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CONTENTS
CONTENTS
ON THE STATE OF PUBLIC HEALTH
1858 The first Annual Report of the Chief Medical Officer
PROGRESS CHECK
PASSIVE DRINKING
The collateral damage from alcohol
PROSTATE CANCER
What to do with the pussycats?
PAIN
Breaking through the barrier
ANTIMICROBIAL RESISTANCE
Up against the ropes
SAFER MEDICAL PRACTICE
Machines, manikins and Polo mints
THE REGIONS
Health problems and initiatives
2
6
12
16
24
32
40
48
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This is the latest in a series of Annual Reports produced
by Chief Medical Officers since Victorian times.
2008 was a year of important anniversaries.
The sixtieth anniversary of the founding of
the NHS was celebrated in July. The 150th
anniversary of the first Medical Act – which
established the General Medical Council –
was celebrated in the autumn.
The first Chief Medical Officer’s report was
also published 150 years ago, and in one
section of this year’s Report I have reflected
on the impact of the great sanitary reformers
in Victorian England. I am only the fifteenth
person to hold the post of Chief Medical
Officer since those distant times.
making me the longest serving in 40 years.
In 2009, I will be publishing an account of
the work of the Chief Medical Officer over
the last decade.
Looking back over the last year, aside from
the celebration of past achievements and
historical landmarks, it has been another
period of major change and activity in health
and healthcare.
The first of our number, Sir John Simon,
wrote the initial report on the nation’s
health. He also helped to bring about major
improvements in public health, in particular
through championing the need for the early
Public Health Acts. A stream of public health
legislation followed over the years and the
first wave of Medical Officers of Health took
up their posts to spearhead improvements in
sanitation and infant and child health. We
owe our present state of health and
longevity to those pioneers.
The final report of the review of the NHS,
High Quality Care for All, carried out by
Parliamentary Under Secretary of State and
practising surgeon Lord Darzi, is a major
landmark in the development of the NHS.
The work undertaken for the report was
widely participative, notably involving
thousands of front-line clinicians around the
country. I was asked by Lord Darzi to lead
the national strand of work on quality and
safety in healthcare, and I reported to him in
March. His final report states that quality will
be the ‘organising principle’ of the NHS. This
is a highly significant commitment and one
that should be welcomed widely by
clinicians, patients and the public.
Simon served for 21 years, by far the longest
spell in office as Chief Medical Officer. In
2008, I passed my tenth anniversary in post,
In my 2002 Annual Report, I warned of the
impact of the obesity ‘time bomb’ on the
future health of the population. Since then,
3
ON THE STATE OF PUBLIC HEALTH
ON THE STATE OF PUBLIC HEALTH
CMO ANNUAL REPORT 2008
public concern and media coverage have
seldom drifted far from the problem. The
very valuable report produced by the
government’s Foresight Programme
reviewed and analysed the scientific
evidence relating to obesity very extensively.
It led to the publication in January 2008 of
Healthy Weight, Healthy Lives: A CrossGovernment Strategy for England.
In April 2008, the Secretaries of State for
Health and Children, Schools and Families
asked me, together with the Chief Medical
Officers of the other United Kingdom
countries, to review the scientific evidence
relating to young people’s health and alcohol,
and to produce advice. In January 2009, I
published my findings in Draft Guidance on
the Consumption of Alcohol by Children and
Young People, including the recommendation
that children under the age of 15 years should
avoid alcohol completely. This guidance is to
help parents, families and, most of all,
children and young people themselves to
change the way they view alcohol.
It is now well over a year since the
implementation of legislation to create
smoke-free workplaces and public places in
England. The legislation has been effective,
widely complied with and popular.
Experience from elsewhere in the world
shows that tobacco control measures cannot
stop, even after a major breakthrough like
‘smoke-free’. Action must continue
indefinitely if the death toll from tobacco is
to be halted. I am particularly concerned
about illicit tobacco and smuggling, a subject
I drew attention to in an earlier Annual
Report. More needs to be done urgently to
tackle this problem.
I can also report steps forward this year in the
field of medical regulation and revalidation.
In July, my expert working group published
its principles and next steps, laying out the
process and provisional timetable for
revalidation, including both relicensing
(confirming that doctors practise in
4
accordance with the General Medical
Council’s generic standards) and
recertification (confirming that doctors on the
specialist and general practitioner registers
conform with standards appropriate for their
specialty of medicine). These early steps on
the road to improved regulation will come
into effect soon, strengthening the quality of
the medical workforce and protecting the
patients it serves.
As a nation, we continue to prepare
ourselves for the most serious threats. In
2008 alone we saw new guidance for
maternity, dental and mental health services
in the event of pandemic influenza. June also
saw a major NHS national workshop on
pandemic influenza preparedness, and a
United Kingdom international preparedness
strategy was published in October.
Another concern is the recent rise in
measles. In 2008 there were 1,348
laboratory-confirmed cases, nearly 40%
higher than the 2007 total of 990 cases.
Following a decade of relatively low
vaccination uptake, there is now a large
number of children who are unvaccinated,
or who did not complete the course of
measles–mumps–rubella (MMR)
vaccination, and are unprotected against
infection. The potential exposure of a large
number of unprotected children to the
measles virus means that there is a real risk
of a large measles epidemic. Estimates
suggest that an epidemic in England could
result in 30,000 to more than 100,000 cases
of measles in children and young people,
and six to 20 deaths. These children and
young people will also be susceptible to
mumps and rubella. In August, I launched an
MMR vaccine catch-up campaign to address
this issue. Work to increase MMR vaccine
uptake and reduce the risk of a measles
epidemic will be ongoing throughout 2009.
I was also pleased to see the launch of
Health is Global in September. This first
cross-governmental strategy on global
health followed on directly from my own
consultation report in 2007. Realising that
the health of England is dependent on the
health of the wider world around us is an
important step forward in our increasingly
globalised health economy.
This year I have established the annual Chief
Medical Officer’s Public Health Awards.
They are designed to reward the excellent
and often unrecognised work done
throughout the country by many different
professions to improve the health of the
population around them. We have a proud
history of public health in this country. I
hope that these awards will highlight the rich
and diverse work being done to continue
this tradition.
While looking back over the past 150 years
is illuminating, as the faces on the cover of
this Report reflect, I have also been thinking
about the medical and health leaders of the
future. Over the last four years, I have
employed junior doctors in my office to help
me in my work and to give them first-hand
experience of management and policy. They
are right at the heart of government and the
national leadership platform. This year I have
formalised the process, creating the Chief
Medical Officer’s Clinical Advisor scheme.
Sixteen young and talented doctors are
working with clinical leaders in a variety of
high-profile posts across the country as part
of this pilot process. In the same way as the
Public Health Awards will reward success,
I hope this scheme will nurture a future
generation of doctors who can bring
together their clinical knowledge with
management and policy skills to create
true clinical leaders.
In this year’s Annual Report, I address five
new health topics.
First, the impact of alcohol on health and
society. A great deal has been spoken and
written about the problem of alcohol in this
country, and much of it has focused on the
In the first chapter of this Report, I scope
‘passive drinking’ and advocate it as a
concept that should underlie policies and
campaigns. I point out that there is no
national consensus that as a country we
should substantially reduce our alcohol
consumption. This is despite the average
adult consuming the equivalent (in units of
alcohol) of 120 bottles of wine a year. And
despite the fact that, while alcohol
consumption has fallen in many European
countries over the last 40 years, it has
increased here. The twin pillars of reducing
consumption of alcohol are price and access.
In the Report I call for further action on both.
Second, I have addressed the problem of
prostate cancer. It is the second biggest
cancer killer in England. One man is
diagnosed with the disease every 18 minutes
and around 26,000 men each year are
diagnosed with localised prostate cancer.
They do not know if they are harbouring a
‘tiger’ (an aggressive, life-threatening cancer)
or a ‘pussycat’ (a tumour that is unlikely to
harm them). I have proposed a series of
measures that will improve the quality of
advice offered to men faced with difficult
decisions about their treatment.
Third, I have highlighted the extent of
chronic pain. Every day, millions of people
experience disabling chronic pain, which
imposes a heavy burden on them, their
families and the economy at large. Although
we now have effective means of tackling
both pain and the consequences of pain,
services have not kept up with demand and
too many people struggle to cope with their
symptoms.
Fourth, I have discussed antimicrobial
resistance. Antibiotics save thousands of
lives a year in England, but many bacteria are
now resistant to them. In some diseases,
because of resistance, the last line of
defence has been reached. In this chapter,
I recommend a series of measures that will
help to improve the rational use of antibiotics
and reduce resistance levels, protecting
these valuable drugs for years to come.
My final chapter looks at how simulation
can be used to prepare doctors for the
challenges of real-world medical practice.
Medical practice is, by its nature, risky. With
advances in the complexity of care that can
be delivered comes an inexorable growth in
the possibility for error. Doctors encounter
new and difficult situations at a time it really
matters – when, for example, somebody’s
life is at stake. The art of simulation offers
the potential to change this. I draw on
examples from around the world to
demonstrate how practising through
simulation can better prepare doctors for
when they encounter a situation for real. I
also look at the lessons that we can learn
from other industries.
ON THE STATE OF PUBLIC HEALTH
upsurge of alcohol-related disease and the
extent to which alcohol fuels antisocial
behaviour and crime. Progress in the field of
tobacco-related illnesses was boosted by the
recognition that passive smoking – inhaling
smokers’ fumes – is a hazard to the health of
non-smokers. This led to the introduction of
smoke-free legislation in 2007 and promoted
the idea that ‘non-smoking’ rather than
smoking is the social norm. There is no
similar awareness or concern about ‘passive
drinking’ – the collateral damage caused by
alcohol. Yet the impact of drinking goes far
beyond the individual’s health and well­
being. It causes crime and violence in the
home and on the street, sexual assault and
rape, damage to the unborn baby, road
accidents, and the excessive consumption of
NHS resources.
understanding of ‘wellness’ will help us to
support the public in improving their
own health.
My concern over the growing obesity ‘time
bomb’ facing this country is well known, and
the East Midlands is looking at the possibility
of using interactive computer games to help
obese children lose weight. Initial results
look promising, and this could prove to be
one of the ways of engaging overweight
children in exercise.
The London Regional Public Health Group
and NHS London are using data sharing to
tackle the growing problem of knife crime in
the capital. The hospitals involved are
collecting anonymised data from emergency
departments on assault type, location and
assailant details. These are being used to
supplement data from sources such as the
Metropolitan Police in order to help develop
effective crime prevention initiatives.
As in previous Reports, I am extremely
grateful to many colleagues within the
Department of Health and outside who have
contributed to the Report. The opinions
expressed and the conclusions drawn are
my own. I hope that you will all continue to
work to tackle the issues I have raised and to
improve further the health of the nation.
Sir Liam Donaldson
Chief Medical Officer
The regional public health teams continue to
work on a range of innovative projects that
address key public health issues.
The North West region undertook work to
define what it means to be well’. Although
this issue is complex, its findings reinforced
the idea that being well is not simply the
same as not being ill. Gaining a better
5
1858 THE FIRST ANNUAL REPORT OF THE CHIEF MEDICAL OFFICER
150 years ago, Sir John Simon (1816–1904), the first Chief Medical Officer, presented a report to
Parliament describing the ‘State of Public Health in England’. This report, which was to become the first
of the Chief Medical Officer’s Annual Reports, was not merely an historical record of the events of the
year, but was meant to inspire, instruct and urge action as well as to describe methods and chronicle results.
Since this first report there has been a regular series of published Annual Reports from Sir John’s
successors, raising the key health issues of the day over the last century and a half. The first report provides
a revealing image of health and society in England in the mid 19th century. Many aspects of the health of
the population that were being discussed then have strong parallels today.
1858: Historical context
For some, 1858 was a time of hope and progress. Darwin presented his papers on evolution by natural
selection at the Linnaean Society, the first transatlantic telegraph cable was sent and, in the United States
during the Lincoln–Douglas debates, Abraham Lincoln warned that slavery would divide the nation.
Overseas, Britain was engaged in the Second Opium War (1856–60) with France and the United
States against China. The First War of Indian Independence was suppressed, starting 99 years of direct
British rule in India.
7
At home, our country was increasingly democratic. The Great Reform Act of 1832 had widened the
vote and improved the fairness of electoral representation. The Jews Relief Act of 1858 removed the words
“on the true faith of a Christian” from the oath to become a Member of Parliament, allowing Jews to sit in
the House of Commons. Emmeline Pankhurst, who would lead the suffragette movement and help secure
votes for women, was born in 1858.
Although an atmosphere of enlightenment and social reform was developing, the life of the average
English citizen was still hard, dirty and unpleasantly short.
England’s social and economic status at the time of the report
The population of Britain in 1858 was changing. People were moving from the country to live in
the cities, lured by the promise of regular work and better wages in the new factories. The census of 1851
showed for the first time that more than half of Britain’s population was living in urban areas.
The towns and cities of the Industrial Revolution were not pleasant places to live. They were
overcrowded, dirty and disease-ridden. Outbreaks of typhoid and typhus were provoked by lack of
sewers and clean water and poor housing. Cholera had recently arrived from India, and Europe was hit
by three epidemics in 1832, 1848 and 1854. It was only in 1853, five years before the publication of the
first Annual Report, that John Snow had demonstrated that cholera was a waterborne illness. Through
his investigation of an outbreak in Soho, he famously halted the epidemic by ordering the removal of the
handle of the Broad Street pump. However, the germ theory of disease was not widely accepted and
many academics and ‘scientists’ continued to maintain that diseases like cholera were caused by Miasma
(invisible, noxious vapours arising from decomposed materials).
Social commentators such as Charles Dickens highlighted these terrible socioeconomic conditions and
their impact on health, and called for change. Reformers such as Edwin Chadwick and Joseph Bazalgette
worked to improve sanitary conditions.
Reform of the sanitation system was certainly needed. 1858 was the year of the ‘Great Stink’ of
London. Foul smells from the raw sewage flowing into the Thames combined with a particularly hot
summer to cause a stench that threatened to overpower the city’s population. It was so bad that
Parliament and the law courts considered relocating themselves outside the city. MPs in the House of
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CHOLERA WAS A MAJOR PUBLIC HEALTH ISSUE AT THE TIME OF THE FIRST ANNUAL REPORT
Source: Punch magazine, 1852
Commons sat behind lime-soaked curtains, in an effort to keep the stench out, and rapidly moved to vote
for a Bill to fund a new sewerage system for London.
England’s health then and now
Average life expectancy in the United Kingdom in 1856 was 40 years. Today it is 79 years. Modern
inequalities in health status between different parts of the country are mirrored by an even wider gap in
the past. In 1851, a boy born in the provincial market town of Okehampton had a life expectancy of
57 years, but if he were born in inner city Liverpool he could expect to live an average of only 26 years.
Today, the boy born in Okehampton could expect to live to 79 years while in Liverpool his counterpart
would expect to live to the age of 74 years.
Some things were improving. By 1849, the neonatal mortality rate (children dying within a month
of birth) measured by the Quakers in London was 33 deaths per 1,000 births, compared with 112 per
1,000 one hundred years earlier. This is still some way off the rate of 3.4 deaths per 1,000 births of today.
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HEADLINE HEALTH STATUS (THEN AND NOW)
1850s
Today
17 million
51 million
40.4
79.6
Male life expectancy in Okehampton (a rural market town)
57
79
Male life expectancy in Liverpool (an urban area)
26
74
Neonatal mortality rate (deaths per 1,000 live births)
33
3.4
Population
Average life expectancy (years)
Source: Office for National Statistics; Wrigley and Schofield, 1989; Woods, 1982; Daunton, 1995
The role of the Chief Medical Officer and the Public Health Acts
Sir John Simon, the first Chief Medical Officer and author of the first Annual Report, fought hard
to create and then establish the role of an independent adviser to the government on any matters
concerning public health.
In the mid 19th century, the government was starting to take a legislative interest in public health,
but had no explicit source of expert medical advice. In 1848, the first national Public Health Act was
passed, establishing a national General Board of Health. At first, this had no medical representation but
instead focused on sanitation and the environment. It was only when Liverpool (1847) and then London
(1848) passed local Acts establishing Public Health Departments that the first Medical Officers of Health
were appointed.
Simon, then a surgeon at St Thomas’ Hospital, became the first Medical Officer of Health for London.
In this role, he collected and interpreted mortality and morbidity information weekly, advised on sanitary
improvements such as clean water and sewerage, and advocated the creation of a Ministry of Health.
In 1855, he was appointed Medical Officer to the General Board of Health, a national body, in
effect becoming the first Chief Medical Officer. When this Board was dissolved in 1858, he became the
nominated medical adviser to the Privy Council. In this position he established a series of reviews of
health policies, including the national vaccination campaign, and helped to develop the Registrar
General’s collection of vital statistics and reports. He also investigated industrial health, housing
conditions and hospital provision.
10
As an academic, and a civil servant, he was particularly notable for his use of statistical evidence to
direct public health policy. In our current age of evidence-based medicine, Simon was ahead of his time.
It was through his involvement with the construction of the
SIR JOHN SIMON
Public Health Acts that Simon was able to secure one of the most
important functions of the Chief Medical Officer – the right to report
independently on any matter concerning public health. And it was
his confident assertion of this function that created his authority with
Parliament and the public soon after his appointment.
Later in his career he was also responsible for revising the
government’s quarantine measures, was instrumental in the creation
of local sanitary authorities and administered the reformed
vaccination system set out in the 1867 Vaccination Act. He remained
active throughout his later life, publishing a review of English
sanitary institutions in 1890, 14 years after his retirement.
Vaccines, dirt and disease
In his first report, Simon wrote of the need for a national vaccine campaign and described a series
of recent epidemics in England. He discussed the problem of sanitation and its effects on health and
highlighted variations in regional mortality levels.
While poor sanitation is no longer a significant threat to health in this country, the other topics
featured in Simon’s first report still seem relevant to the modern public health agenda.
Simon described the difficulty he faced in organising an effective national vaccination campaign
against smallpox. Some current issues, such as the variable take-up of childhood immunisations, were
not a problem for Simon: the Vaccination Act of 1853 had made it a legal requirement for all children to
be vaccinated. However, other considerations in planning a successful campaign, such as the need to
ensure adequately trained medical staff, apply as much now as they did then. His call for better training
and the need to employ workers with a sound knowledge of the vaccination process rings true today, as
a modern goal is to ensure the competency of healthcare professionals in the NHS.
11
Simon also gave detailed descriptions of epidemics, their causes and efforts to control them. He
described an outbreak of cowpox in Wraysbury and an epidemic of typhoid and other ‘common filth
fevers’ in Windsor. Although the diseases that cause epidemics have changed, the central role of the
Chief Medical Officer in providing information and advice to government and the public on the control
of epidemic disease has changed little. New, emerging diseases remain a threat: in the 1850s cholera
was making headlines, in the early 21st century it was SARS. My own recent Annual Reports have
covered West Nile virus, HIV, MRSA and pandemic influenza, and given explicit recommendations on
how to reduce the threat they pose to public health.
A striking similarity between the first Annual Report and the reports of today is Simon’s call to
arms regarding the inequalities in health that are evident across the country. His appeal to the Privy
Counsellors, in a section entitled ‘On the State of Public Health in England’, sounds as relevant now as
it did then:
“The essential points which I deem it necessary to bring under your lordships’ consideration
… the inequality with which deaths are distributed in different districts of the country.”
‘On the State of Public Health in England’, Report of the Chief Medical Officer, 1858
“Although this country has seen increased prosperity and overall reductions in mortality over
the last 20 years, the gap between those at the top and the bottom of the social scale has widened.”
The current Chief Medical Officer’s Annual Report, 2001
The task facing the Chief Medical Officer has changed over the last 150 years. New diseases have
emerged, the demographics of the population are different, and the risk factors we face have altered. The
essential function – that of providing the highest quality advice, to both the government and the public,
on how to improve the nation’s health – remains unaltered.
PROGRESS CHECK
PROGRESS CHECK
This section reports on progress made on the key
issues and actions that I recommended in my
2007 Annual Report.
Under their skins: Tackling the health
of the teenage nation
The evidence is clear that good health in the
teenage years is inextricably linked to a
young person’s ability to fulfil their potential.
In last year’s Annual Report I called for a new
focus on teenage health. The teenage years
are a risk-taking period of life, closely tied to
the rite of passage into adulthood. Although
the majority of teenagers cope well, large
numbers of teens are exposed to and take
part in high-risk behaviours such as binge
drinking, drug taking and unsafe sex. Habits
adopted in the teenage years can form
behaviour for a lifetime. Keeping teenagers
well is a valuable investment in the health of
the population in the future.
It is clear that teenagers have special health
needs that must be addressed. I made a
number of recommendations to assist in this,
including: holding a national summit to take
stock of health promotion and healthcare
services for teenagers; establishing a young
people’s panel to advise on national
campaigns that address risk taking in the
teenage years; and reviewing the current
health provision for young people who
move to adult services.
Although my recommendation to reduce the
legal alcohol limit to zero for drivers aged
between 17 and 20 years has yet to be
adopted, launching the idea stimulated a
vigorous debate that has helped to raise the
profile of this important issue. Similarly,
the recent Investing in Teenage Health
Conference – a summit that brought
together both policy leaders and front-line
clinicians – made important inroads into an
often neglected area. Following on from the
conference is a Teenage Health Summit,
which will bring together teenagers from
across the country, including representatives
of the Youth Parliament, to engage in a
discussion with senior policy officials from
the Department of Health. It is hoped that
from this dialogue will flow new ideas
about how to involve teenagers in health
policy and how best to address their
health challenges.
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CMO ANNUAL REPORT 2008
In February 2009, the Department of Health
published Healthy lives, brighter futures:
The strategy for children and young
people’s health, developed jointly with the
Department for Children, Schools and
Families. This strategy is aimed at improving
the health and well-being of all children and
young people, and includes provision to
implement standards to ensure that all
young people receive appropriate
healthcare wherever they access it.
I am also pleased to note that efforts are
under way to examine the potential for
academic appointments in adolescent
health, as I recommended in my Report.
In addition, the Department of Health is
working hard to bring together data streams
so that access to the data is made simpler,
enabling improved understanding of
adolescent service needs and better
adolescent health service provision.
While you were sleeping:
Making surgery safer
Despite impressive advances in surgical
care, patients still die from preventable
harm. The burden of such harm is a serious
public health problem when considered in a
global context. For individuals, the suffering
is made worse by the knowledge that the
error was preventable. In last year’s Annual
Report I drew attention to two areas in which
surgical errors are still a problem: hip
replacement surgery, where there was an
unacceptable variation despite good
evidence of best practice; and burr holes
used in neurosurgery, in which wrong site
surgery has occurred on multiple occasions.
In response to my recommendation, the
National Patient Safety Agency has
established the Clinical Safety Board for
Surgery, thereby creating a forum in which
these concerns can be raised, and solutions
developed and implemented. The Board
includes representatives from all the key
medical Royal Colleges and professional
14
Jenner’s legacy: Creating vaccines
for the future
organisations, as well as the National
Confidential Enquiry into Patient Outcome
and Death (NCEPOD). It has begun its work
by examining the two areas I drew attention
to in last year’s Report – burr holes and hip
replacement surgery. The Board has
reviewed and approved the rapid response
that was recently issued on burr holes, and is
currently involved in the rapid response that
is being developed on the use of bone
cement in hip surgery.
Human nature is such that errors will never
be eliminated, but we have learnt how to
design systems with sufficient flexibility and
attention to detect such events before harm
occurs to the patient. One such revolution is
the World Health Organization’s Surgical
Safety Checklist pioneered by Dr Atul
Gawande. The United Kingdom has been in
the vanguard of embracing this change, and
the recent European launch of this checklist
will provide important practical advice and
tools to clinicians and hospitals attempting
this culture change. The National Patient
Safety Agency’s Clinical Safety Board for
Surgery is currently advising on how use of
the Surgical Safety Checklist can best be
implemented in England.
The NHS, too, increasingly recognises that
patients need to understand and be aware of
the data on surgical outcomes. In my Annual
Report I called for regular collection and
analysis of 30-day mortality and morbidity
data to be introduced nationally, and made
public. The recent publication of such data,
at Trust level, is a vital step towards
improving patient safety.
Vaccination is arguably the most important
public health development in the history of
humankind. Over the last 200 years it has
saved hundreds of millions of lives
worldwide. In last year’s Annual Report,
I looked at the continuing work to develop
new vaccines. Some vaccines on the horizon
could not just prevent infectious diseases –
they could also prevent or treat some
cancers and other chronic conditions, such
as type 1 diabetes, that have never before
had the potential to be preventable. I also
highlighted work currently under way to
develop new vaccines for a number of
diseases, including Clostridium difficile,
meticillin-resistant Staphylococcus aureus
(MRSA) and influenza.
One of my recommendations was that extra
effort should be focused on London to
improve the low levels of vaccine uptake.
I am pleased that this work is now well under
way. London has established a Childhood
Immunisation Project with primary care trust
chief executive and public health leadership.
Primary care trusts agreed to a substantial
investment in the project, the twin aims of
which are to support measles–mumps–
rubella (MMR) catch-up campaigns and to
ensure the future sustainability and ‘fitness
for purpose’ of immunisation systems in
London. NHS London has also made a
substantial contribution to a programme to
PROGRESS CHECK
raise awareness of the seriousness of
measles, and to stimulate positive responses
to invitations to vaccination. Primary care
trusts are also being encouraged to find
ways to address system failures in data flow,
call and recall, and access. These efforts
must not stop – a recent dramatic rise in
measles cases in London shows the effect of
a decline in vaccination and the concomitant
decrease in herd immunity.
A pathological concern:
Understanding the rise in
oesophageal cancer
Levels of oesophageal cancer in the
population of England are among the worst
in Europe. While some other nations’ rates
are falling, in England the situation has been
getting worse. Last year I highlighted these
worrying trends, and expressed concern
that not enough is known about why this
is happening.
cancer nationally, and making practical
recommendations on how to improve the
service provided.
In my Report I also recommended further
research into the causes of oesophageal
cancer. I was pleased to see that research
of this type is now under way. The Midlands
Oesophageal Adenocarcinoma
Epidemiology Study (MOSES), based at the
Sandwell and West Birmingham Hospitals
NHS Trust, is currently recruiting patients
in a study that will allow us to understand
better the risk factors of this disease.
I look forward to further work addressing the
other recommendations I made, including
the creation of a public alert system
whenever there is an unexplained increase
in a serious disease.
On equal terms: Achieving racial
equality in medicine
This chapter of my Annual Report drew
attention to the problems that have faced,
and still face, the ethnic minorities in
medicine. I presented evidence to show
concerns at a variety of time points in an
individual’s career: selection for medical
school; job selection, including for
consultant posts; referral to the General
Medical Council; and in granting clinical
excellence awards. Whilst many of the worst
aspects of such discrimination have
improved, there are still causes for concern.
The results of the first National OesophagoGastric Cancer Audit were published by the
Information Centre for Health and Social
Care last year, working in collaboration with
the Royal College of Surgeons, the
Association of Upper Gastrointestinal
Surgeons and the British Society of
Gastroenterology. The audit also intends to
publish further results later this year. This
audit has been reviewing the quality of care
provided to patients with oesophageal
The response of doctors to this chapter has
further galvanised my efforts in this area.
I recently held the inaugural round table on
racial equality in medicine. This allowed me
to hear first-hand of the barriers and the
solutions to this problem that exist within
medicine. I have also written to the Office
for National Statistics to ask about the
feasibility of work to explore further the
nature and causes of the higher mortality
rates among ethnic minority doctors,
particularly those of African origin.
Many of my recommendations in this
chapter called for action across the NHS,
and indeed across wider society. I called for
both the Department of Health and the
Department for Children, Schools and
Families (Aimhigher) to increase access to
medicine among disadvantaged ethnic
minority groups.
While race and equality concerns are best
tackled by society as a whole, it is vital that
the medical profession looks to take an active
lead on these issues. It is for this reason that
I have written to both the General Medical
Council and the Postgraduate Medical
Education and Training Board to ask them to
explore the possibility of including equality
and diversity in Tomorrow’s Doctors and the
postgraduate medical curricula respectively.
I have also written to the General Medical
Council encouraging it to continue to
promote the collection of ethnicity data.
I would also like to see chief executives,
public health directors and medical directors
setting personal stretch targets relating to
medical workforce race equality, and for
medical directors to raise concerns about
discrimination and racial inequality.
Additionally, I am keen to see the wider
adoption of mentorship schemes
throughout medicine.
Achieving racial equality in medicine is
a hugely important aim, and my Report
called for a number of actions and
recommendations that have not been
addressed as yet. I will be monitoring closely
the progress of action in these areas.
15
PASSIVE DRINKING: THE COLLATERAL DAMAGE FROM ALCOHOL
PASSIVE DRINKING:
THE COLLATERAL DAMAGE
FROM ALCOHOL
The many people who drink regularly to excess cause
damage far beyond their own bodies. Directly and
indirectly they affect the well-being and way of life of
millions of others.
KEY POINTS
• Drinking alcohol is a deeply
ingrained part of our society; each
year, the average intake per adult is
equivalent to 120 bottles of wine.
• Since 1970, alcohol consumption has
fallen in many European countries
but has increased by 40% in England.
• The consequences of drinking go far
beyond the individual drinker’s
health and well-being. They include
harm to the unborn fetus, acts of
drunken violence, vandalism, sexual
assault and child abuse, and a huge
health burden carried by both the
NHS and friends and family who care
for those damaged by alcohol.
• Success on another big public health
killer – tobacco – continues to
require multifactorial action, but
a key element has been raising
awareness about the impact of
passive smoking.
• There is no similar awareness or
concern about ‘passive drinking’ –
the consequences of one person’s
drinking on another’s well-being.
It is not recognised as a concept or
a rationale for action.
• There is no stated national
consensus that as a country we
should substantially reduce overall
alcohol consumption, but such a
reduction would benefit the health
of many who drink – and those
affected by passive drinking.
• The price and availability of alcohol
affects its consumption and the
damage that it causes.
17
Though widely accepted, alcohol is
immensely harmful. In 2006, 16,236 people
died from alcohol-related causes. The
number of deaths from alcohol-related liver
disease has almost doubled in the last
decade. Alcohol has a major impact on
individual drinkers’ health: it causes cancers
of the liver, bowel, breast, throat, mouth,
larynx and oesophagus; it causes
osteoporosis; and it reduces fertility.
Some point to the potential benefits of
alcohol, but these tend to be greatly
overstated. Above the age of 40 years,
drinking a small amount of alcohol may
reduce the risk of heart disease and stroke.
For those who drink beyond this low level,
and for those under 40 years who drink any
amount, alcohol increases the risk of these
diseases. For those of any age, drinking any
amount of alcohol increases the risk of
cancer – there is no safe limit. Across
England, alcohol results in over 13 people
being admitted to hospital for every one that
it prevents.
Despite its known harms, one-quarter of the
adult population – about 10 million people –
now drink above the recommended lowrisk levels.
18
35
10
30
8
25
6
20
15
4
10
2
Percentage smoking cigarettes
5
Litres of pure alcohol consumed per head
0
0
78
19
79
19
80
19
81
19
82
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
Litres of pure alcohol consumed per head
40
12
19
Every week, two-thirds of adults in England
drink alcohol. The average adult drinks the
equivalent of 120 bottles of wine every year.
Since 1970, alcohol consumption has fallen
in many European countries. In France and
Italy it has fallen by more than 40%. In
England it has risen by more than 40%.
Drinking alcohol is a deeply ingrained part
of English culture.
45
14
Percentage smoking cigarettes
CMO ANNUAL REPORT 2008
Figure 1: Since 1978, smoking has fallen and alcohol consumption has risen
Source: Office for National Statistics; Institute of Alcohol Studies
Smoking: a different story
In contrast to the rise in alcohol
consumption, there has been considerable
recent success in combating smoking. The
number of people who smoke tobacco has
fallen considerably over the last 30 years
(see Figure 1).
1 July 2007 was a landmark day for public
health, as England’s public places and
workplaces became smoke-free. I first
recommended this action in my 2002 Annual
Report. At the time, this call received a good
deal of support from some, but it also met
with significant hostility. In the intervening
years, England has undergone a fundamental
shift in its collective attitude to smoking.
The smoke-free legislation represented the
greatest single public health improvement for
a generation and, when it came, was widely
welcomed. The country adapted to it well –
more than 75% of people approved.
The change represented a widespread
agreement that others should not suffer
ill effects when people choose to smoke.
It is less than two years since the change
came into effect. In this short time, society’s
collective attitude has shifted still further.
Breathing clean and healthy air has become
the expectation. Just as many people can no
longer recall the days when smoking was
permitted on trains and aeroplanes, so it will
seem an absurdity to the next generation to
contemplate that people once routinely
socialised in environments known to be
such a hazard to human health.
When I made the call for passive smoking to
be taken seriously, it was because I realised
that common knowledge was not being
translated into a common will. The dangers
of passive smoking were well known, but
this was prompting little action. There was
a high level of awareness that passive
smoking causes lung cancer, heart disease
and asthma attacks, yet passive smoking,
in certain environments at least, was simply
the expectation, the social norm.
One key aim of the smoke-free legislation
was to reduce markedly the extent to which
people have to breathe in second-hand
smoke. The positive impact goes well
beyond this. It was hoped, for example, that
the legislation would create a supportive
environment for smokers who wish to stop.
One year on from the legislation there has
been a 20% increase in demand for NHS
Stop Smoking Services. It was also envisaged
that the legislation would reduce the
acceptability of smoking: a 10% increase in
the number of people who forbid smoking in
their home provides some evidence of this.
England’s recent success in reducing the
harms of smoking illustrates that complex
public health problems can be tackled very
effectively. Success came when a crucial
realisation dawned – that smoking is not
simply a problem for those who smoke,
it is a wider problem for society.
• nobody is physically or sexually
assaulted because of alcohol
• nobody dies in an accident caused
by alcohol
Passive drinking: a concept whose
time has come
In contrast to smoking, alcohol is too often
viewed as a problem for individuals rather
than for society. This is not the case. The
second-hand effects of alcohol consumption
– which I collectively term ‘passive drinking’
– are more complex in their causation than
those of passive smoking, and more wideranging in their impact.
For some, the effects of passive drinking
start even before birth. Every year more than
6,000 babies in Britain are born with fetal
Like smoking tobacco, drinking alcohol affects both the individual drinker and
other people
SMOKING TOBACCO
DRINKING ALCOHOL
For the individual
Causes cancers of the lung, lips,
tongue, throat, larynx,
oesophagus, kidney, pancreas
and bladder
Doubles the risk of death from
heart disease and doubles the
risk of stroke
Cancer
Causes cancers of the liver,
bowel, throat, mouth, larynx,
breast and oesophagus – there
is no safe alcohol limit
Heart disease and stroke
Above the recommended limits,
increases the risk of heart
disease and stroke – small
amounts of alcohol may offer
limited protection
Causes osteoporosis
Bones
Causes osteoporosis
Reduces fertility
Fertility
Reduces fertility
For others
In pregnancy, increases the risk
of miscarriage, premature birth
and stillbirth
Unborn child
In pregnancy, increases the risk
of miscarriage, premature birth
and stillbirth and causes fetal
alcohol spectrum disorder
Second-hand smoke causes
asthma attacks and chest
infections
Children
Second-hand family drinking
causes behavioural and
emotional problems and
underperformance at school
Produces unpleasant and
unhealthy air
Society
Produces intimidating and
dangerous public places
• no child has to cower in the corner
while its mother is beaten by a
drunken partner
• the streets are welcoming for all on
Saturday night
• the streets are free of urine and vomit
on Sunday morning
• people who want to stop drinking or
to drink less are guaranteed the
support of their peers to do so
• nobody has to see their father,
husband, sister or daughter die
young as a result of drinking too
much alcohol.
alcohol spectrum disorder. It can cause
brain damage, memory deficits, facial
abnormalities and problems with physical
and emotional development. The disorder
is caused by one thing – women who drink
substantial amounts of alcohol while
pregnant. Drinking alcohol while pregnant
is also associated with miscarriage,
premature birth and stillbirth. Over 7,000
women are admitted to hospital every year
for miscarriages resulting from alcohol.
Drinking alcohol in pregnancy may also
increase the risk of sudden infant death
syndrome (cot death).
The effects of passive drinking continue
through childhood. Up to 1.3 million
children are adversely affected by family
drinking and around a quarter of child
protection cases involve alcohol. Children
of problem drinkers are more likely to have
behavioural difficulties and emotional
problems and to underperform at school.
In 2006, 660 children were killed or injured
in road accidents caused by alcohol. In total,
over 7,000 people were injured, not
including the drink-drivers themselves, and
560 people died due to drink-driving.
19
PASSIVE DRINKING: THE COLLATERAL DAMAGE FROM ALCOHOL
Imagine a country in which...
CMO ANNUAL REPORT 2008
DRINK
DRIVING
FAMILY
BREAKDOWN
CRIME
FETAL ALCOHOL
SPECTRUM DISORDER
DOMESTIC
VIOLENCE
MARITAL
PROBLEMS
SEXUAL ASSAULT
AND RAPE
INTIMIDATING
BEHAVIOUR
UNEMPLOYMENT
The effects of passive drinking continue into
adulthood. Living with somebody who
misuses alcohol can be a horrendous ordeal.
Alcohol can make a partner’s behaviour
unpredictable, aggressive and erratic.
Marriages in which one or both partners
have an alcohol problem are twice as likely
to end in divorce. British Crime Survey
figures for 2007/08 suggest that 125,000
alcohol-related instances of domestic
violence occurred over this one-year period.
Alcohol-related crime affects both children
and adults. Aggressive behaviour resulting
from alcohol misuse, in particular binge
drinking, is a major cause of street violence.
The British Crime Survey found that almost
half of the 2 million victims of violence
thought that their attacker was under the
influence of alcohol, with 39,000 reports of
serious sexual assault also being associated
with alcohol consumption.
Alcohol-related crime has a particular effect
on those at the front line of public services.
Half of all assaults on staff in hospital
emergency departments are committed by
those under the influence of alcohol. Those
delivering services in communities also risk
alcohol-related assaults. There are over
8,000 alcohol-related assaults on police
officers every year. This makes it difficult to
deliver community services in areas where
staff feel threatened. It demoralises front­
line healthcare and other professionals.
In 2008, there were 1.25 million instances
of alcohol-related vandalism. This damage
to cars, parks, streets and public transport
costs millions of pounds to repair and
20
NHS OVER­
BURDENED
NOISE AND
DISRUPTION
makes communities less attractive places in
which to live.
The effects of crime extend beyond those
who are directly attacked, creating an
environment of fear. Drunkenness also
creates an unpleasant social environment.
A survey of 30,000 adults in the North West
of England in 2008 found that 45% avoid
town centres at night because of others’
drunken behaviour.
Crime and antisocial behaviour associated
with alcohol result in major costs to the
emergency services and the criminal justice
system, as well as costs incurred because of
victims requiring time off work. Together,
these costs are estimated to total £7.3 billion
per year.
Alcohol causes problems in the streets, in
the home and in hospitals. It also has an
impact at work. At least 14 million working
days are lost per year. A 2007 survey
covering a two-year period found that 50%
of employers had to discipline employees for
Figure 2: As the affordability of alcohol has increased over the last 20 years,
so has consumption
60
50
Increase since 1988 (%)
PROBLEMS
AT WORK
When one individual is ill due to alcohol, his
or her family bears the burden. My 2001
Annual Report drew attention to the major
upturn in the incidence of chronic liver
disease and cirrhosis related to alcohol
misuse. The chronic, debilitating illness that
alcohol misuse can cause does not affect just
the individual. Friends and family often act
as carers, giving up their time, energy or
even employment. The whole of society
bears the burden of alcohol-related disease.
Within the NHS, every hour a doctor or
nurse spends with somebody who has
become ill or injured due to alcohol is an
hour that could be spent with another
patient. Each year, there are 800,000
admissions to hospital due wholly or in part
to alcohol. One in every four accident and
emergency attendances is related to alcohol.
From general practitioners to ambulance
services to sexual health clinics, few parts
of the NHS are spared from the effects
of alcohol. The total cost to the NHS is
estimated to be £2.7 billion per year.
40
30
20
10
0
-10
1988
1990
1992
1994
1996
Source: HM Revenue and Customs; Office for National Statistics
1998
2000
2002
2004
Affordability
2007
Consumption
4,000
Current
3,500
40p
50p
3,000
2,500
70p
2,000
1,500
500
Over the last 20 years, the country’s
disposable income has risen faster than
alcohol taxation. Alcohol has become ever
more affordable and consumption has risen
(see Figure 2).
Current 40p
50p
1,000
70p
Current 40p
50p
The price we pay
70p
0
People drinking within low-risk levels
People drinking at hazardous levels
People drinking at harmful levels
Source: Independent review of the effects of alcohol pricing and promotions, University of Sheffield, 2008
alcohol misuse at work, and that 31% had
dismissed at least one employee because of
an alcohol problem. Alcohol misuse causes
unemployment, absenteeism and reduced
productivity at work. These effects cost the
economy up to £6.4 billion per year.
The tangible harms of alcohol – such as
hospital admissions, crime and reduced
productivity – are relatively straightforward
to measure. But the collateral damage from
drinking goes beyond this. It is difficult to
assign a financial cost to the experience of
living with somebody who is dependent on
alcohol, or of losing a child to drink-driving.
The intangible costs of passive drinking –
the total human misery that it causes – are
difficult to quantify. We do not currently
know the true total cost of passive drinking
and consequently it is too easily
underestimated or ignored.
Alcohol policy: recent developments
There have been important recent
developments in the government’s
alcohol policy.
The Know Your Limits campaign aims to
increase awareness of recommended lowrisk drinking levels (not more than 3–4 units
per day for men, or 2–3 units for women)
and the unit content of alcoholic drinks. Prior
to 1996, the government’s recommended
levels were stated as ‘per week’. The change
to ‘per day’ levels reflects the fact that health
is not just affected by the volume of alcohol
consumed in a week, but by the pattern in
which it is consumed. The same is true for
many of the effects of passive drinking: in
particular, binge drinking and crime are
closely related. The United Kingdom is now
ranked third highest in Europe for the
number of drinks consumed in one sitting.
The Department for Transport is currently
consulting on means to reduce the harm
of drink-driving. The legal blood alcohol
concentration for driving is currently set
at 80mg/dl, the second highest limit in
Europe. The Department for Transport is
considering whether reducing this would
be an effective policy. In my 2007 Annual
Report, I recommended that the legal
blood alcohol limit for drivers aged between
17 and 20 years should be reduced to zero.
In December 2008, the Home Secretary and
the Health Secretary announced proposals
to tighten licensing laws. They propose to
ban promotional offers in bars which
encourage excessive consumption, and that
customers should be able to see the unit
content of all alcohol when they buy it.
These are useful developments that help
individuals moderate their own drinking.
The licensing of establishments that serve
alcohol is a function performed by local
authorities, which have the power to fine
licensees or to amend or revoke licences if
conditions are not met. When licences are
granted and reviewed, there is currently
little consideration of the establishment’s
impact on the population’s health. The
effects of passive drinking need to be
directly examined when premises are
licensed.
In 2008, the government commissioned
research by a team at Sheffield University
to examine how changes in alcohol prices
would affect its consumption and related
harms. The team analysed the likely impact
of pricing changes on the population as a
whole. They also specifically examined
the impact on three groups of particular
concern – drinkers aged under 18 years,
Effects of a minimum price of
50p per unit
Bottle of wine
A 750ml bottle of wine
(12% alcohol by volume)
could not be sold
for less than £4.50
Bottle of whisky
A 700ml bottle of whisky
(40% alcohol by volume)
could not be sold for less
than £14
Six pack of lager
Six 500ml cans of lager
(4% alcohol by volume)
could not be sold for
less than £6
Large bottle of cider
CIDER
A 2 litre bottle of cider
(5.5% alcohol by volume)
could not be sold
for less than £5.50
21
PASSIVE DRINKING: THE COLLATERAL DAMAGE FROM ALCOHOL
Annual consumption per person (units of alcohol)
Figure 3: Setting a minimum price per unit impacts heavier drinkers far more
than those drinking at low-risk levels
CMO ANNUAL REPORT 2008
Figure 4: The effect of a 50p minimum price per unit
Every year there could be…
• 3,393 fewer deaths
• 97,900 fewer hospital admissions
• 45,800 fewer crimes
• 296,900 fewer sick days
• A total benefit of over £1 billion
Substantial effects would be seen immediately. The full effect would be seen by 2019 if the policy is introduced in 2009.
Predictions are based on data for alcohol consumption and related ill health available when modelling was undertaken.
Source: Independent review of the effects of alcohol pricing and promotions, University of Sheffield, 2008
18–24-year-old binge drinkers, and harmful
drinkers (women drinking more than 35
units per week and men drinking more than
50 units per week).
There is a clear relationship between price
and consumption of alcohol. As price
increases consumption decreases, although
not equally across all drinkers. Price
increases generally reduce heavy drinkers’
consumption by a greater proportion than
they reduce moderate drinkers’
consumption. The specific means of
increasing prices can be targeted further to
minimise the impact on those who drink at
low-risk levels while significantly decreasing
the consumption of those who drink above
these levels. This is possible because those
who drink more tend to choose cheaper
drinks. Introducing a minimum price per unit
of alcohol would therefore affect heavier
drinkers far more than those who drink
in moderation.
If the minimum price per unit were set to
50p, for example, this would decrease
consumption by high-risk drinkers by 10.3%,
while consumption by low-risk drinkers
would fall by only 3.5% (see Figure 3). For
some high-risk drinkers, such a decrease
would be sufficient to bring them out of the
high-risk category and would benefit
drinkers’ own health. However, decreasing
consumption of alcohol in this way would
also substantially reduce the impact of
passive drinking in England.
The Sheffield University team examined the
impact of various potential pricing policies
on health, crime and the wider economy.
They concluded that positive benefits would
be seen as soon as a pricing policy was
implemented and that decreases in violent
crime and workplace absence would be
among the first effects. Other effects would
take years to reach their maximum level
as the benefits of decreased drinking
accumulated.
These effects are worth waiting for. After 10
years, a 50p minimum price per unit would
be expected to reduce the annual number of
deaths from alcohol-related causes by over
one-quarter (see Figure 4). It would reduce
the annual number of crimes by almost
46,000 and hospital admissions by nearly
100,000. It would significantly reduce
absenteeism and unemployment.
Implementing this particular pricing policy
would save an estimated
£1 billion every year.
22
The work by Sheffield University provided a
number of alternative solutions, including
different minimum prices in on-trade and
off-trade settings. For example, off-trade
prices (applicable in off-licences and
supermarkets) could be set to a minimum of
40p per unit. On-trade prices (at restaurants,
bars and pubs) could be set to a minimum of
£1 per unit. This policy also has an estimated
benefit of nearly £1 billion per year.
Establishing minimum pricing requires
government action. Supermarkets are
particularly liable to sell alcohol at low prices.
Currently, no single supermarket chain
would increase its prices and risk losing
customers to competitors, and Competition
Commission rules prevent supermarkets
working together to set prices. A minimum
price per unit would overcome this problem
and help reduce the harms caused by selling
alcohol sometimes for as little as 11p a unit.
This recent research provides strong
evidence for a clear and effective way in
which the government can act to tackle the
country’s alcohol problem. It is vital that
such action is taken urgently to improve the
health of those who drink and to protect
those whose health and well-being suffer
because of the drinking of others.
Conclusions
Passive drinking kills. It causes family
breakdown and violent crime. It costs the
economy billions of pounds. It causes
misery. It affects many spheres of life and
leaves no communities untouched.
Quite simply, England is drinking far too
much. England has an alcohol problem.
Alcohol is harming society. Alcohol is not
simply a problem for the minority who are
dependent on it – it is a problem for
everybody.
PA SSIV E DRINKING: THE COLLATERAL DAMAGE FROM ALCOHOL
ACTION RECOMMENDED • There should be a national
consensus, prompted by
government, that as a country we
should substantially reduce alcohol
consumption.
• Passive drinking should be
acknowledged as a key issue.
It should present a consolidated
rationale for action and be the basis
of a national campaign.
• The total impact of passive drinking
should be calculated by means of a
national study including a full
economic analysis.
• Licensing laws should reflect the full
impact of passive drinking, making
public health considerations central
to licensing.
• As an immediate priority, the
government should introduce
minimum pricing per unit as a means
of reducing the consumption of
alcohol and its associated problems.
Consideration should be given to
setting the minimum price per unit
at 50 pence.
23
PROSTATE CANCER: WHAT TO DO WITH THE PUSSYCATS?
PROSTATE CANCER: WHAT TO DO WITH
THE PUSSYCATS?
Prostate cancer is common. Radical treatment can cure
the cancer but leaves many men incontinent or impotent.
Some cancers do not need treatment because they grow
very slowly. Identifying these tumours is hard. This leaves
patients and their doctors with very difficult decisions.
KEY POINTS
• Prostate cancer is second only to
lung cancer as England’s biggest
cancer killer in males. There is no
known cause.
• One man in England is diagnosed with
prostate cancer every 18 minutes.
• Two common types of prostate
cancers are the tumours that grow
rapidly and can spread to other parts
of the body (dubbed ‘tigers’) and
those that remain localised to the
prostate gland and grow very slowly
(dubbed ‘pussycats’).
• The localised, slow-growing tumours
often produce no symptoms and do
not shorten life, while full-blown
treatment (with surgery or
radiotherapy) can cause incontinence
and impotence.
• There is no way of predicting which
localised, slow-growing prostate
cancers will become aggressive, grow
and spread (turn from ‘pussycats’ into
‘tigers’), leaving men and doctors with
difficult decisions about treatment.
• Population screening is not supported
by current evidence but the results of
large-scale trials are awaited.
• A policy of ‘active surveillance’ is
advocated for localised, slow-growing
tumours but doubts remain about
whether this is the most appropriate
approach.
• Widespread PSA blood testing,
particularly for middle-class patients
referred from ‘well man’ clinics,
means that this dilemma is becoming
more common.
• Rates of radical prostatectomies are
higher in men living in the most
affluent areas. The reasons for this
health inequality are unclear but may
relate to different levels of awareness
of PSA testing and of the symptoms
of prostate cancer.
• Around 26,000 men each year in
England are diagnosed with localised
prostate cancer. Many do not know
if they are harbouring a ‘pussycat’ or
a ‘tiger’.
25
120
100
In England, one man is diagnosed with
prostate cancer every 18 minutes. It is
second only to lung cancer as the biggest
male cancer killer. Overall, 8,500 men die
from prostate cancer each year in England.
By 60 years of age, 50% of men would have
evidence of prostate cancer if their prostate
were to be examined under the microscope.
Most of these men do not develop
symptoms of prostate cancer and die of other
causes, unaware that they had the disease.
The disease is rare in men under 40 years of
age. It is more common in men with a family
history of the disease and in some ethnic
groups. Black African and black Caribbean
men in England are three times more likely
to get prostate cancer than white men, but
South Asian men are less likely to get
prostate cancer. No cause of prostate cancer,
either genetic or environmental, has yet
been discovered.
Prostate cancer may present with difficulty
starting or stopping passing urine, or passing
urine more often, particularly at night. Pain
when passing urine or during orgasm may
also indicate prostate problems. Blood in the
urine or semen is another symptom,
although this is unusual for prostate cancer.
Sometimes it shows up only after it has
Rate per 100 000 population
CMO ANNUAL REPORT 2008
Figure 2: The incidence of prostate cancer has risen, but mortality has remained
relatively stable
80
60
40
20
0
75
19
77
19
79
19
81
19
83
19
85
19
89
19
91
19
93
19
95
19
97
19
99
19
01
20
03
20
05
20
Year of diagnosis/death
Source: Cancer Research UK
spread outside the prostate gland, most
often to bone, with symptoms such as back
or leg pain. It can also be detected very
early, before it has even caused symptoms,
using a prostate specific antigen (PSA) test
and surgical biopsy.
If detected before it has spread, prostate
cancer can often be cured. It is treated with
surgery (radical prostatectomy) or with
radiotherapy, either by an external beam of
high-intensity X-rays (radical radiotherapy)
or by implanting radioactive seeds directly
into the prostate (brachytherapy).
Prostate cancer is different
Prostate cancer does not behave like other
cancers. If bowel or lung cancers are left
untreated, they will progress and cause the
death of the patient. This cannot be said of
prostate cancer. In many cases, prostate
Figure 1: Prostate cancer is common but rarely kills and rarely causes symptoms
Men without prostate cancer
Men with undiagnosed prostate cancer
Men with diagnosed prostate cancer
Men dying of prostate cancer
Men dying of all causes
Source: Cancer Research UK; Health Technology Assessment Programme
26
87
19
Incidence
Mortality
cancer does not progress beyond the
prostate gland, nor does it cause harm.
Prostate cancer is much more common than
other cancers, yet only 3% of all men die from
it. Men diagnosed with prostate cancer are
three times more likely to die of some other
cause than of prostate cancer (see Figure 1).
Some prostate cancers are very aggressive,
invading and spreading rapidly, but most are
slow growing and remain in the prostate
gland. These slow-growing cancers,
particularly in older men, are unlikely to
cause health problems, and there is a risk of
over-treating them. These two types of
prostate cancer have been dubbed ‘tigers’
and ‘pussycats’ to describe their different
propensities to grow and spread.
When prostate cancer is detected very early,
and it is still unclear whether the tumour is a
‘tiger’ or a ‘pussycat’, men are faced with a
difficult decision. Their cancer may never
trouble them. Treatment may not prolong
their life but may cause harm, such as
impotence or incontinence. Studies suggest
that as many as one in three men treated
for prostate cancer may have serious
complications. On the other hand, they may
have a tumour that will turn out to be a ‘tiger’
and progress rapidly and threaten their life.
Understanding the rise in
prostate cancer
Since the 1970s, the number of new
diagnoses of prostate cancer has risen
rapidly (see Figure 2). This rise is usually
attributed to more people being tested.
Initially, this was because of more operations
PSA testing rate per 100 000
men over 40 years
6,000
5,000
4,000
3,000
International comparisons
2,000
The incidence of prostate cancer varies
greatly across different countries (see
Figure 4), although mortality from prostate
cancer is relatively similar. Prostate cancer is
the most common cancer in men in Europe,
with 350,000 new diagnoses every year and
80,000 deaths. Many countries can show a
gradual increase in the incidence of prostate
cancer since the 1960s, and sharper
increases in the 1990s coinciding with the
popularity of PSA testing.
1,000
0
97
96
19
19
98
19
99
19
02
01
00
20
20
20
Source: Adapted by permission from Macmillan Publishers Ltd: Pashayan N, Powles J, Brown C and Duffy SW. Excess cases of
prostate cancer and estimated overdiagnosis associated with PSA testing in East Anglia. British Journal of Cancer 2006; 95(3): 401–5
Figure 4: Age-standardised mortality and incidence rate for prostate cancer
by world regions
Northern America
Australia/New Zealand
Western Europe
Northern Europe
Caribbean
South America
Southern Africa
Southern Europe
Central America
World
Middle Africa
Western Africa
Eastern Europe
Eastern Africa
Western Asia
South Eastern Asia
Northern Africa
South Central Asia
Eastern Asia
Trends in mortality are less clear. In some
countries (France, Australia and the United
States) there was a small rise in agestandardised mortality during the 1980s,
followed by a small fall in the 1990s. Other
countries have stable mortality rates
(Belgium and Sweden), and some show a
continuing steady rise (Poland and Ireland).
Screening
0
20
40
Source: Cancer Research UK
(known as transurethral resection of the
prostate or TURP) for apparently benign
prostatic enlargement, where the tissue
removed is examined under the microscope
for signs of prostate cancer, and more
recently because of the introduction and
increasing use of the PSA test. The PSA test
detects a chemical produced by the prostate
gland. It is raised in many diseases of the
prostate, including cancer. A PSA test by
itself cannot diagnose cancer – this requires
a surgical biopsy. Much of the recent rise in
prostate cancer follows the introduction and
60
80
Rate per 100,000
100
120
Incidence
Mortality
greater use of PSA testing (see Figure 3).
The more doctors look for prostate cancer
the more cases they will find. However,
despite the recent rise in diagnoses of
prostate cancer, the number of men dying of
the disease has remained relatively constant.
This suggests that many cancers that are
being detected would never have become a
problem within the lifetime of the man. In
some parts of the country an estimated 40%
to 60% of cancers fall into this category, and
in screened populations this figure may be
as high as 85%.
Prostate cancer screening, where men within
certain age bands in a population are offered
a regular PSA test, is carried out in Germany
and France. Even in these countries it does
not happen in a systematic fashion, so not
everybody is offered the screening test. If the
PSA level is found to be raised, a biopsy of
the prostate can be taken to look for cancer.
The purpose of screening is to detect cancers
as early as possible, before they become
symptomatic. The hope is that if the cancer is
detected early, it can be treated before it
spreads and threatens the man’s life.
In this country, population-based screening
programmes are in place for breast, cervical
and bowel cancer. The breast and bowel
cancer screening programmes were
introduced only after research had
demonstrated a clear reduction in mortality
among patients offered screening. Cervical
screening started before the era of
randomised controlled trials in screening,
but its impact on mortality has subsequently
become very clear. There is a common
27
PROSTATE CANCER: WHAT TO DO WITH THE PUSSYCATS?
Figure 3: PSA testing rates are rising in men without a previous diagnosis
of prostate cancer
CMO ANNUAL REPORT 2008
Figure 5: Tigers and pussycats: the different types of localised prostate cancer
OVERALL RISK LEVEL
LOW RISK
INTERMEDIATE RISK
HIGH RISK
PSA <10
PSA 10–20
PSA >20
Extent and
aggressiveness
of the cancer
PSA level
perception that early detection of cancer in
healthy people must be of benefit. Any
apparent increase in survival may, however,
simply be due to what is known as ‘lead-time
bias’. This occurs when a cancer is
diagnosed earlier, giving an apparent
increase in the length of survival without
changing the point at which that cancer
causes the patient’s death. This is often the
case with prostate cancer. In prostate cancer,
screening also detects cancers that would
never have been clinically apparent within
the lifetime of the patient.
To date, no trial of prostate cancer screening
has convincingly shown a reduction in
mortality. The results of two large
randomised trials of screening men for
prostate cancer, one in the United States and
one in Europe, are awaited.
The majority of prostate cancers detected by
screening are early cancers that may become
‘tigers’ but are more likely to be ‘pussycats’.
Finding more of these cancers leads to
distress and anxiety, and potentially to
unnecessary treatment resulting in
impotence and incontinence. It may be only
when correct identification of ‘tigers’ at an
early stage and better treatments are possible
that population screening becomes viable.
That is why, with the current state of
evidence, the National Screening
Committee recommended that screening
should not be introduced in England.
However, it did recommend that men should
be able to request a PSA test from their
general practitioner, after appropriate
counselling. Guidance on the provision of
information to men who are considering
28
having a PSA test is set out in the Prostate
Cancer Risk Management Programme.
Around 6% of men in England over 45 years
of age have a PSA test each year. Between
20% and 40% of these have no symptoms of
prostate cancer, suggesting that screening
of sorts is taking place.
Management of low-risk cancers
In England, around 90% of prostate cancers
are diagnosed while still localised. This
means that over 26,000 new diagnoses of
localised prostate cancer are made each year
in England. Such tumours can be classified
as high, intermediate and low risk,
depending on rectal examination findings,
the PSA level and the appearance of the
cancer under the microscope (see Figure 5).
Men with high-risk cancer have a tumour
that is clearly a ‘tiger’ and might be cured
with radical treatment. Intermediate-risk
cancers are starting to behave like ‘tigers’
and have an even greater chance of cure,
given prompt radical treatment.
The low-risk group presents the greatest
dilemma. These tumours can be cured with
radical treatment but also have a high
likelihood of turning out to be ‘pussycats’. If
left alone they would probably never cause a
problem. The number of men with a low-risk
tumour is harder to estimate, but is probably
around 5,000 to 10,000 each year.
The management of low-risk cancers
confined to the prostate is currently one
of the biggest challenges in the whole of
patient care. There is no good way of
predicting which cancers will progress to
become life-threatening ‘tigers’.
An important study has shown that, if 100
men with early localised prostate cancer
were left untreated, then in eight years’ time
it could be expected that 30 of them would
have died, 14 from their prostate cancer. Of
those still alive, 15 would have some degree
of incontinence and 32 would be impotent.
If 100 similar men were treated with a radical
prostatectomy, 24 would have died, nine of
their prostate cancer. Of those still alive,
around half would be incontinent and 61
would be impotent (see Figure 6).
Complication rates may now be lower than
this thanks to improvements in surgical
technique, particularly in centres performing
large volumes of prostate surgery. This is
why current policy in England recommends
that centres offering radical prostatectomy
should be performing at least 50 procedures
each year.
So, although there may be a survival
advantage in treating low-risk prostate
cancer, this comes at the expense of
significant side effects. Twenty men need
radical treatment in order to save one life.
In saving one man’s life, five men may be left
incontinent and another four impotent as a
consequence of their treatment. With the
type of cancer detected by screening, more
than 40 men would need to be treated to
save one life.
Men with low-risk localised prostate cancer
face the difficult decision of whether to have
radical treatment and risk the side effects or
take the small chance that their cancer may
progress and threaten their life.
To avoid these side effects, some doctors
recommend ‘active surveillance’ for low-risk
200 men with early prostate cancer
Radical treatment group (100 men)
Alive and well: 8
Alive with complications:
Impotence: 31
Incontinence: 7
Both: 30
Dead from
prostate cancer: 9
Dead from
other causes: 15
Active surveillance group (100 men)
Alive and well: 30
Alive with complications:
Impotence: 25
Incontinence: 8
Both: 7
Dead from
prostate cancer: 14
Dead from
other causes: 16
Source: Scandinavian Prostate Cancer Group Study No. 4
Case Study: Jim
Jim is 65 years old and recently retired. He is married, still enjoys his sex life and plays golf
twice a week. He recently went to his GP for a PSA test – two of his friends recommended
it. His GP talked about the limitations of the test, but Jim thought he would go ahead. The
test came back slightly raised and the GP was not sure what to do, so he sent Jim to a
hospital specialist. The hospital specialist said the result was of unclear significance so
suggested another test. This involved taking a sample from the prostate. This showed
prostate cancer in the early stages. The doctor seemed quite reassured but Jim was
shocked and accused his doctors of confronting him with a ‘hellish decision’. After thinking
about it he wanted the prostate cancer cut out. The doctor suggested that Jim follow a
strategy of ‘active surveillance’, but Jim was so worried about the cancer that he asked
another doctor for an opinion. The second doctor agreed that taking out the prostate was a
reasonable thing to do. Jim had his prostate removed, but suffered from both impotence
and incontinence. The incontinence was relatively mild, but bad enough for Jim to need a
pad. The impotence was Jim’s biggest concern – it affected not only his sex life but also his
relationship with his wife and his self-identity as a man. He tried several different
treatments to help with impotence but with limited success.
localised prostate cancer. Regular PSA tests
are used to monitor the disease, sometimes
with repeat biopsies of the prostate. Cancers
that show signs of growing or changing
(turning from ‘pussycats’ into ‘tigers’) can be
treated radically. However, delaying radical
treatment could mean that the window of
opportunity for cure is missed and that the
cancer escapes control. The National
Institute for Health and Clinical Excellence
(NICE) has recommended ‘active
surveillance’ as the first-line treatment for
the most indolent of localised cancers. There
are trials showing promising results from this
approach but they include only small
numbers of patients and have not produced
data to show that this approach is effective
beyond five years.
The emotional impact of a
‘hellish decision’
Making a decision about treatment is
difficult and a source of great anxiety for
many patients. Weighing up the risk of
complications against the potential for better
survival is finely balanced. Living with a
diagnosed but untreated cancer is an
unnerving experience and seems
counterintuitive. That is why many men opt
for treatment, firmly believing that they are
prolonging their life. Others may be mindful
of the evidence and medical advice and
worry about some of the intolerable side
effects of treatment. They may be willing
parties to a policy of ‘active surveillance’.
There are tools available to model the likely
progression of a given man’s cancer using
his age and other measures such as the size
of the prostate, his PSA level and grade of
cancer. These can give the percentage
probabilities of a particular outcome, such as
cancer progression or death within a certain
time period. However, they are only
statistical models to aid decision making.
They do not remove the ‘whether to treat’
dilemma entirely. The patient and his doctor
are still left with the need to choose whether
to gamble that they are dealing with a
‘pussycat’ rather than a ‘tiger’, called by
one man a ‘hellish decision’ (see case study).
Men who choose not to have radical
treatment have to adjust to living with a
diagnosis of cancer for the rest of their life.
Even if the likelihood of the cancer
becoming clinically significant is small, there
may still be financial implications of being
labelled with a cancer diagnosis, for example
when obtaining life or travel insurance.
The impact of the current PSA
testing policy
The Prostate Cancer Risk Management
Programme enables any man to request a
PSA test from his general practitioner. This
test should follow a discussion about the
pros and cons of PSA testing so that the man
can make an informed choice. The uptake of
PSA testing is markedly lower in populations
with increased levels of deprivation. It is also
lower in populations with higher proportions
of ethnic minorities. The reasons for this are
unclear but may be due to different levels of
awareness of the symptoms of prostate
disease and PSA testing.
29
PROSTATE CANCER: WHAT TO DO WITH THE PUSSYCATS?
Figure 6: Comparing radical prostatectomy and active surveillance
outcomes after eight years
Directly age-standardised prostatectomy rates for
men aged 45 years and over per 100 000
CMO ANNUAL REPORT 2008
Figure 7: Radical prostatectomy is carried out more commonly on men in
the most affluent areas
50
45
40
35
30
25
20
29.1
31.6
34.4
41.7
43.3
Q1
Q2
Q3
Q4
Q5
15
10
5
0
(most deprived)
(least deprived)
Source: Hospital Episode Statistics
Radical prostatectomy is carried out
significantly more commonly on men living
in affluent parts of the country (see
Figure 7). Men living in these areas are over
30% more likely to have the operation than
those living in the most deprived areas. This
is unlikely to be due to a markedly higher
true incidence of prostate cancer among
professional men. It is more likely to
represent differential access to services and
therefore a health inequality.
It may be that PSA testing is used less
frequently by general practitioners working
in deprived communities or that men in those
communities are less likely to seek help when
they have symptoms. Alternatively, it is
possible that men living in more affluent
areas are more proactive about seeking PSA
testing, sometimes in the absence of
symptoms. Some men in the most affluent
areas may be being treated unnecessarily.
Hopes for the future
There are two large studies under way that
are investigating treatment options for
localised prostate cancer: a United Kingdom
study called ProtecT (Prostate testing for
cancer and treatment) and an international
study called ProSTART (Surveillance therapy
against radical treatment in patients
diagnosed with favourable risk prostate
cancer). These aim to offer some clarity on
the way forward for these men.
30
cancer) and partial prostatectomy (removing
only the cancer, leaving any undiseased
prostate behind). These treatments offer the
possibility of comparable cure rates to more
conventional treatments but with a reduced
risk of side effects. They are promising but
remain experimental for the time being.
In the longer term, it is hoped that new
methods will emerge to assess which of the
early cancers will become ‘tigers’, for
example measuring sarcosine levels in the
urine. The ability to assess how aggressive a
cancer is will help target radical treatment on
tumours that are more likely to spread.
Improvements in surgical technique, such as
the da Vinci robot, and more targeted
radiotherapy have the potential to reduce
the side effects of treatment. In addition,
novel forms of treatment are being
developed for localised prostate cancer,
including cryotherapy (destroying the
cancer by freezing it), focused ultrasound
(directing high-intensity sound waves at the
While the results of these important studies
are awaited, it is vital that men
contemplating having a PSA test are truly
informed. This will include being aware that
there is a high chance that they will be
diagnosed with a cancer that will never
affect their health. This diagnosis will not
increase their life expectancy but may well
affect their life in many ways. Equally
important is the use of tailored advice for
each man with a new diagnosis of localised
prostate cancer, incorporating an
understanding of the nature of his cancer,
the man’s values, and his life expectancy.
Case Study: Mick
Mick is 68 years old and retired a few years ago. He had back pain and had lost weight,
which led his GP to do a ‘battery of tests’. The tests all came back normal, except for his
PSA test. Mick didn’t really understand why his GP was concerned about the small rise in
his PSA, particularly as his back pain had gone away. The hospital specialist did an internal
examination and reported that his prostate was slightly large, which was normal for a man
of his age. He recommended a biopsy of the prostate. Mick found this painful. The biopsy
showed some early signs of prostate cancer. Mick spent a long time talking to the hospital
specialist about what to do. They used a ‘nomogram’ to calculate Mick’s risk of the cancer
becoming aggressive and spreading over the next 10 years, and the risk of Mick
developing incontinence or impotence with treatment. Mick knew he had problems with
his heart, and wasn’t sure that he would live much beyond 10 years. Like other men of his
age, he had an active sex life and did not want to compromise that. He agreed to have
regular PSA tests and internal examinations to monitor his cancer. Life continues more or
less as normal, although Mick worries about what may happen in the future and whether
he has made the right decision.
PROSTATE CANCER: WHAT TO DO WITH THE PUSSYCATS?
ACTION RECOMMENDED • Adequate pre-test counselling, as set
out in the Prostate Cancer Risk
Management Programme, must be
carried out before PSA testing an
asymptomatic man.
• Structured information and decision
aids to help weigh the risks and
benefits of treatment should be
provided to all men diagnosed with
localised prostate cancer.
• All men whose localised prostate
cancer falls into the low-risk category
should be offered a full options
appraisal that considers both radical
treatment and ‘active surveillance’.
• The reasons for health inequalities in
radical prostatectomy rates should
be explored further.
• The findings of ongoing National
Cancer Research Institute-funded
work on the early identification of
which low- and intermediate-risk
tumours will progress to lifethreatening tumours should be
monitored closely. New diagnostic
and prognostic tools that emerge
from this research should be
incorporated into guidelines as they
become available.
• Research should continue into new
treatments for localised prostate
cancer that seek to minimise side
effects without compromising
survival, and this research should
consider patient-reported outcome
measures.
• Data gathered on prostate cancer by
the National Cancer Registry should
be enhanced to enable better
surveillance of trends in the disease
and its treatment and outcomes.
31
PAIN: BREAKING THROUGH THE BARRIER
PAIN:
BREAKING THROUGH
THE BARRIER
Each year over 5 million people in the United Kingdom
develop chronic pain, but only two-thirds will recover.
Much more needs to be done to improve outcomes
for patients.
KEY POINTS
• Pain is one of the world’s most
common symptoms: it affects
7.8 million people in this country.
• Chronic pain appears to be more
common now than it was 40 years
ago.
• Chronic pain has a major impact on
people’s lives, causing sleeplessness
and depression and interfering with
normal physical and social
functioning.
• All age groups are affected: a quarter
of school-age children reported pain
(on average lasting more than three
years), while most elderly residents of
nursing homes experienced frequent
moderate to severe pain.
• It has been estimated that back pain
alone costs the economy £12.3 billion
per year. The cost of pain from all
causes is far higher.
• The limited number of specialist pain
clinics around the country are
inundated with referrals, and only 14%
of people with pain have seen a pain
specialist. Systems and infrastructure
are not adequate to meet need or
demand.
• Better coordination of services and
services designed around the patient’s
needs are essential.
• Chronic pain and its consequences
are not as well controlled as they
could be. Early intervention may stop
pain becoming persistent.
33
CMO ANNUAL REPORT 2008
Pain is an unpleasant sensory or emotional
experience that is a signal of actual or
potential harm to the body. Acute pain by
its nature is transient but can recur, while
chronic pain is persistent. Chronic pain may
be complex, often with no identifiable
purpose or basis. Untreated, pain becomes
entrenched and more difficult to treat. The
consequences of long-term pain have a
serious impact on both patients and society.
It has been estimated that 7.8 million people
in the United Kingdom now suffer with
moderate to severe pain that has lasted over
six months. Over a third of households have
someone in pain at any given time.
The numbers are rising. Repeated surveys
show that chronic pain is two to three times
more common now than it was 40 years ago.
Women report chronic pain more
frequently. The same is true for people from
socially or financially disadvantaged groups
and some ethnic minority groups. United
Kingdom citizens of South Asian origin are
three times more likely to suffer disabling
back pain than their non-Asian peers.
Women are at greater risk of chronic pelvic
pain, report migraine headache three times
more commonly than men, and are
disproportionately affected by pain
syndromes such as fibromyalgia.
It is difficult to know exactly how many
people have chronic pain. An estimated 11%
of adults and 8% of children experience
severe pain. Each year, over 5 million people
in the United Kingdom develop chronic
pain, but only two-thirds will recover.
Chronic pain becomes more common with
age: the probability of suffering chronic pain
at age 50 years is double that at age 30
years. However, chronic pain is not only a
problem for older adults: the most common
time to report chronic pain is in the decade
between 40 and 50 years of age.
Chronic pain may be neglected at both ends
of the age spectrum. In a study of United
Kingdom nursing homes, most residents
experienced constant or frequent moderate
to severe pain, despite the fact that 99%
were on pain medication. Conversely,
chronic pain affects a quarter of school-age
children (a third severely), with pain lasting
on average more than three years.
Site of pain
Muscle, bone and joint pain are the main
causes of chronic pain, with back pain and
osteoarthritis together responsible for over
half of all cases. Every year, 1.6 million adults
in the United Kingdom develop back pain
that stretches beyond three months. At any
one time, a quarter of adults over the age of
40 years in the United Kingdom have knee
pain, and in around half of them this pain is
disabling. On top of this, half a million adults
have rheumatoid arthritis, where the joints
are attacked by the immune system.
“For three years, since I was 14, I’ve had severe pelvic pain. I have tried
painkillers and been to see my general practitioner, but nothing much
helps. I’ve missed a lot of school, and worry I may fail my A levels or be
too ill to sit through an exam. I can’t keep up with my friends’ social
Joanne, gynaecological pain
activities. Pain is ruining my life.”
34
Severe and recurrent headache is common.
Around 12% of the population experience
migraine, and a further 9% of women and 3%
of men suffer with chronic daily headache.
Pelvic pain lasting more than six months
affects a million women in the United
Kingdom; an additional one in eight women
suffer from severe menstrual pain.
Up to 5% of the population are affected by
chronic widespread pain of unknown cause,
including diagnoses such as fibromyalgia.
Recent data from the United States found
that, one year after being admitted to hospital
for treatment of a serious injury, almost twothirds of people still reported pain. Surgery
itself may be a cause of pain: one year after
hernia surgery, almost two-thirds of patients
report ongoing pain as a result.
Among children and adolescents, the most
common cause of pain is muscle-, bone- or
joint-related, with headache and abdominal
pain each responsible for a quarter of all
cases of chronic pain in that age group.
United Kingdom: pain in numbers
• 7.8 million people live with
chronic pain
• £3.8 billion cost of adolescent pain
• £584 million spent on prescriptions
for pain
• 1 million women suffer with chronic
pelvic pain
• 1.6 million adults per year suffer with
chronic back pain
• 49% of patients with chronic pain
experience depression
• 25% of sufferers lose their jobs
• 16% of sufferers feel their chronic
pain is so bad that they sometimes
want to die
• 1 pain specialist for 32,000 people
in pain
Thuwaraka, non-specific pain
Impact on lives
Chronic pain ruins lives: 65% of sufferers
report difficulty sleeping and nearly 50%
report problems conducting social activities,
walking, driving or having a normal sex life.
In 49% of those with chronic pain there is
depression, and this can result in suicide.
Chronic pain reduces quality of life more
than almost any other condition. Pain often
becomes intertwined with the lives of
people living with it. Pain has been
described as ‘exhausting’ and ‘mentally
draining’, and the experience of living with
it ‘frustrating’, ‘isolating’ and ‘humiliating’.
Chronic headache significantly impairs
quality of life. Disability is common, with
70% of migraine sufferers reporting some
disability, of which 25% is severe.
Young people with ongoing pain have more
mental health and social problems, miss
more school than their peers, and tend to
achieve less academically than expected.
Taken together, all these factors have the
potential to seriously harm a child’s future.
The financial impact for both the sufferers and
their families is shattering, and the burden to
the economy as a whole is huge. People with
chronic pain are seven times more likely to
quit their jobs due to ill health than the
general population. Overall, 25% of people
with chronic pain eventually lose their jobs.
Conditions associated with chronic pain are
among the most expensive to treat.
Musculoskeletal diseases, such as arthritis,
make up one of the most expensive disease
groups for healthcare costs.
People with chronic pain account for a
significant proportion of general practitioner
appointments each year and are relatively
high users of accident and emergency,
diagnostics and outpatient services. In 2007,
on top of money spent by patients on non­
prescription medication, the NHS in England
spent £584 million on 67 million prescriptions
for analgesia and anti-inflammatory drugs.
However, indirect costs, largely due to the
loss of work opportunities, may be even
greater than this. In 1998, it was estimated
that the cost to the United Kingdom of back
pain alone was £12.3 billion – 22% of UK
health expenditure in that year – and the
main part of this cost was due to work
days lost.
Chronic pain is the second most common
reason for claiming incapacity benefit.
People with chronic pain often do not know
how quickly, or whether, they are going to
recover. This makes it difficult for them and
their employers to plan for their return. Very
often, people fail to come off these benefits.
Defining and measuring pain
Pain is subjective. It is not easily measured,
unlike blood pressure or body temperature.
Few report their pain being assessed
effectively. Only 15% of patients have
completed even a simple scoring system.
Fewer than half of nursing home residents
said that their carers had asked them about
their pain. Identifying and assessing pain is
an undervalued clinical activity and is not
seen as a priority in assessing a patient,
particularly in emergency settings.
Assessing complex and chronic pain is rarely
of value if undertaken in isolation from
assessments of the effects of pain. Early and
appropriate identification of these effects
can help reduce their impact and prevent
disability.
Psychosocial factors are known to play an
important role in the generation of disability
and distress secondary to pain. If people
worry excessively about the sources of their
pain, they tend to become more inactive.
Gauging the potential threat value of pain is
difficult for patients. It is vital for healthcare
professionals to promote active coping
strategies at an early stage to aid recovery.
In Australia, a mass television campaign that
encouraged people to stay active in spite of
their pain had a dramatic and prolonged
effect on sickness absence.
Controlling pain
Chronic pain is a complex phenomenon.
When pain continues for a long time, the
nervous system changes and becomes
overactive. The normal mechanisms that
damp down the sensation of pain stop
working. Biological, psychological and social
factors combine to exacerbate and entrench
the symptoms. Patients are affected by both
the symptoms of pain and the impact it has
on their lives.
Modern pain management should address
all of these elements with an integrated
approach. Early identification of each
patient’s needs allows a plan to be tailored.
With appropriate support, some people can
be taught the skills to maintain normal
function. Others have pain that may become
complex and chronic and require more
elaborate interventions.
People are generally keen to help
themselves. No one wants to be in constant
pain. Therefore, given proper support and
information, most people will benefit from an
integrated approach that addresses different
aspects of their pain simultaneously. This
may involve a focus on activity and
rehabilitation, balanced drug therapies,
psychological therapies, electrical nerve
stimulation, and, occasionally, appropriate
injection techniques. Complementary
therapies also have their place. The key
factor appears to be ensuring that aspects
of care are integrated and joined up, rather
than instigated sequentially or in isolation.
35
PAIN: BREAKING THROUGH THE BARRIER
“I’m constantly in agony, and I lost my job six years ago due to
‘performance issues’. My doctor told me I have fibromyalgia, but has
been unable to explain the cause of my pain, and I feel my family has no
patience with me now. Painkillers do nothing to help. Some days I can’t
get dressed, the pain is so bad. I feel that no one really understands.”
CMO ANNUAL REPORT 2008
Table 1: Prescribed medication for chronic pain
Pain medication
UK (%)
European average (%)
Paracetamol
38
18
Non-steroidal anti-inflammatories
23
44
Cox-2 inhibitors
3
6
Weak opioids
50
23
Strong opioids
12
5
Percentage of respondents reporting pain medication prescription for chronic pain
Source: Breivik et al, 2006
Patients report that being listened to and
given choices over treatment are just as
important as the therapies themselves.
Medication
Conventional painkillers address pain in a
number of ways. Paracetamol is simple,
effective and has minimal side effects. It is
thought to reduce pain by interrupting or
suppressing pain signals along the nerves.
Its value is often underestimated. Opioids,
such as morphine or related compounds,
affect the way in which pain is processed in
the brain and spinal cord to reduce the
sensation of pain. Anti-inflammatories have
many side effects and so are less useful
unless there is significant inflammation
causing the pain.
Other medications change the way in which
messages are sent along the nerves, or how
they are processed by the brain and spinal
cord. These include some anti-depressant
medications and some anti-epileptic
medicines such as gabapentin.
Persistent pain will often require one or
more of these elements to be addressed in
order to maximise the benefits of treatment.
Where patients understand the purpose
behind different medicines, it is more likely
that they will take them appropriately, and
that they will benefit.
Different ways of delivering medication may
be appropriate. Anti-inflammatory drugs can
be given as gels and opioids can be
36
incorporated in skin patches. People with
constant pain generally find it easier to
manage with slow-release formulations.
Treatments such as capsaicin skin cream
(derived from chilli peppers) cause an
increased release in the nerve endings of
‘substance P’, which creates the feeling of
heat or burning and is involved in the
transmission of pain. Over time, repeated use
of the cream causes the nerves to run out of
this transmitter, and the pain is reduced.
These new methods of delivery may
improve effectiveness, reduce side effects,
or be easier for patients to manage.
There is little standardisation of drug
treatments, and pain treatments vary widely
between countries. The United Kingdom
uses significantly fewer non-steroidal anti­
inflammatory drugs and more opioids than
the European average (see Table 1). Opioids
need close monitoring and it is evident that
they lose their usefulness over the long term.
Non-drug treatments
Transcutaneous electrical nerve stimulator
(TENS) machines work in a number of ways.
Simply put, they work by using electrical
energy to directly activate nerves in the
spinal cord. In the same way in which pain is
helped by rubbing a painful body part, this
competes with the ‘pain signal’ and blocks it,
as explained by the ‘Gate theory’ proposed
in the 1960s. However, more complex
mechanisms are likely to exist as well.
Whatever the mechanism, TENS treatment
can have a significant effect on many types
of pain if used properly, often in conjunction
with other treatment options.
Acupuncture may work in a number of
ways. It may have a counter-irritant effect as
well as encouraging the release of the
body’s own painkillers (endorphins). Many
other rationales have been proposed, and
there is much controversy about
acupuncture. However, there is no doubt
that some patients report significant benefit
for some pain problems.
Maintaining or regaining a degree of physical
function is widely accepted as crucial to
reducing the effects of pain. Physical
therapy and/or appropriate rehabilitation
programmes both treat pain directly and give
patients the knowledge and skills to maintain
their own health and function. This may also
help to maintain psychological well-being.
Many localities now run physical activity
and leisure services or equivalent schemes,
some of which are targeted at people with
complex pain. These aim to reintroduce
and maintain good physical function and
health. Health trainers can improve patients’
confidence in doing things despite their
pain. This also reduces the risks of heart
disease and obesity.
“Ten years ago, I was diagnosed with arthritis of the knee. I’ve since had
both knees replaced. Now I’ve got osteoporosis in my spine. It gives me
terrible back pain that never leaves me night or day. I’m only 67, but
feel ancient. I find it difficult to leave the house and cry all the time.”
Lily, bone and joint pain
Cognitive behavioural therapy can help
patients break the cycle of pain, fear,
immobility and disuse that leads to everworsening pain. This approach also helps
to develop self-management and coping
strategies, and to improve social and
physical functioning, even where the
underlying pain cannot be improved
significantly. The newer, third-wave
therapies such as mindfulness and
acceptance-based therapies have proved
to be very useful.
Participation in expert patient programmes
allows people with chronic pain to learn
from the experiences of others. Patients gain
the skills to become confident in managing
their own pain and learn how to work in
partnerships with their clinicians. Although
these programmes may work better for
some patients, they report the need to have
advice from a healthcare professional as
well. Patient support groups such as Pain
Concern and Action on Pain can play a vital
role in mentorship.
Helping patients remain in, or return to,
work is an essential goal. Patients with
chronic or complex pain, their carers and
employers, may see leaving the workplace
as beneficial. Remaining in work is essential
to physical and mental health, and improves
quality of life and self-esteem. Employers
play a key role in understanding and
contributing to rehabilitation and the
patient’s reintroduction to work. A
constructive approach, looking at flexibility
of roles, retraining, modification of hours
and other options, can yield rewards for the
patient, the employer and society.
In 2006, over a third of chronic pain patients
in the United Kingdom reported inadequate
control of their pain. More than two-thirds
said that at times their medication was
unable to control their pain completely.
Across Europe, 42% of sufferers agreed that
they would spend all their money on pain
treatment if they knew that it would work,
and one in six felt that some days their pain
was so bad they wanted to die.
services were unequal and inconsistent
and suffered from insufficient funding.
Prescribing was inconsistent, and guidelines
were lacking. Across the regions, there was
a six-fold variation in the percentage of
primary care organisations providing
funding for pain management services in
primary care. Even where services exist,
anecdotal reports suggest that there is a
significant hidden demand within
communities.
“For the last 20 years I’ve had violent migraines that can last for days at
a time. This happens once or twice a month, and when I feel like this I
can’t work. I’m a self-employed plumber, and lose a lot of income as a
result. Also, I’m a single parent, and when I have a migraine I really
struggle to manage to look after the children. Medication just doesn’t
Colin, headache
seem to help.”
All healthcare professionals encounter
people in pain. Some elements of the NHS
have an increased focus on pain, whether it
be within general practice, physiotherapy,
rheumatology, orthopaedics or pain
management services. Similarly, some local
authorities provide services that address
chronic ill health, including pain. However,
local pain services are very thinly spread
around the country, and the design and level
of integration varies widely. Teaching at
undergraduate level is patchy and
inconsistent.
An ideal service would have much clearer
links between the various elements of care
and those who provide them, with clear,
straightforward pathways based on highly
variable patient need. Early initial
assessment would focus on preventing
disability, and would separate people
needing aggressive specialist pain strategies
from those requiring less invasive selfmanagement and goal-orientated functional
rehabilitation. Those patients needing
specialties such as rheumatology or
neurology would be channelled
appropriately along these routes, with highquality assessment tools allowing rapid
referral and access. Both specialties could
ensure that there is some exposure to pain
management as part of postgraduate
training.
In primary care, the provision is equally
variable. A recent report into the organisation
of pain management services in primary care
across the United Kingdom found that
Much care could be provided best in a
community setting. Specialist support could
then focus on the most complex situations
and provide backup to primary and
In 2005, only 14% of people in pain had
been seen by a specialist in pain medicine.
While the majority had seen their general
practitioner about their pain, 16% had not
consulted anyone at all in the previous year.
37
PAIN: BREAKING THROUGH THE BARRIER
Services
CMO ANNUAL REPORT 2008
Figure 1: Management of chronic pain in Southampton
Level 3:
Specialist care
Complex pain relief
Individual psychological
therapy
Expert screening
team assess need
Level 2: Community care
Pain management programme
Expert patient programme
Patient support groups
Level 1: Primary care
Primary care team, outpatient physiotherapy, community
pharmacists supported with treatment guidelines,
educational programme, pain management staff supervision
Source: Price, 2006
community care services. A major initiative
to widen access to high-quality pain services
would improve the lives of millions of
people.
In moving towards such an ideal, it is
important to establish the orientation,
philosophy and model of care delivered by
local pain services. The traditional pain clinic
tended to put a great deal of emphasis on
treating the area affected by pain (for
example with painkilling injections).
Modern pain services differ from this in
three respects.
Firstly, the range of approaches to pain is
wider, including techniques such as
cognitive therapy. Secondly, there is a strong
focus on the impact of pain more widely,
rather than purely on the pain itself. Here,
the effect on daily functioning and overall
health – mobility, sleep and depression, and
the ability to work and interact socially – are
very significant in successful treatment and
rehabilitation. Thirdly, today’s services are
multidisciplinary, which seems to be the
most significant step forwards in treatment.
Many specialist professions, not just doctors,
have an important role to play. It is also
38
important to integrate the approach to pain
services across primary and secondary care.
The service model in Southampton (see
Figure 1) is one way in which a local health
service has delivered a more patient-focused
approach. Other areas have used different
models and different ways of integrating
healthcare and community services.
Unfortunately, a shortage of resources can
limit the achievement of this ideal, and non­
integrated care may persist in many areas.
In 2007, the Royal College of Anaesthetists
established a Faculty of Pain Medicine.
There are currently nearly 500 fellows in the
United Kingdom, most of whom work less
than full time in pain medicine. This roughly
equates to one full-time pain specialist for a
quarter of a million people: the Royal
College of Anaesthetists and the British Pain
Society recommend one per 100,000. This
means that there are about 32,000 sufferers
per full-time specialist. It is unsurprising that
services around the country feel
overwhelmed by referrals and unable to
cope with the workload, let alone
concentrate on delivering change.
Pain services face a number of challenges in
meeting patient need. Innovative services
face the additional challenge of securing
funding. Most services are funded
according to the number of patients seen,
rather than the complex services they
provide. Invisible services, such as
supporting general practitioners or other
services, are not accounted for. Where new
ways of working reduce the number of
patients who need to be seen in specialist
clinics, this can result in a significant loss of
funding for the service, further risking
innovation and even the viability of local
services.
Care for long-term conditions such as
complex and chronic pain should be
focused on the patient, and services should
work together seamlessly, delivering the
elements that patients need quickly and
effectively. To improve outcomes for
patients, effective commissioning should
promote integrated services so that the
patient is entered into the right services for
them as speedily as possible.
PAIN: BREAKING THROUGH THE BARRIER
ACTION RECOMMENDED
• Training in chronic pain should be
included in the curricula of all
healthcare professionals.
• Consideration should be given to the
inclusion of the assessment of pain
and its associated disability in the
Quality and Outcomes Framework
for primary care.
• For patients in hospital, a pain score
should become part of the vital signs
that are monitored routinely.
• The feasibility of a national network
of rapid-access pain clinics providing
early assessment and treatment
should be explored.
• A model pain service or pathway of
care with clear standards should be
developed by experts.
• All chronic pain services should
supply comprehensive information to
a National Pain Database.
• Agencies involved in the
management of patients with chronic
pain should form local pain networks
to work together to improve the
quality of local services.
• The Health Survey for England
should routinely collect data on the
impact of pain on quality of life.
39
ANTIMICROBIAL RESISTANCE: UP AGAINST THE ROPES
ANTIMICROBIAL RESISTANCE: UP AGAINST THE ROPES
Antibiotics have given us the upper hand over many
infectious diseases for the last 60 years. Inappropriate and
unnecessary use has now reduced their effectiveness.
Closer control is needed to protect their usefulness, and
new antibiotics need to be researched and developed.
KEY POINTS
• Antibiotics are life-saving drugs, but
many bacteria are now resistant to
them.
• Antibiotics are also used in large
quantities on animals, adding to the
threat of resistance.
• In some diseases, because of
resistance, the last line of defence
has been reached.
• Even though these drugs are
becoming less effective, fewer
companies develop new antibiotics
because they yield only small profits.
• Resistance is caused by excessive
use of antibiotics: bacteria evolve
and block antibiotic attempts to
destroy them.
• Potential solutions include public
education, improved prescribing
by doctors, tighter regulation of use
in animals, and more research into
new drugs.
41
Antibiotic resistance
An antibiotic’s effectiveness is not a
permanent state. Bacteria develop
resistance to antibiotic attack by acquiring
new characteristics through genetic
mutation or transfer. Within eight years
of its first widespread use, penicillin was
ineffective against the majority of cases of
Staphylococcus aureus in hospitals.
Over the last 80 years, society has grown
accustomed to the security that medicines
give. Before modern antibiotics, simple
infections had life-threatening potential. The
blister from the ill-fitting shoe, the scratch
from the thorn bush, the chesty cough could
all progress to life-threatening infections.
Minor infections could develop unchecked
and lead to bloodstream spread, and often
death. Without antibiotics, the only hope
was that the body’s natural defences would
fend off the infection.
Today, many infections are merely a source
of inconvenience or minor discomfort. If the
antibiotics that we take for granted today
were to cease working completely, the
burden on society and individuals would be
very great.
resist the threats to their survival. Bacteria,
however, reproduce at rates thousands of
times faster than more complex organisms.
Evolution for them is in ‘fast forward’ and so
the process of gaining and spreading
resistance happens very rapidly.
Lives saved by antibiotics
Every time an antibiotic is used, it potentially
becomes less effective in the population as a
whole. Overuse and inappropriate use of
antibiotics reduce their efficacy and their
ability to cure human disease.
The total number of lives saved by
antibiotics each year is large. Three
examples of conditions that would often be
fatal without antibiotic treatment –12,000
cases in one year alone – are bacterial
meningitis, osteomyelitis and pneumonia
(see Table 1).
The same evolutionary pressures that
enabled the human race to adapt, survive
and thrive allow bacteria to change and
Table 1: Patients admitted to hospital
each year with severe conditions
caused by bacteria, requiring antibiotic
treatment
Disease
Number of
hospital
admissions
Bacterial meningitis
1,269
Osteomyelitis (bacterial
bone infection)
3,971
Pneumonia (where
bacteria are confirmed
as the cause)
6,834
Source: Hospital Episode Statistics 2006/07
42
Figure 1: Resistance to cefotaxime in E. coli bloodstream infections is rising
12,000
15
Number of isolates tested
% resistant
10,000
8,000
10
6,000
4,000
5
2,000
0
0
19
94
19
95
19
96
19
Source: Health Protection Agency, 2008
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
% resistant
A variety of different drug compounds can
selectively kill bacteria, or prevent their
replication. These medicines – antibiotics –
can cure many common and some serious
illnesses, and make many operations and
transplant procedures much safer.
A world without antibiotics
Number of isolates tested
CMO ANNUAL REPORT 2008
On an autumn day in 1928, Alexander
Fleming, a microbiologist working at St
Mary’s Hospital in Paddington, noticed a
strange phenomenon in a Petri dish that
had accidentally been left lying on a lab
bench. A ring had appeared around a
colony of mould. Bacteria were not
growing within it. The discovery of what
would become the drug penicillin had a
profound impact on humankind.
Azithromycin % resistant
5
4
3
The resistance picture in England:
some examples
2
1
0
20
01
02
03
20
20
20
04
07
20
06
20
05
20
Neisseria gonorrhoeae, a sexually
transmitted bacterium that causes an
uncomfortable genital discharge, has shown
increased resistance to both ciprofloxacin
and azithromycin (see Figure 2).
30
Ciprofloxacin % resistant
E. coli is a bacterium that is a common cause
of food poisoning and urinary tract
infections. Resistance levels to the antibiotic
cefotaxime have gone from 1% to 12% in the
last 10 years (see Figure 1).
25
20
15
10
5
0
00
20
20
01
02
20
03
20
04
20
20
05
20
06
20
07
Levels of meticillin-resistant Staphylococcus
aureus (MRSA), although improving, are
also high in the United Kingdom when
compared with other parts of Europe (see
Figure 3).
Source: Gonococcal Resistance to Antimicrobials Surveillance Programme
Figure 3: Proportion of S. aureus bacteraemia due to MRSA in Europe, 2007
No Data
< 1%
1–5%
5–10%
10–25%
25–50%
> 50%
Source: European Antimicrobial Resistance Surveillance System
43
ANTIMICROBIAL RESISTANCE: UP AGAINST THE ROPES
Figure 2: Resistance to azithromycin and ciprofloxacin has increased in
N. gonorrhoeae in the United Kingdom
CMO ANNUAL REPORT 2008
Increasing, and worrying, levels of resistance
are developing in other bacteria, including
klebsiella and campylobacter.
In some cases, such as some resistant
Acinetobacter baumannii and certain
extended spectrum beta-lactamase (ESBL)­
producing bacteria, there are only one or
two antibiotics left that work. These are the
last lines of defence against such infections.
A faltering pipeline of new drugs
The future availability of new antibiotics to
counter antibiotic resistance is less certain.
After the initial optimism of the 1940s, 50s
and 60s, new antibiotic drug discovery has
fallen strikingly. The number of new
antibiotic compounds licensed each year has
fallen considerably over the last 20 years.
Only three new classes of antibiotics have
been licensed in the United Kingdom in the
last five years (see Figure 4).
Pharmaceutical companies are only likely to
bear the high cost of new drug development
if they make a profit. Antibiotics give a lower
return on investment than most other drugs.
They are usually used in short courses,
compared with chronic disease drugs that
are long-term or lifelong treatments. Fewer
drug companies are spending money on
developing new antibiotics. Prices are set
high as drug companies try to claw back the
cost of research and development.
In pursuit of profit, drug companies
aggressively market new products to ensure
that they are prescribed as often as possible.
The latest drugs, to which resistance has not
yet been developed, should be held in
reserve as a last resort. A profit-driven
market cannot be relied upon to meet
society’s needs.
44
Figure 4: The number of new antibiotics licensed in the UK is falling
30
25
20
15
10
5
0
1979 –1983
1984 –1988
1989 –1993
Source: Medicines and Healthcare products Regulatory Agency
1994 –1998
1999 –2003
2004 –2008
Packs of antibiotics prescribed
per 1 000 people per day
4.0
– 36%
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0
1997/98 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07
Irresponsible antibiotic use in the
agricultural sector
Source: Goossens et al, 2008
Very large quantities of antibiotics are used in
the agricultural industries, particularly in
animal husbandry. The total volume of
antibiotics used in the United Kingdom for
agricultural purposes in 2007 was 387 tonnes.
Learning from experience elsewhere
Although England has one of the lower rates
of antibiotic prescribing in Europe (14 daily
doses per 1,000 people per day, compared
with a European average of 18), there are
still too many antibiotics prescribed.
In France, a similar major antibiotic
education campaign produced a reduction
in outpatient antibiotic prescription of 23%.
Penicillin resistance in Streptococcus
pneumoniae fell from over 50% to less than
40% during the campaign (see Figure 6).
Resistant bacteria developing in animals could
pose a threat to people. Antibiotics must be
used in moderation in agricultural settings
and only when necessary for animal welfare.
A significant step forward has already been
made by the European Union-wide ban on
the use of antibiotics as growth promoters.
Figure 6: Resistance rates in France have fallen since the start of the
national campaign
60
National plan to prevent
antibiotic resistance begins
50
40
30
20
10
0
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
Resistance rates for several common
microbes also fell. Erythromycin resistance
in Streptococcus pyogenes, a common
cause of tonsillitis, fell from 17% in 2001 to
2% in 2007.
Some active ingredients authorised for
animals are used to treat people too. Large
volumes of quinolones and cephalosporins
are prescribed by vets, even though they are
important for treating human infections.
Proportion of penicillin non-susceptible
S. pneumoniae strains (%)
Other countries have been successful in
reducing the volume of antibiotics
prescribed. The Belgian government has
made a concerted effort to drive down
inappropriate prescription of antibiotics,
particularly in the primary care sector. The
Belgian Ministry of Health ran a seasonal
campaign over the autumn and winter
months from 2000 until 2007, which aimed
to educate the public about the rational use
of antibiotics. It used a combination of
booklets, posters and high-profile television
and radio adverts. The campaign helped
reduce outpatient antibiotic prescription by
36% (see Figure 5).
The Advisory Committee on Antimicrobial
Resistance and Healthcare Associated
Infection has run a number of successful
campaigns in England. However, education
campaigns for both the public and clinicians
have not been on the same scale as those in
Europe.
Source: Eurosurveillance, 2008
45
ANTIMICROBIAL RESISTANCE: UP AGAINST THE ROPES
Figure 5: Outpatient antibiotic use has fallen since the start of the national
campaign in Belgium
CMO ANNUAL REPORT 2008
Prescription only
Although England has taken significant steps
forward in the control of antibiotic usage,
recent moves to make certain antibiotics
available from pharmacists without
prescription must be extended with caution.
Azithromycin, an antibiotic used to treat
chlamydia, can now be purchased without
prescription, provided there is a positive test
result for the disease. Although this is an
innovative way to deal with the considerable
public health implications of chlamydia,
further moves to widen access to antibiotics
without prescription will need to be
balanced carefully against the risks of
promoting greater resistance.
A public good
The potency of one of the key weapons in
the medical armoury is being eroded. The
harm caused by each unnecessary
prescription is not visible at the time, and so
society fails to take action that is necessary
to stop the problem worsening.
Correcting this situation will require a
paradigm shift in thinking. The effectiveness
of antibiotics should be seen as a common
and collective public good.
Every antibiotic expected by a patient, every
unnecessary prescription written by a
doctor, every uncompleted course of
antibiotics, and every inappropriate or
unnecessary use in animals or agriculture is
potentially signing a death warrant for a
future patient.
46
ANTIMICROBIAL RESISTANCE: UP AGAINST THE ROPES
ACTION RECOMMENDED • Existing public education campaigns
about responsible use of antibiotics
should be raised in profile, in line
with practice in some other European
countries.
• There should be a ban on the use of
certain types of antibiotics
(quinolones and cephalosporins) in
animals, in order to protect their
activity in humans.
• Antibiotic packaging should carry a
warning, reminding people of the
need to take them responsibly and
appropriately.
• No further antibiotic classes should
be made available without
prescription unless there is careful
consideration of the potential public
health consequences.
• Alert ‘flashes’ should be added to
packaging for antibiotics where
resistance levels are rising rapidly.
• Consideration should be given to
novel ways to stimulate research and
development of new antibiotics,
including public–private
partnerships.
47
SAFER MEDICAL PRACTICE: MACHINES MANIKINS AND POLO MINTS
SAFER MEDICAL PRACTICE: MACHINES, MANIKINS
AND POLO MINTS
Tomorrow’s healthcare professionals will benefit from
a much wider range of training techniques and scenarios
than has been the case in the past.
KEY POINTS
• Using simulation to constantly
practise skills and rehearse
emergency situations is a vital part
of air safety.
• Air safety has improved greatly
because the skills of pilots
(particularly in dealing with crises)
and the ability of teams to work
together are regularly reinforced
through simulator-based training
and assessment.
• Skills in medicine have traditionally
been learnt and practised with real
patients, but simulation methods
(both low and high technology) are
increasingly available.
• Studies of simulation training for
surgical skills have shown that
surgeons trained in this way make
fewer errors and carry out
technically more exact procedures.
• While simulations and simulated
tasks to develop skills are established
in many medical training centres in
this country, some other parts of the
world are far ahead of us.
• Many doctors attending simulation
courses (including those for life­
saving resuscitation) are now having
to pay for them out of their own
pockets and struggle to be released
from service commitments to attend.
• Simulation offers an important route
to safer care for patients and needs
to be more fully integrated into the
health service.
49
CMO ANNUAL REPORT 2008
ploughed into a flock of birds. The right
engine caught fire and shut down, followed
moments later by the left engine. A total of
155 lives hung in the balance. Captain
Chesley Sullenberger, calmly, professionally
and with formidable skill, landed the plane
on the Hudson River – a feat never before
achieved. The audio recording of the
captain’s conversation with air traffic control
is remarkable. There is an absolute sense of
calm, of someone retaining control in the
face of such a dire situation.
Elaine Bromiley went into hospital in 2005
for a routine nose operation. Her two young
children eagerly awaited her homecoming.
The operation was minor and she had few
concerns. For her husband, Martin, a pilot
and human factors expert, that day was to
change his life forever.
Elaine walked into the anaesthetic room and
was put to sleep. The anaesthetist then
started to put in the breathing tube, which is
necessary when someone is anaesthetised.
It is rare to encounter problems. On that day,
intubation was not routine. The anaesthetist
could not insert the tube. No oxygen was
getting into Elaine’s lungs, and it was
proving impossible to pass a tube into her
throat. The surgeon and another
anaesthetist joined him. Even between the
three of them, they were not able to place
the breathing tube.
This emergency situation is well known to
anaesthetists. It has a name: ‘Can’t intubate,
can’t ventilate’. There is a clear emergency
procedure to deal with it. There is a simple
emergency mantra for dealing with this
eventuality: ‘Oxygenate not intubate’. The
protocol for the urgent management of this
situation escalates rapidly, including the
early abandonment of attempts to intubate
in favour of pursuing oxygenation by any
means, and culminating in the use of a piece
of equipment to reach the windpipe via the
50
front of the neck. This provides oxygen to
the lungs, bypassing the throat entirely. The
percutaneous tracheostomy kit was available
in the room, but the three doctors did not
use it. What should have been a habit was
not. Instead, they focused on repeatedly
trying to insert the standard throat tube,
despite the fact that this was not working. As
they concentrated on doing this, they did
not realise how much time had passed. Over
the next 20 minutes, as their attempts
repeatedly failed, Elaine’s brain was starved
of oxygen. By the time a breathing tube was
finally put in place, it was too late. Elaine’s
brain had been irreparably damaged by the
lack of oxygen. She remained in a coma and
died two weeks later.
On 16 January 2009, US Airways flight 1549
took off from La Guardia airport in New York
City. Minutes after take-off, the plane
“Simulation is a technique – not
a technology – to replace or
amplify real experiences with
guided experiences that evoke
or replicate substantial aspects
of the real world in a fully
interactive manner.”
Professor David M Gaba
Stanford University, USA
A similar incident involving total engine
failure had occurred exactly a year earlier in
London. British Airways flight 38, arriving
from Beijing, lost power to both engines as
it came in to land at Heathrow. The co-pilot
expertly navigated the plane, carrying 152
passengers, to the ground just short of the
runway. It sustained extensive damage on
landing, but nobody on the plane was
seriously injured.
Engine failure is an emergency for pilots.
‘Can’t intubate, can’t ventilate’ is an
emergency for anaesthetists. Yet while more
than 300 passengers on the two aircraft
survived, Elaine Bromiley died. On both
flights, there was potential for panic. Instead,
the unfamiliar was familiar because it had
been encountered many times before, not in
real life but in a simulator. Although it is a
rare occurrence, pilots regularly rehearse
engine failure in simulators. So when faced
with a real situation, habit takes over. And
even in a scenario so rare that it’s a surprise,
pilots have developed mental strategies that
allow them to prioritise and make crucial
decisions rapidly and successfully. Habits are
developed and reinforced by continual
exposure in the simulator.
Not all anaesthetists, by contrast, regularly
rehearse the ‘Can’t intubate, can’t ventilate’
scenario. They learn the theory of what to
do and they learn the practical skill. But they
do not routinely practise the scenario, even
though simulated methods are available.
SAFER MEDICAL PRACTICE: MACHINES MANIKINS AND POLO MINTS
Novice–expert continuum
Mastery
Refinement through supervised clinical practice
Simulation enables people to train for rare
events that will not occur often enough for
experiential learning to be of real benefit.
Unfavourable comparisons between
medicine and other high-risk industries have
been made before. When a person steps on a
plane, their risk of dying in an air crash is one
in 10 million. When a person is admitted to
hospital, their risk of dying or being seriously
harmed by medical error is one in 300.
Excellence
Proficient
Introduction
and initial development using simulation
Competent
Advanced beginner
Novice
Experience
“In one study, surgeons trained
on a simulator were twice as
fast and twice as accurate as
those who had not been.”
One way in which high-risk industries
reduce risk from rare events is through
simulation. Simulation allows people to
prepare for such risky events in a safe
environment. It recreates conditions that
closely resemble reality, while removing any
danger. It means that when people confront
a real emergency situation, they do so with
the experience of detailed rehearsal. It is
widely used in aviation and in the military. It
is slowly being adopted in medicine.
Simulation of rare events does not create
automaticity; rather, by using simulation
‘over-learning’ occurs. People can be
prepared to manage rare events without
panic and disorganisation.
Improving skills
Medical education has been caricatured as
‘see one, do one, teach one’. This describes
a process in which learners observe the
teacher undertaking a technique; then they
perform the technique themselves once
under supervision; and then they are
deemed capable and safe to perform the
technique unsupervised and, indeed, to
teach others. Medical schools have
generally realised that such a model is not
Source: Adapted from Dreyfus and Dreyfus, 1986
appropriate for the 21st century. Most
medical students now learn to take blood
from a plastic arm before attempting to take
it from a real arm. They learn to sew two
pieces of plastic together before suturing
any real skin. For these and other basic skills,
simulation is now used routinely.
Simulation can also be used to teach more
complex skills. Junior surgeons can attend
courses to learn to perform laparoscopic
(keyhole) surgery. They often use the same
equipment that they will use in the operating
theatre. They develop their fine
coordination skills by using the equipment
to stack Polo mints, put matches through
hoops, and chop chicken. Honing clinical
skills requires constant practice. Attending
courses and classes is important but so too
is practising.
Malcolm Gladwell, in his recent book
Outliers, suggests that the key to perceived
genius is really often devoted practice. It is
crucial to learn the right way and then
practise these habits. Incorrect methods do
not sneak in and become habit by accident.
Simulation allows this to happen because
learning is accompanied by assessment and
feedback, unlike learning from real surgery,
where all too often the only feedback is from
adverse events. Breaking complex new tasks
into small chunks, which can be repeated
with assessment until learnt, is a technique
developed by the father of deliberate
practice Anders Ericsson. To allow junior
doctors to do this, local access to such tools
is required at times that suit the trainee.
Simulation improves performance. Research
at Imperial College London has shown that
simulation improves the skills of surgeons in
training. One study observed surgeons
operating on pigs to remove the gallbladder.
Some surgeons had received simulation
training for this; others had not. Compared
with surgeons who had not completed
simulation training, the surgeons who had
done so were twice as fast at completing the
task (2,165 seconds compared with 4,590
seconds) and twice as accurate (requiring
1,029 movements rather than 2,446
movements).
Simulation reduces errors. A trial in Sweden
demonstrated that junior surgeons who had
been given virtual reality training for keyhole
surgery made significantly fewer errors than
their peers who had not. Their colleagues
made, on average, three times as many
errors and took 58% longer to carry out
an operation.
51
CMO ANNUAL REPORT 2008
Table 1: Types of simulator by earliest identified date of reference
Simulator
Date of first publication
Fibre endoscopy
1987
Endoscopic retrograde cholangiopancreatography (ERCP)
1988
Colonoscopy
1990
Endoscopic trainer
1993
Laparoscopic surgery
1994
Hysteroscopy
1994
Hollow organ closure
1994
Total hip replacement
1995
Ophthalmic simulator of laser photocoagulation
1995
Ophthalmic surgery
1995
Intravenous catheter insertion
1996
Otolaryngology
1996
Laparoscopic surgery
1997
Abdominal aortic aneurysm (AAA)
1998
Inferior vena cava filter placement
1998
Strengthening team-work
Sigmoidoscopy
1998
Shoulder arthroscopy
1999
Surgical suturing
1999
Breast biopsy
1999
Transurethral prostatic resection
1999
Computer-based interventional cardiology
2000
Gone are the days of the lone hero doctor.
Delivery of safe, high-quality healthcare
requires many different professionals to
work together as a team. When a sick
patient is rushed into hospital, paramedics,
nurses and doctors must be able to work
together quickly and effectively. When an
emergency occurs in childbirth, the team
includes midwives, obstetricians,
paediatricians, nurses and anaesthetists.
Vulnerable patients need occupational
therapists, physiotherapists, pharmacists
and social workers to work together with
doctors and nurses to ensure a safe
discharge from hospital. However good
each individual’s technical skills are,
avoiding tragedy depends on them working
together as a team.
Bronchoscopy
2001
Upper gastrointestinal endoscopy
2003
Source: Cooper and Taqueti, 2004
Figure 1: Funding for compulsory
basic surgical skills
courses
Entirely funded by student
Partially funded by student
Not funded by student but by other
e.g. deanery
Not specified
Source: Royal College of Surgeons of Edinburgh
electronic logbook records
52
Changes in the structure of medical training
have resulted in a reduction in junior
doctors’ hours. As a result, doctors complete
fewer hours of training in total before
becoming consultants. Today’s doctors are
exposed to fewer patients than their
predecessors. Modern training provides
fewer opportunities for doctors to practise
practical procedures. Some have expressed
concern that this may result in lower clinical
standards. Simulation-based training will be
an important part of bridging this skills gap
in the future.
Access to simulation is patchy. Despite their
proven effectiveness, junior surgeons
usually have to pay to attend these
laparoscopy courses from their own pocket
(see Figure 1). Senior doctors struggle to be
allowed out of service commitments to
attend these courses and increasingly have
to pay for them out of their own pocket.
Course prices have increased significantly:
the average price of a paediatric resuscitation
course in 1997 was £300; now it is around
£500. Given the critical nature of these
courses, the rationale for making doctors pay
for courses themselves is unclear.
Use of a simulator to learn practical skills
occurs mainly on an ad hoc basis. Whether
or not a junior surgeon has access to
simulation largely depends on which
hospital they are working in at the time.
Highly realistic training environments, such
as operating theatres or wards that
authentically replicate actual clinical
environments, can be used to train and
develop clinical teams, especially when
linked to audio-visual recording and
behavioural debriefing. Clinical teams can
be put through their paces managing
complex, rare or serious clinical scenarios.
Some people inherently work well in teams,
but everyone can improve their skills. Teamworking is best learnt from experience. The
usefulness of full-immersion, clinical teambased simulation is that it allows people to
work on these skills in a controlled and safe
environment. Elaine Bromiley may have
been alive today if the theatre team had
had better insight into crisis resource
management skills and if they had had
regular emergency simulation training to
refine these skills.
Cheshire and Merseyside
Simulation Centre
Montagu Clinical Simulation Centre
Trent Simulation and Clinical Skills Centre
Learning to debrief
Simulated scenarios give adequate time to
encourage reflection and to identify what
could be done better. The team is debriefed.
Many of the best simulations involve the
participant being filmed, so that later they
can watch and critique their own
performance. Once acquired, debriefing
techniques learnt in simulation should be
applied to real clinical situations. Learning
to learn from real events makes for safer
healthcare. After finally placing Elaine
Bromiley’s breathing tube, the team looking
after her continued with their day. They did
not have the opportunity at the time to reflect
on and learn from the traumatic events.
Unlike the situation in other high-risk
industries, debriefing after a critical event
is not routine in medicine.
Assessing skills
Simulation forms an important part of skills
assessment for both medical students and
doctors. In many schools of medicine,
communication skills are tested in mock
scenarios using actors in place of patients.
Medical school examinations may include
observation of students taking blood from
a plastic arm, or suturing a rubber pad.
Complex manikins can mimic heart
conditions that can be discovered only
through careful clinical examination. In some
parts of the world, testing using simulation
has become mandatory. For example, since
2004 all newly qualified doctors in Israel must
participate in a national simulation-based
training course lasting five days. In order to
complete their training, anaesthetists in Israel
have to successfully complete a practical
assessment using simulation.
Addenbrooke’s
Simulation Centre
Hertfordshire Intensive Care and
Emergency Simulation Centre
Bristol Medical Simulation Centre
St George’s Advanced
Patient Simulator
Chelsea and Westminster Hospital
and Anaesthetic Simulator Centre
Barts and the London
Medical Simulation Centre
Portsmouth Simulation Centre
Peninsula Simulation Suite
Simulation allows researchers to identify
common mistakes caused by gaps in
clinicians’ knowledge. Once found, training
can be altered to make sure that these gaps
are filled. By watching how teams function in
a variety of simulated settings, specialist
observers can alter the protocols, improving
usability, safety and effectiveness. Observers
can determine how teams respond to
changes in the environment, such as lighting
or noise levels. New medical devices can be
trialled before being distributed. Simulation
may allow many types of problem to be
highlighted and put right long before any risk
to patients can occur. Many complex clinical
procedures have now been standardised.
Teams carrying out these tasks can follow
predetermined pathways to make sure that
they are achieving best practice. This is
essential in time-critical activities such as
resuscitation, where teams must work rapidly
and consistently to achieve a good outcome.
Simulation can be used to develop and
assess these procedures.
Simulation in the United Kingdom
Since the mid 1960s, courses have been run
to rehearse emergency conditions in both
medicine and trauma, for example where
patients have stopped breathing, have
collapsed or have suffered major blood loss.
These courses are based on a simple
principle – that in difficult, taxing conditions,
people revert to routine and habit. To ensure
safe practice, good habits need to be a reflex
action. That means rehearsing simple,
standardised techniques for performing
complex procedures. This approach has
made a fundamental difference to how acute
medicine operates in the United Kingdom.
At the heart of these courses is simulation.
This often requires little in the way of
technology, but much in the way of time
and effort from both trainers and trainees.
Currently, junior doctors are expected to
undergo simulated resuscitation training
once every four years. Airline pilots are
required to show proficiency in simulated
emergencies every six months.
53
SAFER MEDICAL PRACTICE: MACHINES MANIKINS AND POLO MINTS
Figure 2: Examples of high-fidelity simulation centres
CMO ANNUAL REPORT 2008
Figure 3: Comparison of medicine and aviation high-fidelity simulation availability
British Airways
NHS in England
3,200 pilots
34,000 consultants and 47,000 doctors
in training, including 12,000 surgeons
14 high-fidelity simulators
Fewer than 20 high-fidelity simulators
Resuscitation training courses are
considered mandatory for junior doctors.
However, the NHS is not able to provide
such training routinely throughout a medical
career. Upon reaching senior grades,
doctors no longer need to demonstrate
resuscitation competence under simulated
conditions.
The NHS has yet to embrace simulation
widely as a mechanism to objectively
identify those doctors suitable for certain
specialties, although some specialties – such
as ophthalmology and cardiac surgery –
have started to do this. Procedure-specific
simulation (for example planning the
operation about to be carried out) is also
possible and enhances team-work
dramatically, as well as ensuring that the
correct equipment is in place.
Teaching and learning by simulation need
not necessarily involve complex technology.
Situational learning can often be achieved
with only basic resources. However, highfidelity simulation, using advanced
technology to artificially replicate reality,
provides a unique opportunity to immerse
practitioners in a highly realistic
environment. Access for doctors to these
technologies is still limited (see Figure 2).
Admittedly, high-fidelity simulators are not
yet applicable to all fields of medicine, but
their availability is much lower than in the
airline industry (see Figure 3).
54
The international standard
MSR, the Israel Center for Medical
Simulation founded by Dr Amitai Ziv,
simulates settings including an emergency
department, operating theatres, clinics, a
pharmacy and more. Every one of its
patients is made of plastic or is an actor. It is a
world leader in using simulation to train
healthcare professionals. Every year, more
than 7,000 doctors and other healthcare
professionals pass through its doors. It has
some of the most advanced medical
simulation technology that exists.
Forming safe habits: simulation
Individual
skill
Handling
emergencies
Team-working
ability
Situational
awareness
In England, the current picture is less
promising. Simulation is regarded as a useful
add-on rather than a compulsory and core
part of training. However, some NHS
organisations have started to take a more
organised approach to simulation. Over the
last two years, the London Deanery and
NHS London have invested £11 million to
provide simulation facilities to hospitals
throughout London. Every acute hospital
trust in London now has them.
Lessons from the aviation industry show that
learning increases if the training is designed
and taught by pilots. Training pilots teach in
the simulators and ‘fly the line’ – fly as
normal commercial pilots. This ensures that
they can spread their knowledge to others
during routine flights. It also means that
training is respected and appreciated. These
positions are highly sought after. It is
important that senior doctors become
trainers in medical simulation and that the
role is not just left to more junior enthusiasts.
Although there are examples of excellent
practice, there is not yet the national
capacity or coordination that is needed.
Simulation does not yet form a sufficient part
of medical training and assessment.
Furthermore, too great a burden is placed on
individuals to fund such training themselves,
compared with other industries where
mandating the training has meant that
funding is provided by employers.
Simulation works. Simulation is important to
medicine. The NHS must be able to provide
the type of simulation that would make a
difference to patients like Elaine Bromiley.
SAFER MEDICAL PRACTICE: MACHINES MANIKINS AND POLO MINTS
ACTION RECOMMENDED • Simulation-based training should be
fully integrated and funded within
training programmes for clinicians at
all stages.
• A skilled faculty of expert clinical
facilitators should be developed to
deliver high-quality simulation
training.
• Simulation-based training needs to be
valued and adequately resourced by
NHS organisations.
• The importance of human factors
training to safe care should be widely
communicated.
• Each medical Royal College should
identify a lead for simulation training.
• National Patient Safety Agency serious
incident reports should be made
available to simulation centres to
embrace learning to prevent such
incidents in the future.
• A national centre for simulation
techniques should be established
to maintain and disseminate
leading-edge methods and new
developments.
55
THE REGIONS
Health problems and initiatives
North
East
In this section, each of the geographical
areas covered by England’s nine public
health groups highlight a specific issue
or local health intervention.
North
West
Yorkshire
and the
Humber
East
Midlands
West
Midlands
East of
England
London
South East
South West
THE REGIONS
NORTH EAST
North
East
North
West
Yorkshire
and the
Humber
Aligning public health research
with service needs
Efficient treatment of disease requires hard
evidence. Time and money spent on
treatments that do not work short-change
both those who receive them and those who
are denied effective treatment as a result.
Disease prevention is no different. It is
necessary to identify those interventions that
work and are affordable, and then ensure
that they are implemented comprehensively.
Yet public health interventions suffer too
often from an inadequate evidence base. It
is essential that the public health research
efforts of universities are coordinated with
the needs of the public and of preventive
services.
To this end, the Centre for Translational
Research in Public Health was established in
June 2008. This unique regional
collaboration unites Newcastle, Durham,
Sunderland, Northumbria and Teesside
universities with regional partners, including
primary care trusts and NHS Trusts, the
Government Office for the North East, the
Association of North East Councils and One
North East, in pursuit of shared public health
research goals. Funded by an initial grant of
£5 million via the United Kingdom Clinical
Research Collaboration, the Centre aims to
link work in various public health areas (such
as alcohol, tobacco, obesity and inequalities
in health and healthcare) to the situation and
needs of the population in the region. It
focuses strongly on seeking evidence for
implementation of change, not only by the
NHS but through all of the structures that
can influence the health of populations.
Eight new public health academic staff have
been appointed. They will contribute to and
lead research programmes that develop and
evaluate public health interventions, and will
work to get this evidence taken into account
in mainstream policy and practice. They will
be supported by PhD students working on
specific topics such as dietary change, the
best use of health trainers, reducing alcohol
use in young people and maximising health
through local area agreements. Six new
studentships started in 2008 and a further
four will follow during 2009. These numbers
will increase as the Centre attracts further
grants for work in additional key areas.
East
Midlands
West
Midlands
East of
England
London
South East
South West
Representatives from a swathe of local and
regional organisations are involved in the
direction and activities of the Centre.
Agreements are being developed on the
work programmes needed to tackle the
worst and most intractable of the region’s
public health problems, such as smoking,
obesity, alcohol misuse and social inequality.
This collaboration reflects both the national
recognition that insufficient investment has
been made in the translation of research
findings into practice, and the increasing
need for concerted action to tackle the
greatest killers and causes of health
inequalities of our time. Moreover, it
recognises that what is local also holds
global messages. The Centre is committed
to supporting an evidence-based approach
to public health commissioning and to
delivery of the North East’s strategy for
health and well-being, ‘Better Health, Fairer
Health’. Making solutions work for the North
East will help us to understand better how
approaches and services must be tailored to
the needs of the populations they serve.
57
CMO ANNUAL REPORT 2008
NORTH WEST
North
East
North
West
Yorkshire
and the
Humber
A new perspective on
being well
Each year, the Health Survey for England
collects a large amount of detailed and
complex data about the nation’s health.
Examining and understanding patterns
within the data can provide useful insights
to help guide the planning of public health
services and strategies.
The North West region examined data from
the Health Survey for England 2006, initially
to help quantify the relationships between
reported success in quitting smoking and
individual characteristics, including lifestyle,
health status and economic status. The
analysis showed that the overwhelming
majority of smokers quit successfully
between the ages of 25 and 50 years, but
that the more affluent individuals tended to
quit at a younger age. Early successful
quitting was more likely in those who were
moderate drinkers, who were above normal
weight, who engaged in vigorous
recreational physical activity, and who ate
plenty of fruit and vegetables. Those who
were inactive, had a poor diet, were
underweight or normal weight and did not
drink (or drank to excess) were less likely
to quit successfully. These facts and others
demonstrated a significant general trend –
that people with healthy and positive
lifestyles were likely to succeed sooner in
their attempt to quit smoking.
This finding encouraged the region to use
the data to tackle a broader question – the
issue of what it is to ‘be well’. By increasing
our understanding of ‘wellness’, we are
better placed to support the public in
improving their own health (as ‘being well’
helps people to reduce the unhealthy
aspects of their lives) and better placed to
identify those aspects of services that
encourage the early acquisition of ‘being
well’ in different populations.
58
The issue is a complex one. The Health
Survey for England asks participants a
number of questions that relate to their own
general health. A technique known as
categorical principal components analysis
was used to simplify and summarise the data
to see patterns within it.
Results showed that people tended to report
higher levels of ‘being well’ if they had
completed secondary school education, had
a higher income or job status, reported good
mental well-being, and were a member of a
local group or organisation (whether
religious, sporting or social). ‘Being well’
increased up to the 35–44 year age bracket,
especially among the affluent, but then
declined in the 55–64 year age group and
above. The analysis reinforced the idea that
‘being well’ is not the same as ‘not being ill’.
The analysis also showed the importance of
community factors. People who enjoyed
living in their area and who had helpful
neighbours reported greater levels of ‘being
well’. Such people were also healthier by
other measures. They were less likely to
have a long-term mental illness, for example.
The findings underline the need for lifestyle
and behaviour change interventions to
consider the broader social context of
people’s lives. Effective public health
East
Midlands
West
Midlands
East of
England
London
South East
South West
interventions should consider using a wider
social model of service delivery involving
social support. At North Cheshire Hospital,
the Warrington Hospital Volunteer Project,
run by Warrington Community Alcohol
Service, trained volunteers to analyse
admission slips, identify regular alcoholrelated admissions, and offer brief
interventions, befriending, mentoring and
support to identified dependent drinkers.
Over the 18 months of the project,
volunteers received 163 referrals, out of
which 101 appointments were made and
49 clients subsequently engaged with the
core alcohol service. By working with the
alcohol liaison nurse, the project contributed
to a reduction in repeat attendances. In the
year prior to the start of the project, 26 people
were responsible for 226 alcohol-related
hospital admissions. The following year the
same 26 people had only 62 admissions
between them. This work is leading the North
West to consider new models for lifestyle
change that pay attention to the general
factors that enable people to ‘be well’.
Further work is planned to look at how
personal and community resilience may be
supported. It is clear that social participation
and engagement are constituents of
‘being well’.
Improving the health of
vulnerable migrants
Yorkshire and the Humber is home to an
estimated 8,000 asylum seekers, 5,000
refused asylum seekers, 20,000 refugees and
40,000 economic migrants. The region has
the second largest number – just over 20% –
of all asylum seekers and refugees in the
country. Some arrive in good health and are
able to access health services, but others are
extremely vulnerable. This may be due to:
• traumatic events such as war,
imprisonment, genocide, persecution and
exploitation, as well as the journey itself,
which is often arduous and unsafe
• loss of role or status held in their home
country
• anxieties from awaiting asylum decisions
• poverty, poor accommodation, denial of
the right to work, discrimination and racial
harassment.
Language, ethnicity and culture can each act
as a barrier to services, as can prejudice and
confusion about entitlement. In turn, poor
health can be a barrier to integration and
involvement in a new community.
Recent scoping by the Yorkshire and
Humber Regional Migrant Partnership found
that, though in general health services are
good, health agencies appear to be much
further behind other sectors, such as
housing, education and employment, in
recognising and addressing the needs of
migrants. Evidence suggests that health
organisations are now relying less on
individuals such as health visitors, practice
nurses and general practitioners to
champion the needs of migrants and are
responding more strategically.
There are a number of challenges associated
with tackling migrant health: it is a politically
sensitive area; the populations in question
are small but have disproportionately high
levels of need; and there are a number of
very disadvantaged communities, for
example the Roma, who bring with them a
history of exclusion and discrimination and
often extremely poor health.
Historically, services have been
commissioned reactively by individual health
communities. They have tended to lack the
capacity to act strategically, for example to
adapt to rapid demographic shifts while still
meeting needs sensitively and appropriately.
They have sometimes operated in isolation,
remaining separate from established black,
minority and ethnic services despite the
overlap in skills. Services have relied on a
small number of highly experienced and
dedicated front-line champions. The work is
extremely challenging and recruitment and
retention can be problematic. Demographic
data are limited, making service design
a challenge.
THE REGIONS
YORKSHIRE AND
THE HUMBER
North
East
North
West
Yorkshire
and the
Humber
East
Midlands
West
Midlands
East of
England
London
South East
South West
Training is required – both general training
for all healthcare staff on the entitlement of
migrants to NHS care and on skills for crosscultural working, and specialist training on
early recognition of the effects of torture and
how to manage them. And appropriate
mental health services, particularly those for
children and adolescents, are not always
available in all parts of the region.
Thanks in part to a very active Migrant
Health Interest Group, health organisations
are beginning to recognise the need to work
together. With funding support from some
primary care trusts and the Department of
Health, a new regional migrant health post
has been established to champion this work.
Failure to address the health needs of the
very vulnerable damages the well-being of
the whole community and risks further
widening of the inequalities gap.
Research with general practices across the
region has raised important points about
services. While in some areas registering
with a general practice is straightforward, in
others there may be barriers, such as
demands for documents with proof of
address that the migrant might not have.
Some health workers rely on informal
interpretation by friends or family members,
including children – which can be difficult for
all those concerned – instead of calling on
the formal interpretation support available.
59
North
East
North
West
Yorkshire
and the
Humber
expenditure of sedentary and dynamic,
interactive video game play. It also
investigated whether the time spent playing
can contribute towards daily moderate to
vigorous physical activity in children.
Using interactive computer
games to reduce obesity in
children
In the East Midlands, as in many other
regions, obesity is on the increase among
children, particularly boys. The proportion of
boys who are obese increased from 10.9% in
1995 to 17.3% in 2006. In girls, the obesity
level rose from 12% to 14.7% over the same
period.
Data highlighted that, during active game
play, energy expenditure can be increased
by approximately 42% above the levels
measured during sedentary game play (see
Figure 1).
Further evidence indicated that the heart
rate can be raised and sustained at moderate
to vigorous intensities during active game
Figure 1: Energy expenditure of children while at rest and while playing interactive
computer games
6
5
4
3
East of
England
London
South East
play. These highly interactive games may
offer a means of providing the
recommended daily physical activity for
children while at home. They may also
provide an opportunity to increase levels of
physical activity in obese children. If children
engaged in active play for 60 minutes a day
over a year, they would burn approximately
7.5lbs of body fat.
The second phase of the study is using
interactive, dynamic gaming systems as an
intervention strategy for physical activity
engagement. Gaming consoles, with
associated games, will be provided to
20 children to use freely over a period of
12 weeks. Participants will be drawn from
‘Go 4 It’, a scheme in Nottingham providing
physical activity and healthy eating advice
and support to overweight and obese
children and their parents. Many individuals
in this group face barriers to exercise
engagement. Interactive games, which can
easily be played in the safety of the child’s
own home environment, may be one way of
minimising these barriers.
This second phase is due to be completed
by late spring 2009. The findings will be
used to develop a strategy to encourage
behavioural change in children and promote
involvement in physical activity.
2
1
0
1
2
3
4
5
6
7
8
9
10
Time (minutes)
Source: Nottingham Trent University, 2008
60
East
Midlands
West
Midlands
South West
Fifteen children (14 boys and one girl) were
recruited for the first phase of the study,
beginning in February 2008. Their energy
expenditure was determined when at rest,
while playing traditional sedentary video
games on PlayStation, and while playing
interactive multimedia video games (Sony
EyeToy and Nintendo Wii Sports). Their
heart rate was monitored continuously
throughout the 10-minute sampling period.
Video gaming has been strongly implicated
as a major cause of overweight and obesity
in children and young adults. As stopping
children playing video games is unlikely, a
research group decided to investigate the
health benefits of playing more dynamic and
interactive forms of video games. The group
– which included representatives from
GameCity (a street-level programme of
activity that celebrates video games and
interactive entertainment), Nottingham Trent
University, the Department of Health, and
clinicians from Nottingham University
Hospital – investigated the energy
Energy expenditure (kJ per min)
CMO ANNUAL REPORT 2008
EAST MIDLANDS
Rest
Sedentary gaming
Active gaming
THE REGIONS
WEST MIDLANDS
North
East
North
West
Yorkshire
and the
Humber
improved management when it occurs.
Two of the main risk factors for stroke are
smoking and raised blood pressure. In the
West Midlands, vigorous measures are
being taken to reduce the prevalence of
smoking, and general practices are doing
well in regulating the blood pressure of
those on stroke and TIA registers. However,
these measures need to be intensified.
Working to reduce stroke
mortality
The age-standardised stroke death rates in
the West Midlands are among the highest in
the regions (see Figure 1). The death rates
for the over 75s are particularly high.
Although death rates from stroke have been
falling nationally, the gap between the West
Midlands and the rest of the country has
remained.
The National Stroke Strategy recommends
that stroke patients should immediately be
admitted to, and cared for in, specialised
stroke units with rapid access to
thrombolysis where appropriate. Early
provision of specialist treatment from a
multidisciplinary team greatly increases the
chances that the individual will be able to
return home and recover full function. The
National Sentinel Audit of Stroke found that
all West Midlands NHS Trusts and
Foundation Trusts had either an acute stroke
unit or a rehabilitation stroke unit, and many
The high death rates in the West Midlands
are unlikely to be due to a higher incidence
of stroke. Emergency hospital admission
rates for stroke are in the middle of the
regional range, while patients on general
practice registers for stroke and transient
ischaemic attack (TIA) are not out of line
with the rest of the country.
Strategies to reduce death and disability
from stroke rest on initial prevention and
40
40
20
20
0
0
London
South East
South West
had both. Of the 19 Trusts, six were rated
overall to be in the top 25% for stroke
services while two were in the lowest.
Access soon after admission to CT scan or
other form of brain imaging is important, but
in all except two West Midlands hospitals
this takes more than four hours. Facilities for
the management of stroke have improved
in the region, but the high mortality rate
suggests that further improvement
is needed.
The cardiovascular networks are working
with front-line clinicians in the West
Midlands to improve stroke services and
refine patient pathways based on the
recommendations in the National Stroke
Strategy. There is a stroke reference group,
a stroke workforce group and a stroke
research network. These are active
collaborations with leadership from frontline clinicians, all focused on improving
outcomes for stroke management in the
West Midlands.
rth
No
No
rt
Ea
st
Mi
dl
t
W
es
uth
So
th
gla
En
of
Ea
st
So
u
n
nd
o
Lo
East of
England
W
es
t
60
hE
ast
60
Yo
the rksh
Hu ire &
mb
er
W
es
tM
idl
an
ds
80
an
ds
80
Ea
st
100
nd
100
Mortality rate per 100 000
Admission rate per 100 000
Figure 1: Mortality rate and hospital emergency admission rate for
stroke in England
East
Midlands
West
Midlands
Admissions
Mortality
Source: Office for National Statistics death files, 2007; Hospital Episode Statistics, 2007/08; Office for National Statistics mid-year estimates, 2007;
West Midlands Public Health Observatory
61
CMO ANNUAL REPORT 2008
EAST OF ENGLAND
North
East
North
West
Yorkshire
and the
Humber
Improving the welfare of
vulnerable young people
England to see whether the outcomes
obtained in the United States are replicable.
In 2007, NHS South East Essex and its local
authority partners became one of 10 national
demonstration sites in England to test
implementation of the Family Nurse
Partnership. The Partnership is a licensed,
evidence-based prevention and early
intervention programme for vulnerable,
young first-time parents and their children.
It is the first part of the preventive pathway
for the 2–5% most disadvantaged children.
Its aim is to reduce the impact of multiple
deprivation and improve short- and longterm health and well-being outcomes for
children. It also aims to reduce the shortand long-term cost of caring for such
children and families.
Early indications are that the Family Nurse
Partnership will significantly help vulnerable,
young first-time parents. The first year
evaluation, undertaken by Birkbeck,
University of London, suggested that the
scheme can be delivered effectively in this
country. The evaluation also found that:
• the programme is welcomed by hard-to­
reach families and connects with clients
who are likely to benefit most
• clients had high regard for their family
nurses
• almost half the fathers and partners had
been present for at least one Family Nurse
Partnership visit
• the programme has the enthusiastic
support of the nurses, who are seeing
changes take place in health behaviour,
relationships, parental roles and maternal
well-being
• there are early signs that clients now have
aspirations for the future and cope better
with pregnancy, labour and parenthood.
The Family Nurse Partnership, which is
voluntary, involves weekly or fortnightly
structured home visits by a specially trained
nurse from early pregnancy until children
are 24 months old. The nurses use
programme guidelines, materials and
practical activities to work with the mother,
father and wider family.
The Family Nurse Partnership was
developed and researched over more than
30 years by Professor David Olds in the
United States. Three randomised control
trials showed consistent short- and longterm benefits for children and families,
with the greatest impact among the most
vulnerable. Benefits included: improved
women’s antenatal health; fewer
subsequent pregnancies and greater
intervals between births; reduced childrens’
injuries through accidents; reduced child
abuse and neglect; and better language
development. The Partnership has also
shown increased involvement of fathers,
increased family employment and reduced
welfare dependency.
The NHS South East Essex demonstration
site is testing the Family Nurse Partnership in
62
East
Midlands
West
Midlands
East of
England
London
South East
South West
There is also some evidence that prevalence
of smoking in pregnancy was reduced and
breastfeeding rates were higher than
expected. It is too early to draw firm
conclusions.
From April 2009, the pilot will be one of
18 randomised control trial sites. An
economic evaluation of Family Nurse
Partnerships will also be undertaken.
THE REGIONS
LONDON
North
East
North
West
Yorkshire
and the
Humber
Tackling knife crime through
multi-agency data sharing
Knife crime remains a significant issue in
London. The number of individuals admitted
to NHS hospitals in London following assault
with a ‘sharp object’ has been increasing
year on year since 2002/03, particularly
among those under 21 years of age. These
data, however, also include non-knife crime
related cases, so are difficult to interpret.
The Regional Public Health Group and NHS
London have been working closely with
primary care trusts, the Government Office
for London, the Metropolitan Police, the
Home Office and the Greater London
Authority on a joint programme of work to
address both knife crime and alcohol-related
violence, which has also been rising in
London. One element is based on findings
from similar work taking place elsewhere in
the country, which found that a significant
proportion of violence-related cases seen in
emergency departments are not known to
the police.
The Home Office’s Tackling Knives Action
Programme is working with the Regional
Director of Public Health, the Metropolitan
Police and the Government Office for
London to provide support to the hospitals
to help them realise this commitment. The
assistance provided includes training staff
and changing local IT systems to support
data collection.
Whilst each hospital will collect a minimum
data set for sharing with its local Crime and
Disorder Reduction Partnership, the
development of locally sensitive models that
include engagement of clinicians, public
health teams and local communities is being
encouraged. This should help ensure that
the additional public health benefits are
maximised. Youth outreach workers
supporting victims, brief interventions for
patients involved in alcohol-related crime
and enhanced detection of domestic
violence are some examples of local
innovation currently under way.
East
Midlands
West
Midlands
East of
England
London
South East
South West
The hospitals in the Tackling Knives Action
Programme will serve as pilots, with a view
to becoming beacons for data-sharing
practice. Their experiences and the
outcomes of a process evaluation will be
shared at a summit planned for spring 2009.
Collecting simple, anonymised aggregate
data in hospitals of assault type, location and
assailant details can supplement other data
sources, such as the Metropolitan Police and
the British Crime Survey, and help in
targeting crime prevention initiatives, such
as changes to the operating times of
licensed premises, targeted street patrols,
CCTV, fast food outlet relocation and
pedestrianisation of entertainment streets.
In London, six groups of hospitals identified
as being high-priority areas for the
programme, particularly with respect to
knife crime, are committed to start data
sharing by March 2009.
63
North
East
North
West
Yorkshire
and the
Humber
haemorrhage, infection, venous thrombosis,
subsequent placenta accrete and a variety of
less common surgical complications. The
mothers concerned are less likely to initiate
breastfeeding, the duration of breastfeeding
is reduced, and there is less interaction with
their babies at home.
Reducing Caesarean
section rates
Caesarean section rates have been
increasing steadily across England and
Wales in recent years. In 1990, 1998 and
2007, rates were 11.3%, 18.2% and 24.3%
respectively. This trend is not associated
with measurable improvement in outcome
for the babies, and is only partly explained
by demographic factors. In the South East in
2006/07, the rate was the same as the
national rate: one in four (22,295) births
were by Caesarean section and one in 10
of these were elective.
Individual hospitals in the South East, as
elsewhere, show markedly different rates of
Caesarean section (from 19.8% to 28.0%),
which are unrelated to the characteristics of
the populations they serve. A Canadian
study of hospitals with especially low
Caesarean section rates found in those units
a ‘culture’ in which normal birth was the
expected approach, strong clinical
leadership of effective teams, and the active
use of clinical evidence and quality
improvement approaches. A systematic
review in 2007 (including five randomised
studies) found that active measures could
reduce the Caesarean section rate by a fifth.
Caesarean section has greatly increased the
safety of childbirth worldwide. Indications
for the procedure in the United Kingdom
were set out by the National Institute for
Health and Clinical Excellence in 2004, the
most common being fetal compromise,
failure to progress, repeat Caesarean section
and breech presentation.
The experience of one maternity unit in the
South East confirms that a substantial
increase in the proportion of normal births
can be achieved (see Figure 1). This unit
used Focus on normal birth, the toolkit from
Without these indications, normal birth is
safer and better for both mother and baby.
Compared with normal birth, Caesarean
section increases the risk of post-partum
30
25
20
15
10
64
Oct
Nov
Sep
Jul
Aug
Jun
Apr
May
Mar
Jan
Feb
Dec
Oct
Nov
Sep
Jul
2007
Source: Local maternity service clinical database
Aug
Jun
Apr
May
Mar
Jan
Feb
5
0
2008
First birth
East
Midlands
West
Midlands
East of
England
London
South East
South West
the NHS Institute for Innovation and
Improvement (2007), to enhance the work
already taking place in its maternity service.
Specific changes have included:
• midwife team leaders rotating between
high-risk’ and low-risk’ clinical areas
within the unit to share skills and increase
the prevalence of normal births in the
high-risk’ environment
• a consultant midwife in the labour ward
one day a week, with the explicit aim of
helping to reduce intervention rates
• supporting junior staff and multiprofessional team working
• the introduction of a weekly
communication bulletin, with ‘top five tips’
for that week communicated at each
medical and midwifery handover.
The most profound change has been the
increased focus among all staff on keeping
birth normal. The most important factor in
the unit’s success has been the strong
multidisciplinary team that has driven the
initiative, in this case led by a consultant
midwife. This initiative has resulted in a
marked fall in Caesarean section rates and
is a powerful encouragement to other units
across the region engaged in the programme.
Figure 1: Caesarean section rates in a large maternity unit in the South East
Percentage of women having
Caesarean section
CMO ANNUAL REPORT 2008
SOUTH EAST
Later birth
THE REGIONS
SOUTH WEST
North
East
North
West
Yorkshire
and the
Humber
Making the region smoke free
During early 2008, the South West took
stock of its current position on smoking
prevalence and related disease. The General
Household Survey statistics showed that the
region’s adult smoking prevalence (23%)
was above the national average, and
smoking prevalence among 16 to 24-year­
olds (34.9%) was the worst in England.
Recent data show that around 31,000 young
people aged 11 to 15 years smoke. Health
inequalities are widening in the South West.
For example, over the past 20 years lung
cancer incidence in females in the most
deprived communities has increased by
30%, compared with a static pattern for
those in the most affluent (see Figure 1).
A new, intensified approach has been taken
to tobacco use in the South West. Based on
the experience of the Centers for Disease
Control and Prevention in the United States,
the establishment of a new, region-wide
organisation to tackle smoking was
proposed. All 14 primary care trusts gave
approval and rapid action was taken to set
up Smokefree South West. The five-year
investment of over £2.5 million per annum
will be the largest commitment of funding
for tackling tobacco use over the longest
period by any region.
During 2008/09, Smokefree South West
developed an innovative £1.5 million
campaign to stimulate awareness of the
availability and convenience of NHS Stop
Smoking Services. Research had found that
they were largely ‘invisible’. This promotion
rolled out from September 2008 on
billboards, local radio, television, buses,
online and in the press. A database now
holds information on the location of all the
region’s NHS Stop Smoking Services outlets.
There are over 1,000 outlets from Cornwall
to Tewkesbury, in diverse locations such as
Directly age-standardised incidence rates per 100 000
Figure 1: Comparison of trends in female lung cancer incidence in the South West,
deprived versus affluent communities
60
50
40
30
20
East
Midlands
West
Midlands
East of
England
London
South East
South West
libraries, leisure centres and Ministry of
Defence establishments, as well as on NHS
premises. The range of the locations has
been used in the campaign to highlight
convenience of access, particularly for
routine and manual workers, a key group in
ending health inequalities.
Qualitative research found that smokers
have received the messages promoting
accessibility of outlets. Smokers reported
feeling that the NHS is taking them seriously.
The second phase of the campaign will
include advertorials and media partnerships
to continue raising awareness of the easy
availability and convenience of NHS Stop
Smoking Services. The diffusion of the
campaign and its impact on knowledge,
attitudes and behaviour will be monitored
over the next five years. The aim is to leave
a legacy of greater awareness of the
availability of NHS Stop Smoking Services,
and to highlight the fact that smokers who
use these services are more successful
at quitting.
10
0
86 987 988 989 990 991 992 993 994 995 996 997 998 999 000 001 002 003 004 005
1
1
1
1
1
1
1
1
2
1
2
1
2
1
2
1
2
1
2
19
Year of diagnosis (representing the mid-year of the three-year rolling average)
Source: South West Public Health Observatory; Office for National Statistics;
Index of Multiple Deprivation 2007
Most deprived
Most affluent
65
CMO ANNUAL REPORT 2008
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CMO ANNUAL REPORT 2008
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Joseph Bazalgette (1819–1891) Science Photo Library
Emmeline Pankhurst (1858–1928) Getty Images
Douglas Black (1913–2002) Getty Images
Aneurin Bevan (1897–1960) Getty Images
Archie Cochrane (1908–1988) Courtesy of Cardiff University Library, Cochrane Archive, University Hospital Llandough
William Duncan (1805–1863) Wellcome Images
William Pickles (1885–1969) Courtesy of the Royal College of General Practitioners
Austin Bradford Hill (1897–1991) Wellcome Images
John Charles (1893–1971)*
Charles Dickens (1812–1870) Wellcome Images
William Henry Power (1842–1916)*
Kenneth Calman (b. 1941)*
William Farr (1807–1883) Wellcome Images
Charles Hill (1904–1989) Getty Images
Donald Acheson (b. 1926)*
Richard Doll (1912–2005) Science Photo Library
Arthur MacNalty (1880–1969)*
Arthur Newsholme (1857–1943)*
George Godber (1908–2009)*
Liam Donaldson (b. 1949)
Edward Cator Seaton (1815–1880)*
Elizabeth Blackwell (1821–1910) Wellcome Images
John Snow (1813–1858) Wellcome Images
Edwin Chadwick (1800–1890) Wellcome Images
Henry Yellowlees (1919–2006)*
Alexander Fleming (1881–1955) Science Photo Library
Wilson Jameson (1885–1962)*
Richard Thorne Thorne (1841–1899)*
George Buchanan (1831–1895)*
George Newman (1870–1948)*
Florence Nightingale (1820–1910) Wellcome Images
Geoffrey Rose (1926–1993) © London School of Hygiene and Tropical Medicine
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William Osler (1849–1919) Wellcome Images
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John Simon (1816–1904)*
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Mary Seacole (1805–1881) Getty Images
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Jerry Morris (b. 1910) © London School of Hygiene and Tropical Medicine
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