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70 years of the NHS - new specialties, new treatments, new understandings - Dr Anthony Clarke BSc MBBS FRCP

In 1948 the two specialities of rheumatology and rehabilitation did not exist. There were a number of centres that had an interest in rheumatic disorders, including a handful in London and several scattered across the country, often based at one of the spa towns, such as Bath, Droitwich and Harrogate. Such treatment as was available to the rheumatic patient consisted of aspirin and then the addition of gold injections, plus a wide variety of physical modalities. It was not until 1936 that senior doctors with an interest in arthritis and rheumatism formed a scientific body to forward the study of these widespread and disabling diseases.

Rehabilitation had fared a little better, mainly because of the effects of modern warfare. The First War saw the development of improved prosthetics. The Second War saw major advances in some areas. The establishment of the National Spinal Injuries Unit at Stoke Mandeville, became a world leader, not least because of the Paralympic Games which started there. East Grinstead Hospital developed new techniques for the management and resettlement of severely burnt servicemen. Perhaps the most stunning advance was the opening of the intensive service rehabilitation units. The Royal Air Force had four such units, offering multidisciplinary treatment. Of the 12,000 or so air crew admitted during the hostilities, 82% returned to flying duties.

The formation of the NHS coincided with the discovery of steroids, something of a mixed blessing because of the severe side-effects in patients on prolonged high doses. However, it was a long time before any alternative treatments where available. In 1949 the term rheumatology was coined by Hollander, an American physician. Gradually more specialists in Physical Medicine re-badged their departments, as new treatments, particularly in pain relief and then with new so-called disease modifying drugs such as penicillamine, sulfasalazine and azathioprine came on stream. However progress was slow. When I was appointed as a Consultant in Bath in 1977, only one third of medical schools in Britain had any teaching in the rheumatic diseases. I was not allowed to join the Wessex Physicians Club as Rheumatologists were not seen as ‘proper’ physicians. I had to wait five years before I was admitted.

HealthIn the following three decades the understanding of the impact of the rheumatic disorders in the population became obvious and rheumatology departments were to be found in most district general hospitals. Training programmes developed not just for doctors, but also nurses, a profession that was particularly good at offering support to patients with long-term needs. Combined rheumatology/orthopaedic clinics became commonplace. Because many rheumatic diseases have an immunological basis, specialized clinics for systemic lupus erythematosus and similar disorders were established. The introduction of bone density measurement led to a number of rheumatologists taking a special interest in osteoporosis.

The range of drugs increased. Methotrexate (MTX) became the most effective treatment for rheumatoid arthritis (RA). Experience showed that the outcome of RA could be significantly improved by very early aggressive treatment with methotrexate MTX often in combination with other so-called disease modifying drugs. There then occurred a major breakthrough in the management of inflammatory diseases. Although there is a general belief that many diseases such as RA are triggered by infection of one or more kinds, no positive link has been found. However the inflammatory pathway is well documented and a number of so-called biologic drugs have been identified which interfere with or switch off the destructive processes. They are called biologics as they are derived from genetically modified bacterial material. They are very expensive because of the complex manufacturing process and the cost of development. MTX costs about £15 annually to control RA in the majority of cases. The original biologics cost nearly £200 weekly! From being the cheapest department in the hospital, rheumatology became the most expensive. However a number of ‘biosimilars’ are coming onto the market, with the potential to reduce the financial burden on the NHS. The combination of improved drug treatment, early diagnosis, and patient education continues to reduce the social burden of the rheumatic diseases on the population.

Rehabilitation medicine has shown a slow growth from the time it formally dissociated itself in the UK from rheumatology in 1984. Britain still lags behind in the number of rehabilitation specialists per capita when compared to other industrialized countries. Having said that, there have been major advances in rehabilitation in the UK. I will mention two, one medical and one social. The first is the introduction of the Rehabilitation Prescription for patients with severe traumatic injury. This means that at major trauma centres a rehabilitation consultant will provide a treatment programme (and oversee that programme) from the time that the patient is discharged from acute emergency care. Early, appropriate, intervention produces the best outcomes, as the Royal Air Force centres proved in the 1940s.

The social advance takes us back to war. The high profile of injured veterans from Afghanistan and other conflicts and what they can achieve has had a profound effect on the way the British people regard disability. The Invictus Games and the Paralympic successes have been associated with significant advances in prosthetics, for instance, but more importantly, have shown that an impairment does not diminish the opportunity for an individual make their contribution to society.

I am fairly certain that when there is the next reflection on the contribution of the NHS to the British way of life rheumatology and rehabilitation will be seen as entirely different disciplines. I would just point out that the British Society of Rehabilitation Medicine now has a Musculo-skeletal Special Interest Group – what goes round, comes round. 

Content provided by Dr Anthony Clarke,
BSc, MBBS, FRCP.
Consultant in Rheumatology & Rehabilitation

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