d skeleta l ra diogra phy were ca rr ied

out as frequen tly as a xillar y surgery, when the guidelines advised

agains t t he u se of such investigations a nd st rongly recommended

axillary sa mpling to determine t he st age of th e disease.25

Sainsbury and colleagues investigated outcomes in 12,861

women t rea ted in Yorkshire and foun d considera ble va ria tions in

survival between patients treated by different surgeons. Afterallowing for case-mix and other variables, 20 per cent of the

varia tion in su rvival was explained by chem oth era py alone a nd

six per cent by hormone ther apy alone. If chemoth era py ha d been

used in 40 per cent of cases (inst ead of about n ine per cent ) th ere

would h ave been a four per cent increa se in t he five-year su rvival

rate, which would have meant that an additional 500 patients

would h ave been a live after five year s.26

Access to specialists also has a significant impa ct on su rvival. A

study by Gillis a nd Hole measu red t he sur vival out come of care by

specialist surgeons in breast cancer in the west of Scotland. 27

This study found that, after adjustment for prognostic factors,

five- an d t en-year sur vival ra tes were nine per cent an d eight per

cent higher r espectively am ong women tr eat ed by brea st can cer

specialists as opposed to non-specialists. Out of 3,786 patients

studied, only 918 were seen by a su rgeon with a specialist

int eres t.28

Colorecta l Ca ncer

Colorecta l cancer is the second most comm on fat al ma ligna ncy in

both sexes combined, after lung cancer.29 It was responsible for

over 15,000 deat hs in E nglan d and Wales in 1996.30 The Eu rocar e

II st udy of th e per iod from 1985-89 foun d t ha t five-year su rvival

for both men an d women was below th e Eu ropean avera ge. For

En glan d th e ra te was 41 per cent , which placed it t welfth out of

17. Rates in the most successful countries were substantiallyhigher. The five-year survival ra te in th e Nether lands wa s 59 per


39/55


cent for m en a nd 56 per cent for women. In Fr an ce th e ra te wa s

52 per cent for men an d 54 per cent for women .31

Ov ar i an Canc er

Ovar ian can cer is th e four th most comm on cau se of deat h from

cancer amongst females, with an overall five-year relative

sur vival ra te of just under 30 per cent . There ar e 6,000 new cases

an d some 4,000 death s from ovar ian cancer a year.32

One st udy audited seven district h ealth a ut horities in th e Sout h

East Thames region covering 118 newly-diagnosed cases of

ovar ian can cer . Clinical guidelines were agreed before t he st udy

began an d their implement at ion was t hen audited. The guidelineswere based on consensus statements and were very similar to

guidelines in use in the US and elsewhere in the UK. Both

investigation and management of ovarian cancer varied signif-

icantly between hospitals. Only 53 per cent of patients received

the recommended diagnostic procedures, and the inappropriate

investigation may explain the inadequacy of subsequent treat-

men t. Overa ll, only 43 per cent of pa tient s were judged to ha ve

been t he subject of appr opr iat e clin ica l investigat ion a nd m an-agemen t. At S ta ge I, 72 per cent were judged t o have been

inappr opriat ely ma na ged, at St age II, 47 per cent an d a t St age

III, 54 per cent were cons idered t o ha ve been ina ppr opr iat ely

ma na ged, when t heir tr eatment was judged a gainst intern at ion-

a lly accepted gu idelines.33

Another ret rospective review of pat ients in Ma nchester foun d

that fewer than half the patients underwent the generally

accepted su rgica l procedure.34 The a ctu a l conduct of consu lta nt s

was compar ed with t he opt ima l mana gement defined in accepted

consensus statements.35 The study found that in North West

En gland ma ny consu ltan ts were opera ting on a few patient s each,

at th e expense of pa tient sur vival. The r ecommended pr actice was

for pa tient s to be trea ted by specialist tea ms with th e necessar y

combined expert ise and not by individua l consu lta n ts who lacked

th e r equired experience an d knowledge. However, in one su bset

of 76 patients, only 32 received the recommended treatment of

hysterectomy, bilateral salpingo-oophorectomy and infracolicomentectomy.36


40/55

CANCER 31

The CancerBACUP sur vey of ovar ian cancer tr eatment simila rly

found that various international as well as national guidelines

were not being followed. The use of plat inu m/pa clita xel (Taxol)

combina tion t her apy for ovar ian can cer h ad been recomm endedby the J oint Coun cil for Clinical Oncology (a joint body r epr esen t-

ing the Royal College of Physicians and the Royal College of

Ra diologists) an d endorsed by the Depar tm ent of Health s

Stan ding Medica l Advisory Comm itt ee. First -line u se of plat inum

an d Taxol had r esulted in m ore t ha n 70 per cent remission ra tes

an d a n additiona l year of life on avera ge.37

Figu r e 8

Note: Rates a re a ge stan dar dised a nd relat ive. 1985-1989 Eu rocar e II

In th e Can cerBACUP su rvey, individua ls who were responsible

for commissioning services for a roun d ha lf th e na t ions popula tion

work ing in 60 NH S au th orities an d boar ds were int erviewed in

th e sum mer of 1998. Less th an one-fifth of NH S a ut horities a nd

boar ds were able to ensur e th at suitable ovarian can cer pa tients

received t he r ecomm ended plat inum/paclitaxel trea tm ent . In fact,in ma ny loca lities t here were no pa tients r eceiving th is treat men t

from t he N HS. The cau se was almost en tirely finan cial, becau se


41/55


almost all the directors of public health and consultants

approached by the su rvey team were aware of th e effectiveness of

plat inu m/paclita xel tr eatm ent. One lead pur cha ser in souther n

Englan d commented: we recognise tha t we ha ve got t o respond ...The advantages are too great to ignore. But at the same time

th ere ar e cost quest ions, and people ha ve got t o th ink t h rough the

implications.38

In 1996 th e E nfield-Ha ringey Health Authority sent out a lett er

to two tru sts with wh ich it h ad cont ra cts u rging them to cut back

on pa tients receiving the taxanes, Taxoter e (doceta xel) for ovarian

and brea st cancer a nd Ta xol (paclitaxel). The au th orit y, 1.7m in

debt, declared it wa s ta king the a ction becau se it ha d ru n out ofmoney for t reat ment using the dru gs.39

Chemotherapy for cancer has been found to be effective in

clinical t rials, but n ot only is it withh eld from pa tient s, there a re

also difficulties in fun ding fur th er vita l resea rch. R.E. H awkins ,

Clinical E ditor of th e British Journal of Cancerand Director of

Medical Oncology at the Christie CRC Research Centre, has

reported that some trials of potentially useful drugs have been

delayed because of a lack of funding. The ICON3 trial, for

exa mple, was delayed beca use loca l pur cha sers r efused to fun d

th e dru g costs.

Conclusions

Some of th e dispa rit ies described were due t o bad or incons isten t

clinical practice, but the underlying difficulty was the lack of

finance.

It is now accepted that adjuvant chemotherapy improves

sur vival and th at palliative chemothera py impr oves t he qua lity

of life for sufferers of advanced cancers. However, in a lett er t o the

British Medical Journal in September 1997 eleven doctors

representing the Association of Cancer Physicians pointed out

th at th e rea llocation of NHS fun ding to prima ry car e ha d been th e

cau se of ma ssive problems for can cer u nits a nd centr es an d th at

cytotoxic therapy had often been the main target for budget

reductions. Their use had, in effect, not been funded in many

regions. The eleven doctors compared the cost of cytotoxicchemotherapy with other drugs. The total budget for cytotoxic


42/55

CANCER 33

dru gs was about 58m compa red with th e 250m spent on th e

single ulcer-healing drug omeprazole.40 The authors quote

inform a tion from In tercont inent al Medical Stat istics, for th e year

end ing Sept ember 1996, when about 1,038 million wa s spen t ongastr ointest inal d ru gs, 848 million on car diovascular medicines,

282 million on derm a tologica l tr eat ment s a nd only 167 million

on can cer dr ugs.

The situ at ion ha d become bad enough by October 1999 for th e

Secret ar y of Sta te for H ealth , Alan Milbur n, to ann oun ce a n ew

ten-year initiative to improve cancer care. Professor Mike

Richa rds was a ppointed th e Nat iona l Cancer Director to lead th e

programme and Mr Milburn declared that he had asked theNa tiona l Inst itu te for Clinica l Excellence to dr a ft ea r ly guidance

on th e u se of th e t axan es, to end th e postcode lott ery of ca re, as

his press release pu ts it .41 He a lso ann oun ced a n additiona l 80

million for can cer services, but when ques tioned by journ a list s it

tu rn ed out th at th e 80 million was coming out of a sum alrea dy

allocated for NHS improvements and which had already been

announced.42 Such m easur es give the impression of action but , in

rea lity, fa ll a long way short of wha t is r equired.


43/55

34

3

Conclus ions

The m ain findings can be sum ma rised a s follows. The UK ha s

a poor r ecord of preventing dea th from disea ses of the circula -

tory system. After a llowing for th e differen t age str uctu re of each

coun tr y in th e Eu ropean Union, t he U K death ra te from circula-

tory diseases for per sons a ged under 65 was ranked thirteenth outof th e 15 coun tr ies stu died.

The t wo ma in diseases of th e circula tory system ar e corona ry

hear t disease a nd st roke. Corona ry hea rt disease is t he biggest

single cau se of premat ur e deat h, killing 28 per cent of men an d 17

per cent of women in 1996. High blood pr essure is one of th e main

risk factors a nd a successfu l service would pr ide it self on effective

tr eat men t. However, in 1997 u nder ha lf of people with high blood

pressure were being treated successfully (42 per cent were

receiving effective treatment, 21 per cent were being treated

inadequat ely, and 37 per cent were not being tr eat ed at all).

Stroke is th e th ird biggest killer an d th e biggest cau se of severe

disability. Ther e has been solid evidence for some time th at car e

of stroke pa tient s in a specialised st roke unit r educes m ort ality by

25 per cent. An effective health service would pride itself on

providing for str oke pa tient s in t his ma nn er. However, in 1998

only one-th ird of NH S consu ltan ts sa id tha t t heir pa tient s were

usu ally man aged by a str oke un it team or in a str oke un it.

It is also difficu lt t o ta ke a ny pr ide in t he U Ks r ecord in cancer

car e. The best evidence comes from t he 17-na tion E uroca re s tu dy

which compares one-year and five-year su rvival rat es for t he m ain

can cers. It foun d th at En glan d an d Scotlan d ha d th e lowest one-

year survival rates for lung cancer. The five-year survival rate

was little better, with England ranking 12 out of 17, above

Scotlan d, Estonia, Denm ar k, Poland a nd Slovenia.


44/55

CONCLUSIONS 35

For br east ca ncer (15,000 deat hs) En glan ds one-year sur vival

was r anked tent h out of 17 a nd Scot lan ds twelfth out of 17, above

Aus tr ia, Est onia, Poland a nd Slovakia . The five-year sur vival ra te

in E ngland was elevent h out of 17 and in Scotlan d t welfth out of17, above Slovenia, Aust ria , Est on ia, Poland , and Slovak ia.

Colorecta l cancer is t he second largest k iller a ffecting both sexes

(15,000 deaths). For cancer of the colon in men the five-year

survival rate in Scotland an d E ngland was r an ked equa l elevent h

out of 17. For women , Scotlan d a nd En glan d were equa l twelfth

ou t of 17.

Ovar ian cancer is th e fourt h la rgest cancer killer. The five-year

survival ra te for E ngland was eleventh out of 17 an d for Scotla ndth irteen th (see Figur e 8).

There is little doubt that rationing is the root cause of these

problems. In the early 1990s Britain had fewer radiotherapists

per head than Poland and fewer medical oncologists than any

coun tr y in western Eu rope.1 The short age of specia list s r eflect s

th e gener a l sca rcity of doctors. OECD figur es for 1996 show th a t

the UK had 1.7 practising physicians per 1,000 population.

German y had 3.4 per 1,000, Fr an ce 2.9 an d Poland 2.4. The onlycountries with a lower proportion among the 29 studied by the

OECD wer e Korea (1.2), Mexico (1.2) and Turkey (1.1).2 However

well motivated individual doctors might be, if they are in short

supply, the inevita ble r esult is th e dilut ion of ca re.

Tota l spending on health ca re is low by interna tiona l sta nda rds.

In 1997 tota l expenditur e on h ealth care in t he UK was 6.9 per

cent of GDP. The German figure was 10.7 per cent and the

Fr ench, 9.6 per cent . Of th e 29 a dvanced coun tries studied by theOECD, only Hunga ry, Ireland, Korea , Mexico, Poland and Tur key

spent less. To ma tch Germ an levels would requ ire an increa se of

nea r ly 30 billion per year . Even if we leave out private expend i-

ture on health and compare only government spending, the

disparity remains. In 1997 the UK govern men t spent 5.8 per cent

of GDP on hea lth car e, compar ed with th e Germa n figur e of 8.3

per cent . To ma tch th e Germ a n pr oport ion would require near ly

20 billion a year extr a . Gaps of th is ma gnitu de cannot be closed

by measu res such a s special improvemen t fun ds an d efficiency

savings.


45/55


Wha t should be d one? After decades of den ial it is now widely

accepted that NHS rationing is endemic and has harmful

consequen ces for pa tien ts . Would more money be t he answer?

This is n ot th e place to go into the complex issues en ta iled inan y search for a n a lterna tive to th e NH S, but st at e finan ce has

now been test ed in a 50-year pilot schem e which a ny r easonable

and impa rt ial observer would concede ha s been a fa ilur e. We need

an u rgen t pu blic deba te a bout how best t o int roduce a bigger role

for personal payment and insurance without compromising the

pr inciple of access for a ll.

There are countless alternatives available elsewhere in the

world an d a debat e ha s already begun in th e UK. For example,Professor Chris Ham, has advocated an increased role for

competing non-profits.3 Pr ofessor J ohn Spiers ha s advocat ed th e

privat isat ion of hospita ls.4 J ohn Willma n, Consu mer Indust ries

Editor of the Financial T im es, ha s a dvocat ed pat ient cha rges.5

And Oliver Morgan of th e Observerha s put th e case for increased

private finance.6 We hope that our findings will add a little

ur gency to th e sear ch for a better alter na tive.


46/55

37

1 For instan ce, Cooper, L., Coote, A., Davies, A. and J ackson, C.,

Voices Off: Tacklin g th e Dem ocratic Deficit in Health , London:

Ins tit ut e for Pu blic Policy Resear ch, 1995.

2 For example, Professor Alan Maynard at the University of York

is a strong defender of this approach. The journal Effective

Health Care regularly publishes studies of cost-effectiveness.

3 See for exam ple th e publicat ions of Pr ofessor Alan Williams,

Un iversit y of York.

4 Hunter , D., Desperately Seek ing S olut ions, London: Longman,

1997.

5 Klein, R., Day, P. and Redmayne, S.,Man aging S carcity: Priority

Setting and Rationing in the National Health Service,

Buckingham: Open University Press, 1996.

6 Klein et al., Man aging S carcity,1996, p. 123.

7 McKenzie, J . et al., Dialysis decision ma king in Can ada , th e

United Kingdom a nd t he Un ited Sta tes, American Journal ofKid ney Diseases, Vol. 31, No. 1 (Jan ua ry) 1998, pp. 12-18.

8 Roder ick, P . et al., The pr ovision of ren al r eplacemen t th era py

for adults in England and Wales: recent trends and future

directions, Q J Med, Vol. 91, 1998, pp. 581-87.

9 Dep ar tm en t of Hea lt h , The National Survey of NHS Patients.

10 The Clinical St an dar ds Advisory Group was esta blished in April

1991, under Section 62 of the NHS and Community Care Act1990, as an independent source of expert advice to UK health

ministers an d to th e NHS on st an dar ds of clinical care for, a nd

access a nd ava ilability of services to, NHS pa tient s. The Gr oups

members are nominated by the medical, nursing and dental

royal colleges and their faculties, the professions allied to

medicine, and include the chairman of the Standing Medical

Advisory Committee.

11 The St an ding Medical Advisory Comm itt ee is one of five

sta tu tory bodies which a dvise health ministers in En glan d an dWales on t he pr ovision of medical services un der t he N HS Acts .

Members ar e ap point ed by minist ers following nomin at ions by

Notes

Introduction


47/55


professional bodies and include the presidents of all medical

royal colleges. Nine standing advisory committees were first

esta blished in 1949, but un der t he NH S (SAC) Order 1981, four

SACs were reta ined with u ncha nged ter ms of referen ce, to adviseon the provision of medical, nursing & midwifery, dental, and

pha rm aceut ical ser vices in En glan d and Wales. A fifth SAC, now

th e Joint Comm ittee for Vaccina tion an d Imm un isat ion Services,

was subsequently established. SACs perform their statutory

functions in three ways: developing advice (advisory role);

commenting on advice developed by others (consultative role);

and alerting ministers an d th e depar tment to issues which a re

likely to be import an t in t he futur e (monitoring role).

Chapter 1

1 Corona ry Heart Disease S tatist ics, British Heart Foundation,

1998, p. 14.

2 Corona ry Heart Disease S tat istics, 1998, p. 9.

3 Saving Lives: Our Healthier Nation, Cm. 4386, London: The

Sta tioner y Office, 1999, p. 73. See also Dept of Healt h, Coronary

Heart Disease: An Epidemiological Overview, London: HMSO,

1994.


5 The Health of the Na tion, Cm 1523, London: HMSO, 1991, p. 59.

6 Corona ry Heart Disease S tatist ics, 1998, pp. 9-10, 19. The figur es

ar e for m en a ged 35-74 and a re a ge-sta nda rdised, based on t he

Eur opean St anda rd P opulation.



9 Coronar y angioplasty involves inserting a balloon into the

obstructed artery and inflating it to tear the inner part of the

ar ter ial wall in order to reduce the obstr uction. The CABG is

Documents

Delay, Denial and Dilution