Editorial
The practice of neurology has changed a great deal in the 60 years since the National Health Service was created in the United Kingdom. In 1948, hospitals were run by boards of governors and staffed by honorary consultants who earned their living in private practice. Health care was uneven for most of the population; delivered in grandiose style sprinkled with philanthropy; and further motivated by the need for a rich and varied clinical experience. After 1948, advances in biomedical science and the introduction of many new treatments altered clinical practice; and, with the expectation of equal access to increasingly elaborate medical and surgical interventions, costs increased exponentially. The sun was setting on the golden age of Victorian, Edwardian and between-the-wars neurology; and, in Great Britain, the subject now acquired a reputation for being stuck in the tradition of indulgent clinical description, dominated by the National Hospital Queen Square, whose corridors trainees from home and abroad had necessarily to tread as their rite of passage. Very few regional services existed. Most were staffed by single-handed consultants each taking responsibility for vast tracts of the countryside. The provision of services was highly selective, focused on diagnosis, shifting huge numbers in record time, without sensitivity to evolving societal expectations, seldom addressing the needs of trainees and, by the late 1980s, ripe for change.The problem, for medicine in general, was how to contain expenditure, without thwarting professional ambition or compromising on standards of care, whilst managing medicine as a lively political football high on the list of promises in each party manifesto, and on the lips of every hyperbolic news reporter. The solution was to wrestle financial independence from expensive hospitals; to reduce the influence of doctors in general and profligate consultants in particular; to adjust manpower and move the arena for delivering routine clinical care out into the community; to amend training and employment opportunities so that these matched perceived needs rather than vocational aspirations; and to manage from the Centre. Therefore, the National Health Service reforms created trusts, purchasers and providers. Now, the emphasis was on payment for activity linked to agreed costs and performance measurements; the audit of clinical activity; monitoring of competence and probity through governance and appraisal; expenditure determined by efficacy and cost; and emancipation of the patient as customer with pearls of un-wisdom along the way such ‘the complaining patient is the jewel in the crown of the NHS’. The (Sir Bernard) Tomlinson report on the provision of medicine in London (‘Making London Better’) enabled the London Implementation Group (‘no change in London is not an option’) to recommend the merger of 17 medical schools and associated hospitals into five multi-faculty colleges. Programmes of rationalization followed in many other cities and centres.
Many of these changes were necessary and laudable. A critical analyst might highlight the importance of process versus quality; sense cynical attempts to discredit medicine as a profession in order to side-line profligate influence on the electorate; despair of inconsistent strategy and unstable management structures; judge failure to keep training and manpower adjustments in step with policy or needs; note poor use of massive cash infusions; and register desperation at the increasingly complex bureaucracy required to get anything changed or done. But the health service reforms did expose gross under-provision of neurological (and many other) services throughout the United Kingdom, and provided a workable mechanism for rapid and substantial manpower expansion. As a result, many new consultants were appointed and membership of the Association of British Neurologists increased from 51 (1933) to 75 (1950), 125 (1960), 194 (1970) and 1235 (2008).
From 1948, the pulse of academic neurology weakened and could be felt in rather few places: at Queen Square, and in Newcastle, Glasgow and Oxford. In the mid-1960s, there were six professors of clinical neurology in the United Kingdom; that number has since increased to 13 (1987), 47 (2000), 80 (2006) and 87 (2008). As other subject areas embraced scientific medicine and flourished, academic neurology—in the 1970s—was critically under-manned (there were then no lady professors): that it survived is to the credit of a very few individuals who melded the classical disciplines of descriptive neurology with emerging scientific methodologies and investigative approaches, or supported others in these endeavours, and created teams that studied mechanisms of neurological disease and developed rational treatments in a climate of therapeutic nihilism. In 2008, a young trainee might not understand why, as late as the early 1990s, provoking the managerial finger to wag at a neurology department for over-spending its drugs budget could be regarded as something of an achievement—almost a joke. Academic expansion happened because this fulfilled the aspirations of individual universities; opportunities arose from advances in scientific methodology—especially brain imaging; and the quinquennial Research Assessment Exercise that ranks individual institutions and determines funding put pressure on universities to present a balanced academic portfolio including credible research activity in the clinical neurosciences. But there were casualties as funding streams became less predictable, putting the squeeze on individual academics and starting a trend towards the concentration of resources in fewer but fatter departments. Faced with erratic success in securing grant support, but with the need to sustain research infrastructures, academics turned to the pharmaceutical industry for support; and contract research flourished. This re-distribution of resources continues with funding for research and development previously absorbed into the routine costs of providing services throughout the National Health Service, and distributed on a per capita basis irrespective of research productivity, now channelled into a highly focused scheme of Comprehensive Biomedical Research Centres, and Specialist and Thematic Centres and Networks awarded competitively to a small number of institutions, and with staged withdrawal of funding from the rest. Partnerships between the National Health Service, Research Councils and Industry seem to place a higher premium on applied and therapeutic research than other aspects of disease mechanisms.
Training in the 1960s was centred on Queen Square; advancement was unpredictable, maverick, patrician, open-ended and dependent on dead-men's shoes since there was so little consultant expansion. Young neurologists grew old as senior registrars—the time to consultant appointment often being 15 years or more from qualification. Education was based not on teaching but all about providing detailed and meticulous case-notes and looking after patients; research experience was selected from a limited menu and usually ticked a box rather than inspiring long-term academic careers. With introduction of the Calman specialist registrar training scheme came curriculum, and fixed duration as a junior hospital specialist at around 10 years from graduation; but competition at entry led to aspirants being stacked in research posts waiting for a national training number, so that research was a temporary interlude that served many purposes other than academic apprenticeship. The perceived deficiencies in training, and the move towards realizing the political manifesto of a consultant-led workforce, launched ‘Modernising Medical Careers’; designed uniformly for all branches of medicine and surgery, this down-graded the need for research and a solid grounding in general medicine in the interests of early differentiation and getting on with specialist training. Administered through the now notorious ‘Medical Training Application Service’, it brought untold misery to young doctors—especially neurologists—wrong-footed and caught at different stages in and out of the new system. The effect on academic medicine was predictably negative and an acute infusion of newly (part) funded academic training fellowships, clinical lectureships and senior lectureships had to be prescribed as a life saving measure. But the contraction of academic neurology in the United Kingdom and the re-centralization of its distribution are already apparent.
The National Health Service works because people value its principles and, although weary with reorganization, they want to use and work for it. Professionalism of the workforce is the oil that makes the wheels go round. Although easily criticised, the serial reforms from the early 1990s have allowed more people to benefit from services provided close to where they live, and to have equal access to sophisticated and altruistic care; they strengthened the London medical schools and created world-class medical science institutions one of which, University College London, benefits from a modernized and scientifically distinguished Institute of Neurology and National Hospital for Neurology and Neurosurgery; they emancipated medicine in many regional universities; they formalized training and eroded casualties of a system rooted in patronage; they assessed and audited research expenditure and achievement, redirecting resources to people best placed to utilize them; and they made plenty of mistakes. New reports appear and reforms continue—the most recent batch elevating the principles of professionalism and quality as a premium. Together with other branches of medicine, the clinical neurosciences have been alternately buffeted and carried along by the last 60 roller-coaster years. Despite all, in 2008, the National Health Service can be proud of the calibre and commitment of its employees, including those who specialize in the clinical neurosciences; and, equally, people who work for the National Health Service can be grateful for the clinical and scientific opportunities, the camaraderie and sense of purpose and the privileges and nurture of professional aspirations that it provides.
Winding back the historical clock a little further, by around 140 000 years, Jan van Gijn—associate editor of Brain and former editor of the Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine), reviews ‘On deep history and the brain’ by Daniel Lord Small and ‘Brain, Mind and Medicine’ edited by Harry Whitaker, Chris Smith and Stanley Finger (page 2798). In ‘Cicero's brain and vibrating nerves’, Prof. van Gijn, considers the time course of biological, or Darwinian, evolution and the additional accelerations driven by cultural forces and transmitted in a neo-Lamarckian way that are now part of the fabric of the behaving brain. Slowly evolving structures accommodated promiscuous new functions engineered by cultural forces so that ‘our [physical] brains are more suited to the East African savannahs than to industrialised society’. The authors of both books see the age of enlightenment as the crucial directive period in which culture took over from random Darwinian evolution; and Prof. van Gijn brings his own analysis, and knowledge of this and many other periods of history in the neurosciences, to the narrative of how proponents of the ‘fluidist’ school gradually conceded the doctrine of ‘solidism’ by accepting that the brain not the cerebrospinal fluid and electricity passing through nerves are the basis for movement, sensation and cognition.
In the present issue, Stefano Pluchino and colleagues from Milan (Italy), Boston (USA) and Valencia (Spain) revisit the conundrum of what disease process(es) might be corrected by neural stem cell therapy, showing that persistent myelin-antigen driven brain inflammation inhibits the proliferative and migratory properties of endogenous subventricular zone neural stem/precursor cells thereby challenging the assumption that cells potentially capable of regeneration might easily be recruited from an endogenous source (page 2564). But if these stem cells are reticent, Ghazaleh Tabatabai and a team from Tübingen, Munich and Heidelberg (Germany) and Zurich (Switzerland) report that expression of the E-selectin (CD62E) adhesion molecule mediates the attraction of haematopoietic progenitor cells towards glioma cells through the intermediate activities of vascular endothelial growth factor (VEGF) and transforming growth factor beta (TGFβ) acting on endothelium and the tumour cells, respectively (page 2579). Tom Webb and investigators from London and Oxford (UK) and Melbourne (Australia) report further details of a large family with P102L Gerstmann–Sträussler–Scheinker syndrome, and several smaller pedigrees—together providing 84 affected individuals—to show multiple distinct mutations at a CpG hot spot, with phenotypic heterogeneity to some extent explained by epistatic PRNP codon 129 and APOE-E4 genotypes (page 2632). Stijntje Bor and colleagues from Stockholm (Sweden) and Utrecht (The Netherlands) address the concern that subarachnoid haemorrhage may also occur in the relatives of affected individuals showing that the risk is marginally increased for individuals with one affected relative but very substantially so when two or more first degree relatives have already had a bleed, such that prospective screening for asymptomatic aneurysms is then logical (page 2662).
Impaired orexinergic transmission in the hypothalamic–olfactory pathways may explain the olfactory disturbance that occurs in narcolepsy: Paul Baier and colleagues from Kiel (Germany) confirm this defect in patients with narcolepsy–cataplexy and show that it can be reversed by administration of intranasal orexin-A (page 2734) further strengthening evidence for the link between narcolepsy, cataplexy and olfaction. The nature of narcolepsy has been repeatedly addressed since Jean-Baptiste-Édouard Gélineau (1859–1928) first described the disorder (De la narcolepsie, Gazette d’Hôpital de Paris, 1880; 53: 626–28 and 635–37). Pathology is scarce: the link to HLA-DR15*01 suggests an immunological flavour; and the deficiency of orexin-A offers new insights into disease mechanisms. Speculation on the pathophysiology has always been rife and in ‘From the Archives’, we review two papers that barely conceal a spat between two heavyweights of pre-1948 British neurology at Queen Square: ‘Idiopathic narcolepsy: a disease sui generis; with remarks on the mechanisms of sleep’ by WJ Adie (Brain 1926; 49: 257–306) and ‘The narcolepsies’ by SA Kinnier Wilson (Brain 1928; 51: 63–109).
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