Money Lies at the Root of the Hospital Crisis

Jill Sherman and William Greaves asked hospital managers about the daily financial juggling act.

Barbara Young came into the world just three days after the birth of the National Health Service. Her mother, unaware of the social revolution which was to grace the last hours of her pregnancy, had already booked a bed in the fee-paying clinic. ‘So I suppose that makes me one of the last private babies to be born into the working classes,’ she says with an irrepressibly cheerful grin.

Both Young and the NHS are now approaching their 40th birthday, and today she is one of its 192 new-look district managers who were brought in five years ago to replace its old network of conscientious but committee-bound administrators. And, last summer, when she became the first woman president in the history of the Institute of Health Service Management, she didn’t need any extra-sensory perception to know that her near-twin was headed for a crisis.

It is merely the speed of the NHS’s decline into what many pessimists have already diagnosed as terminal sickness which has caught the Institute unawares.

‘We are making our own inquiry into what has happened and how it can best be put right,’ she says. ‘I announced it in June, we began it in September and we plan to come out with our recommendations in May. Now all hell’s let loose and I’m worried that ill-researched and ill-thought-through decisions will have been made in the meantime.’

But does the new breed of all-powerful district managers, over whose institute Young presides, have any right to be judge at its own inquest? Has it succeeded in replacing bureaucracy with boardroom efficiency, or have the sins of the old administration been visited upon its successors? Can business methods and commercial accountability ever share beds with the altruistic ideals of free health? In short, how effectively are the new NHS managers managing?

The right wing of the political spectrum believes them to be far too unenterprising and dependent on the government cheque book. Where, it demands, are the shopping precincts in hospital foyers and the sponsors with their names emblazoned over bandages and across surgeons’ chests? And the left wing, scarcely surprisingly, accuses them of vulgar commercialism in the way they are selling the democratic concept of the health service down the river.

‘So long as we are annoying them both equally I am pretty sure we’re on the right lines. With so much contentious nonsense flying around, we must be the small, still voice of reason,’ says Miss Young, who combines the Institute presidency with her daily job as general manager of London’s Paddington and North Kensington Health Authority – comprising the world-famous St Mary’s Hospital and the third most socially deprived district in Britain.

Since moving to Paddington five years ago from Haringey, where she was district administrator, her self-styled ‘bullying tactics’ have produced cost savings of an average Pounds 1 million a year and a revenue of Pounds 2 million a year from private and overseas patients, as well as generating Pounds 2.6 million for funding such projects as an Aids program and continued the reduction in the number of hospital from nine to five.

Every year the district spends Pounds 4 million on new buildings or refurbishment, treats 29,000 in-patients and 107,000 accident or emergency cases, and screens and treats 42,000 people in health clinics, schools or their own homes.

‘I have a management staff of 250 people here and our costs are 3.9 per cent of turnover. That’s a pretty respectable statistic by anyone’s standards,’ she says. ‘The Health Service has delivered a finer program of cost efficiency than any other British public service in the last five years. We perform better than any other health service in the developed world. And yet there’s still room for improvement.’

The next move towards greater efficiency, to be recommended by Sir Roy Griffiths, managing director of J. Sainsbury, the supermarket chain, and Mrs. Thatcher’s adviser on the NHS, is for Britain’s town halls to take over responsibility for millions of mentally ill, chronically sick and handicapped people who currently come under NHS care.

Miss Young agrees that many councils would be ideally placed to administer such community care but has one serious reservation: ‘Those areas in which the need is greatest are exactly the ones whose local authorities are most severely rate-capped. Why they are rate-capped is no concern of ours – the fact is they will have difficulty in finding the resources and people will suffer.’

Nor is she happy with the philosophy, expressed last week by junior health minister, Edwina Currie, that the nation’s health would be best served on a two-tier system, with those would could afford it turning to private insurance and the NHS looking after the remainder. ‘Look at the system in the United States,’ she says, ‘and you discover that one of the things that happens is that the poor and the chronically sick get a bum deal.

‘Competition is not interested in areas where the potential is low and there are now 40 million people in the States who don’t have access to a decent health service. I don’t think people in this country really want to see a two-tier system.

‘And private insurance is a very inflationary way of running a health system. Patients expect greater comforts like carpets and better food. No one can blame them for that, but money spent on television sets and so on adds to the overall cost of providing a service. Private hospitals also tend to go in for duplication of services because they have to compete with their neighbors on equal terms and that is inefficient, too.’

Sir Roy, who was called in by Mrs. Thatcher in 1983 to introduce into the NHS the kind of dynamic managers who run major companies – and who recommended the switch from district administrators to managers – believes that the quality of NHS management today is ‘quite good – but patchy’.

There are enough examples of well-run hospitals to show what can be done, he says, and ‘a handful’ of managers he would be happy to have with him at Sainsbury’s. Out of 192 districts in the country, that sounds ominously like damnation with faint praise.

To this suggestion, Sir Roy responds that an NHS manager with control over a budget of around Pounds 75 million – in the same league as the top 20 or 30 companies in the country – earns about Pounds 30,000 a year, which is not sufficient to attract the people with the same massive experience and support back-up enjoyed by big business.

On this, at least, Miss Young is totally in agreement. ‘Compared with other European countries our salaries for medical and non-medical staff are very low,’ she says. ‘If we are going to have a National Health Service which has the interest of the public at heart, there have got to be incentives so that doctors and other professional staff are motivated to provide it.

‘Of course we can, and must, look at ways in which we can generate income. Doing deals with the private sector – commercial sponsors, Kentucky Fried Chicken in the front hall, Adidas heart transplants, that kind of thing – is all very well if they can be achieved without diverting staff from their main purpose.

‘We even discussed asking Virgin Atlantic to sponsor our nurses’ training.

‘If we’re lucky, in this district we’ll make Pounds 1 million a year from commercial methods. But out of a budget of Pounds 80 million, that isn’t going to solve the problems of the health service. Something as fundamental as health shouldn’t really have to depend on other people’s generosity.’

So are there no obvious ways in which she could improve the efficiency of the district? ‘There is still too much bureaucracy at my level and above. Twenty per cent of my work is not about running my health district but simply being accountable. It’s hard to be efficient when you have to spend so much time telling people how efficient you are!’

One man who epitomizes the new spirit of commercial adventure within the NHS is ironically a one-time Labor councilor. Now describing himself as a political agnostic, Dr. Ken Grant is district general manager of City and Hackney Health Authority, which includes St Bartholomew’s Hospital, and in the past year has introduced a succession of controversial income-generating innovations.

In that time he has set up two in vitro fertilization clinics with the private sector, shared medical equipment with a private hospital, started charging other authorities for services, and opened a fee-paying breast cancer clinic to screen women aged over 40 in the City., ‘We are now building up a relationship with a private hospital so we can obtain funds when our doctors refer business there,’ says Grant, whose scheme to introduce sponsored operations at Barts has so far failed to attract the involvement of local companies. ‘We’re being held back because I don’t have enough time and so I’m looking to employ someone specifically to work on this area of marketing.’ Compared with a budget of more than Pounds 80 million, however, is even an income of Pounds 1 million from such private enterprise really worth the trouble? ‘Of course it is. You’ve got to invest in order to save and if I can raise Pounds 1 million by spending Pounds 100,000 that’s got to make sense.

‘But let’s get things into perspective. Profit in the private sector is about five per cent of turnover. At the present rate, we are looking at a deficit of Pounds 20 million on a budget of Pounds 90 million in 1991. To recover that we would have to be doing Pounds 800 million worth of business, which is about half of the whole UK private market. We can improve things by our own efforts but we can’t save the health service that way.’

Special Report on Health at Work

Every employer must regard health as an integral part of management, says Dr. Tim Carter, director of medical services for the Health and Safety Executive. ‘One of the dangers,’ he adds, ‘has been that it is so easy for companies to say that they know about safety and can deal with it, but health is for doctors.

‘In fact, the control of health problems at work is very much for the manager, with advisory support.’

healthy workers

There is a far greater conviction now in industry and commerce that the work of medical teams familiar with the special problems of the work-force contribute to business efficiency. But there is another view.

Dr. Adrian Semmence, of the Civil Service Medical Advisory Service, points out that four in 10 British employees have no access to occupational medicine teams. But does their health suffer, he asks, and if so, by how much? How should any provision of teams be financed? What is the minimum service that any advanced country should reasonably provide for the rising number of those who work part-time, at home and in small businesses?

The answer to all these questions, he says, is that no one knows.

Compare Britain with Denmark and France, for example. The French have many more occupational physicians per head than we do, the Danes a lot fewer. Comments Dr Semmence: ‘No one has yet demonstrated any differences in the health at work of workers in the countries concerned that can be laid at the door of occupational health services.’

He sees dangers in the provision of occupational medical teams. One is that they will be used to treat minor illness or to carry out increasingly complex tests which merely reassure senior staff about their health. ‘Another danger is that they will be employed in diffuse and unvalidated health education,’ he says, ‘particularly on the deleterious effects of stress.’

In Dr. Semmence’s opinion, based on large-scale Civil Service screening studies which showed the harmful effects of cigarettes, alcohol, bad diet and lack of exercise, individual behavior is much more likely to be influenced by a good personal doctor than by ‘the intervention of occupational health and academic physicians’.

unhealthy

Nevertheless, no one denies the value of preventive medicine, either at work or anywhere else. A growing number of companies has taken steps to discourage smoking. At Esso’s London headquarters, for example, there are anti-cigarette signs and notices everywhere.

Campaigns against excessive use of alcohol are even more important because drink can not only be harmful to health, but is a potent source of accidents. The Government estimates that alcohol misuse costs more than pounds 1,000 million a year in lost production. Problem drinkers, who are at work, not home, most of the time, have at least three times more accidents than other workers and are absent from work five times more than the average.

According to one study, as each problem drinker on the payroll costs an employer at least a quarter of annual salary, growing numbers of companies have begun to use schemes such as the industrial resources training program of Accept (Alcoholism Community Center for Education, Prevention and Treatment).

This is an independent national charity which last year joined forces with the AMI hospital group to design and to open new centers for treating not only alcohol misuse but over-use of tranquilizers and sleeping pills. The first of these Oakhurst centers opened in London this summer.

There are many other areas in which industry can and does prevent damage to the health of its workers, although much remains to be done. The Health and Safety Executive encourages companies to display its posters on safe work systems, which can help to prevent back strain and hernias, for example, with easy-to-follow illustrated instructions on lifting and carrying.

Because of a European directive, about three million British workers will have to be tested for deafness. This will apply to those subjected to noise levels of more than 85 decibels, which is considerably lower than the 105-decibel level laid down by the executive’s code of practice.

That requirement exposes still further some of the difficulties associated with such preventive measures. Setting up an audiometry facility can cost a company about pounds 4,000.

Moreover, protective measures are not as easy to take as they might seem. Three boilermen in the North-East who suffered severe industrial deafness received relatively low compensation because of their contributory negligence – not wearing the hearing protection the employer had supplied. Workers often do not use such gear because it is uncomfortable or interferes with their work, or perhaps causes skin irritation.

But perhaps the most problematical and contentious aspect of preventing ill health at work now stems from another European directive on the control of substances hazardous to health. The proposed COSSH regulations, and occupational exposure limits that complement them, will apply to more than 40,000 substances and will, among other things, require employers to keep health records of all exposed employees for at least 50 years from the date of the last entry.

The background to this is that in 1979-80, the Health Department awarded more than 5,700 new injury benefits for short spells of incapacity, 850 longer-term benefits and 710 death benefits. These were for diseases that could be attributed to exposure at work to substances other than lead and asbestos, which were dealt with separately.

In 1980 there were more than 20,000 deaths from chronic bronchitis, asthma and emphysema, many of which were linked to jobs. And it is estimated authoritatively, by Doll and Peto at Oxford, that up to 10,000 cancer deaths a year could be prevented if occupational hazards were removed.

The Health and Safety Commission’s consultative document on the COSSH regulations, which has prompted 500 submissions, describes the primary aim as protecting the health of people at work and to ensure that others who might be affected by hazardous substances used in work are not exposed to health risks. ‘So far as is reasonably practicable’.

But an editorial in the Journal of the Society of Occupational Medicine questions what ‘reasonable’ is in this context.

Among factors that have prompted the proposed measures, it says, are greater public awareness of industrial health hazards, pressure groups which exploit undue anxieties, the advance of toxicology, which makes it possible to detect and to analyze the smallest quantities of toxic substances and, by contrast, lack of understanding of how mutagenic, teratogenic and carcinogenic effects occur, so that standards of control are based often on ‘mere guess-work’.

The editorial says this may lead ‘to a distortion of standards or the imposition of controls requiring the deployment of disproportionate resources in all too commonly futile attempts to provide reassurance and to reduce anxiety for which no adequate scientific justification can be found.

‘Confronted by this relentless and often fruitless search for reassurance, is it reasonable to continue to pursue a policy of attempting to allay fears that are inherently unreasonable? Increasingly sophisticated methods of detection would reveal that we are all living in an environment of suspect or known carcinogens at the molecular level’.

Though not dismissive of such misgivings, Dr. John Cullen, chairman of the Health and Safety Commission, believes the COSSH scheme marks an important step forward in the whole area of occupational hygiene. He does not believe that the regulations will, in practice, place an undue burden on industry.

Dr. Cullen says: ‘We want employers to assess the risks of particular substances, to assess the exposure, to develop systems of working with those substances which will be reasonably safe and then to monitor them. In the electronic age, the record-keeping for this is not difficult.’

Prevention, then, will seek to be practicable. The easy ‘solution’ with every potential hazard is to ban it but the COSSH system offers a sensible alternative. ‘If you know it is a nasty’, Dr. Cullen says, ‘you can handle it. You do not have to ban it.’

City Waits with Open Arms for Wellcome on Valentine’s Day

Wellcome, Britain’s second largest drug company, is famed for its ability to bring together lateral thinking boffins and foot-in-the-door salesmen. When the company is floated on the stock market next month the City seems bound to unroll a red carpet, inscribed with an eponymous but fairly obvious message of greeting.

But the drugs group has been even cleverer. In order to guarantee a good reception for the shares, it has arranged for trading to start on February 14, St Valentine’s Day. It is hoping for love at first sight.

healthcare

Even though the stock market has fallen recently, there seems little doubt that investors will be queuing up, cheque books in hand, to subscribe for shares. After the flotation the group will probably be valued at comfortably over pounds 1 billion.

A special poignancy attaches itself to the whole idea of a Wellcome flotation. Underlying its undoubted commercial success there is a hard core of traditional philanthropy, not unlike the Quaker traditions which are part and parcel of Rowntree Mackintosh. It is the commitment to human well-being, as well as a keen eye for the market opportunity, which has led Wellcome to plough huge chunks of its research and development budget into work on treatments for herpes and Aids.

Until now Wellcome’s only shareholder has been a charity, the Wellcome Trust. It was the trust’s decision to sell some of its shares, so it could spread its investment portfolio, that has led to the flotation.

According to Sir David Steel, chairman of the trustees, there was concern about having ‘all our eggs in one basket, notwithstanding the excellence of that basket’.

The relationship between the trust and the company dates back to 1936, the year Sir Henry Wellcome died. Sir Henry, a pharmacist and collector, founded Wellcome in 1880, together with Mr Silas Burroughs, a fellow American and a keen salesman.

health

From the start there was a tension between Sir Henry’s strong commercial instincts and his religious background. When he was 21 he wrote to his parents: ‘I have always had a desire for wealth and still have ..but I want to live a life devoted to the true God and to mankind’.

The trust was set up under the terms of Sir Henry’s will. It was to own the company, then called Wellcome Foundation, so it could use the profits for medical research. In the 50 years of its existence the trust has received pounds 150 million from Wellcome. It was able to spend pounds 22 million last year, making it the largest medical research charity in Britain.

Wellcome, the company, has an almost unrivalled reputation for producing new drugs. Historically it has attracted some of the brightest and best researchers available and, until last year, it had what many in the scientific community regarded as the best pharmacological department in the country.

Wellcome

It was led by Sir John Vane, a Nobel prize winner, and Sir James Black, another world renowned scientist. Their time saw the development of both Septrin, an important anti-bacterial, and Zyloric, a treatment for gout which still accounts for 10 per cent of Wellcome’s sales.

But their main contribution to Wellcome was their work on anti-virals, a field where Wellcome now has a commanding lead. Zovirax, a treatment for herpes, was forst launched in 1981, when many Americans feared an outbreak of epidemic proportions.

Wellcome is currently carrying out clinical trials on a new anti-Aids drug but, as the company is the first to admit, it could be years before the drug reaches the market.

The time lapse between discovering a drug and launching it on the market makes it difficult to assess the contribution of individuals. It is clear, however, that the presence of Sir John Vane and Sir James Black attracted other brilliant researchers, who seem to have been undeterred by rivalry between the two great men.

Whether or not it was as the result of a power struggle or on the advice of Arthur D. Little, the consultants brought in to report on the management of Wellcome’s research, both Sir James and Sir John left the company last year. As one academic put it ‘Morals was shattered. The two big names had gone and, as if to add insult to injury, the Trust gave a vote of no confidence by announcing its decision to sell some of its shares.’

Earlier this month Dr. Pedro Cuatrecasas, the head of American research, announced plans to join Glaxo, Britain’s largest pharmaceutical company. Wellcome’s public relations team did its best to play down the importance of the departure but its task was made by more difficult by subsequent events.

With only two weeks to go before the prospectus was due out, Mr Bill Sullivan, the head of Burroughs Wellcome, the American subsidiary, resigned very suddenly on January 13.

Wellcome’s chairman and chief executive, Mr. Alfred Shepperd denied there had been a dispute about who would be heir apparent, but Mr. Sullivan’s unexpected loss nevertheless underlines the tension between the American and British ends of the operation.

The United States has powered Wellcome’s growth in the past five years, when sales have doubled from pounds 500 million to pounds 1 billion and profits have risen from pounds 50 million to pounds 122 million.
The loss of four key figures in less than 12 months is particularly unfortunate in view of the imminent flotation.

Wellcome is doing its best to dispel the cloud hanging over it with roadshows and presentations to financial institutions. But there is no British Telecom style appeal to private investors.

doctors

Great play is being made of the company’s future plans, in which the anti-Aids drug clearly plays an important part. Other new drugs include Wellbrutin, an anti-depressant which will be launched in the US this year and a new antihistamine, and research continues on treatments for glandular fever and further uses of existing products. Wellcome is also trying to break in to the Japanese market.

These projects should keep Wellcome’s profits moving firmly forward over the next two or three years. This year, however, is proving more problematic, thanks to the vagaries of the exchange rates. The fall in the dollar has hit Wellcome hard so that it is not expected to push up profits very far in the year to end August. The flotation could have been better timed.

The shares will not be finally priced until January 29, when the prospectus is published. Unlike the Government, which has an interest in sponsoring people’s capitalism, Wellcome Trust only has an interest in raising as much money for research as possible. This means the margin for error is small. This time it is science and not the Treasury that benefits.

Women, Abortion, and Politics

Republican Ann Stone represents the new breed of pro- choice Republicans. Although she disapproves of government intrusion into women’s health care issues, she is personally anti-abortion.

‘You have to be very careful how you talk about the issue. Many people on our side are vehemently against the government having this control but they are not for abortion. In fact they would favour some restrictions, with third trimester and sex-selection eliminated as an option. By and large they are very much against abortion as a form of birth control.’

A member of the far right wing of the Republican party, Stone and her group, Republicans For Choice, are putting a conservative slant on the US abortion controversy where the movement to restrict women’s rights has been happening on a state by state basis.

In Pennsylvania, a woman who wants an abortion must first notify her husband, then undergo anti-abortion counselling by her doctor and finally wait a mandatory 24-48 hours before the operation. In Louisiana, abortions are illegal even when a woman’s health is endangered. Doctors who give them can get up to 10 years’ hard labour and a fine between Dollars 10,000 and Dollars 100,000.

The most effective pro-life organisations have not been extremists like Operation Rescue who have attacked abortion clinics and staff, but the more mainstream groups such as the National Right To Life Committee. When Stone talks about ‘birth control’ abortion, she is referring to that organisation’s eight steps to influence state legislatures, called ‘model state legislation’, which have framed the issue for the Republican pro-choicers and anti-abortionists alike.

‘Birth control’ abortion is when women using no other contraceptives abort unwanted pregnancies – hardly a practical solution. For women who do use contraceptives, the sub-text is more frightening. Abortion should be made available only in cases of rape, incest and under life-threatening circumstances. Abortion for sex selection is not an issue in this country. Yet as a National Right To Life Committee spokesman once suggested, tactics like this ‘get the public thinking’. Other model legislations, whether husband consent or the banning of state or even federal funding of public information, have formed the basis for the new statutes.

While in Britain abortion remains a matter for a woman and her doctor, in the US it has become one for the courts. Restrictive state laws, passed this year in North Dakota, Mississippi, Utah and Louisiana, have yet to be enforced, since appeals are still pending. However, one or more of the cases will reach the Supreme Court in an attempt to challenge Roe v Wade, the historic 1973 decision that legalised abortion in America.

‘Most people are saying that Roe v Wade will be overturned,’ says Valerie Syme, editor of Abortion Report, a nonpartisan, daily abortion newsletter. ‘The question is when. It could have a tremendous negative impact on the Republican party. There will be a big voter backlash if it is overturned before the 1992 presidential election.’

Recent polls show that 70 per cent of the American public are pro-choice, in the traditional sense of the phrase, meaning they support a wide range of contraceptive alternatives for women. Although the pro-life movement – with some groups advocating a total ban on contraceptives – is considered an extremist minority, it has had an impact. According to the Alan Guttmacher Institute, clinics giving abortions in rural areas dropped by 19 per cent, and in urban centres by six per cent, between 1985 and 1989.

Despite this, the number of women having abortions has been rising. Statistics from the Centres for Disease Control show that, in 1987, 29 out of 1,000 American women had an abortion. There has been an 18 per cent increase among girls younger than 15, an 11 per cent increase among 15-19-year-olds from the ethnic minorities. The highest rate was 62 per 1,000 among women aged 18 and 19.

Considering that minority women are three times more likely than whites to have abortions, this summer’s Supreme Court ruling, which prevents federally-funded family planning clinics from giving abortion counselling, has been seen as political. The ‘gag rule’ prevents doctors at the 4,500 clinics nationwide from referring patients or even mentioning abortion. Servicing four million lower income women, these facilities are the closest the US gets to Brook Advisory and Well Women clinics.

Planned Parenthood, the largest of the clinic groups, with 900 facilities nationwide, has refused to comply with the ruling and, as a result, has lost Dollars 34 million in government aid, a significant part of its operating budget. In June, Planned Parenthood of New York ran a newspaper ad featuring a picture of a gagged woman with the caption, ‘A pregnant woman needs her doctor’s advice. Not the Government’s opinion.’ According to Alex Sanger, its president and chief executive officer, public response to this ad raised Dollars 106,000; their South Bronx clinic alone needs to make up the loss of Dollars 450,000 in federal funds.

More than the restrictive, anti-abortion laws passed by various states, the Supreme Court ruling has effectively taken abortion out of women’s rights and made it a first amendment issue. Sanger explains, ‘We have framed this whole issue as the doctor-patient relationship and one of free speech. That has a much broader constituency in this country than those who want to have safe and legal abortion preserved. Even some of those in the Republican right wing say the gag rule is a mistake.’

In an effort to overturn the Supreme Court ruling, two bills have already been passed by Congress and to stress that it means business, the Senate has added abortion rights wherever possible. Recently the appropriations bill for the Departments of Labour, Health and Human Services included a provision to allow Medicaid, the government-sponsored medical reimbursement insurance for the poor, to pay for abortion in cases of rape and incest. Previously it would pay only when a woman’s life was in danger.

Although President Bush has threatened to veto any bill that comes before him, moderate and conservative Republicans have asked him to reconsider and not challenge the house and senate to override his veto.

For Republican political activist Mary Dent Crisp, the President’s position is a travesty. In 1980, she was the national co-chair of the Republican National Committee and witnessed the switch Bush made from his widely acknowledged position as a supporter of family planning to anti-abortion in order to join the Reagan ticket – a move that prompted Crisp to denounce his ‘political expediency’. For her grassroots political organisation, the National Republican Coalition for Choice, abortion cuts across party politics. Unlike Stone’s group, which will not withdraw support from anti-abortion Republican candidates, Crisp believes the abortion issue comes first. ‘If Roe is overturned next summer, it will be blamed on the Republicans and it will not only affect Bush’s re-election. Look at the federal elections, the senate and house, gubernatorial races, state legislative races – all these will also be affected.’

It was this scenario that National Committee Chairman Lee Atwater, author of the notorious Willie Horton ads for the Bush 1988 campaign, wanted to avoid. Before his death, he urged Republicans to reverse their anti-abortion stance and adopt a position less offensive to voters. A poll taken of Republican delegates after the 1988 convention showed that 68 per cent of the same people who elected George Bush described themselves as ‘pro choice’. Despite this, Atwater’s successor, Clayton Yeutter, insists that the policy should not be changed. With an election year looming, the Young Republicans have already voted to take the issue out of the platform altogether.

Another fight the President currently faces is the senate confirmation hearings on Clarence Thomas, Bush’s choice to fill the Supreme Court seat made vacant by the retirement of liberal civil rights jurist Thurgood Marshall. ‘With Marshall’s resignation and Thomas’ nomination coming so close on the heels of the gag rule, far more people believe the use of the abortion issue by the right wing is simply an opening wedge on a broader attack on our individual rights,’ maintains lawyer Patricia Ireland, executive vice president of the National Organisation of Women (NOW).

The last Supreme Court appointment, David Souter, was a clear fifth vote against abortion, insists Ireland. ‘But there is a significant difference in having on the court Clarence Thomas or someone equally opposed to the bill of rights and women’s rights, and the way the court is currently structured. Now they have to play to the middle and what Sandra Day O’Connor (the only woman justice) thinks will be an undue burden on abortion instead of going all the way to the right.’

The attack on abortion has been, in part, a failure of the women’s movement, something that Ireland, who is slated to become NOW’s president in December, slowly acknowledges. ‘(We have) been victims of our own success. So many women have walked through those doors of opportunity who 20 or 25 years ago would have been struggling in the women’s movement, and now they have moved on to more personal career goals. A lot of young women have never known a time when birth control and abortion were not legal.’

As a result, NOW has started an intensive campaign against Thomas. In the past, Supreme Court nominees were not asked their views on abortion, something senators have vowed to change during Thomas’ confirmation hearings this month. Already he has refused to make public his views, but the National Abortion Rights Action League (NARAL) recently leaked a copy of a 1987 speech in which he praised an essay by historian Lewis Lehrman who equated the anti-abortion movement with the abolition of slavery.

The anti-abortion movement officially began after Roe v Wade in 1973 and gained momentum in state legislatures where activists were voted in. Even though groups like NOW and NARAL are on the defensive, they have so far stemmed the tide of regressive legislation. In the year following the 1989 Webster decision, in which the Supreme Court allowed states to enact their own abortion legislation, 350 bills were introduced in state legislatures, of which the majority were either killed in committee or vetoed by state governors. Out of 270 bills introduced in 1991, only a handful have become law. But it takes only one case in the judicial pipeline to go to the Supreme Court. Many predict that restrictive laws in Pennsylvania and in Guam, initially passed by that state and US territory in 1989 and 1990 respectively, will reach the high court first.

What will happen if Roe v Wade is overturned? Ireland has no illusions. ‘Women will continue to get abortions but they will once again be unsafe.’ She sighs. ‘Women will start to die again.’

Special Report on Health at Work

The great success of the Clean Air Act, and the many health benefits it brought, are taken for granted by a generation which has never experienced the death-dealing pea-souper fogs that used to enshroud our major cities.

Today the focus has narrowed from environmental pollution of the atmosphere to the health hazards of the workplace. For the workplace is a microcosm of the environment, says Dr. Geoffrey Brown, secretary of the Society of Occupational Medicine, which commemorates its golden jubilee this year.

The factories and offices, the farmlands and oil rigs and shops, the hospitals and public utilities, the schools and print rooms and lorries and laboratories – where millions spend most of their waking hours – are no less in need of being free from hazard to health than the air we breathe.

The importance of health at work, established in legislation by the Health and Safety at Work Act, 1974, and by thousands of regulations since, was acknowledged by the Prime Minister earlier this year.

Mrs. Thatcher was visiting the occupational and hygiene laboratories of the Health and Safety Executive, the large but impressively energetic and expert quango which is the Government’s watchdog on health at work. Commenting on their ‘meticulous’ research, she emphasized that for British industry to remain at the top level, it must not only be efficient, it must also be safe.

The need for controls has been recognized since the earliest days of the industrial revolution.

In 1775, Percival Pott pointed to the high incidence of scrotal cancer among chimney sweeps. The Factory Inspectorate began its work more than 150 years ago, in the same year, 1832, as the Great Reform Act. Later legislation effectively established the world’s first national industrial medical service.

Towards the end of the 19th century, an industrial disease notification scheme was begun and in 1898 Thomas Morrison Legge became the first medical inspector of factories.

Illness and death among munition workers in the First World War made the nation aware that both for humanitarian reasons and to preserve human resources, medical services at the workplace were essential. Even during the interwar slump, many businesses set up health facilities.

More recently, bodies such as Nuclear and Agriculture Inspectorates have done much to maintain and improve health standards among workers in those vital industries. Contrary to widespread belief, incidentally, farming is much more hazardous to health, through noise, dust, pesticides, machinery and animals, than atomic power.

For the past 50 years, the now 2,000-strong Society of Occupational Medicine has greatly advanced the cause of health at work, through scientific meetings, education and training, consultations on new measures and in forming a faculty in occupational medicine within the Royal College of Physicians.

It has, says Dr. Tim Carter, its official historian and director of medical services for the Health and Safety Executive, an ‘evangelical’ role. That has not always made it friends.

Its prime work has been to encourage and respond to government initiatives, its members trying to tread the path between state intervention and voluntary action. Unfortunately, doctors in industry have tended, unjustly, to be identified with the employers’ sectional interests, and their integrity has been questioned.

But with both employers and trade unions lukewarm at first about occupational health, many services might well not have come into existence when they did but for the Society’s proselytizing.

As Dr. Carter points out, Britain differs from most European countries in not imposing statutory obligations upon employers to seek occupational health guidance, but relies on voluntary action. The government’s involvement is chiefly regulatory and supervisory.

Nor, of course, does it provide a treatment service.

The National Health Service, which does, is not specifically concerned with health at work. The Robens Committee in 1972 thought occupational health services might wastefully duplicate the NHS.

It was against this background that the House of Lords select committee on science and technology last year, while calling for a major expansion of occupational health services to cover millions in smaller companies, favored voluntary codes of practice for employers to follow rather than compulsion.

The conflict between the advisory and enforcement roles of government agencies is not easy to resolve. Dr. Tim Carter, believes that employers and trade unions sometimes want occupational health advice to bolster some essentially political position rather than to solve a health problem or help remove a hazard.

As a result, the field services of the Employment Advisory Medical Service of the Health and Safety Executive act more as arbitrators than advisers. Scares about the supposed dangers of visual display units, alarmist talk about asbestos in situ, needless fears about occupationally related cancers, distract the service from the real problems.

That is not to say, of course, that asbestos is not dangerous or that some of the 30,000 or so hazardous substances in industry are not, carcinogenic. But the real challenge is different.

Though facilities in many major companies are first-rate-concerns like Esso, Shell, Marks & Spencer, Rank Hovis McDougall and Kodak are among the most notable – such companies form a mere 20 percent minority.

For the majority, however, mostly medium and small companies, to provide such services requires venture capital which they do not have or do not want to provide.

This means that the 60 doctors and 30 nurses of Dr. Carter’s medical advisory service act as troubleshooters and crisis managers with health problems that need never have occurred. Meanwhile, important new problems – and new technology means these constantly arise – are not being adequately researched.

Ensuring health at work has a further difficult dimension. Safety at work is one thing – it is easy enough to identify dangerous equipment or the need to reduce noise (about a million workers have noise-related hearing defects, often severe and distressing). But it may not be so easy to do something about it.

If work causes you to lose an arm, the issue are clear. But what if it causes you to lose your reason? How to pin responsibility for the ‘sick building syndrome’, the vague but disturbing malaise which afflicts so many who work in modern buildings? How even to know for sure when it is or is not manifest?

However, Dr. John Cullen, the former industrialist who now heads the Health and Safety Commission, which advises the Government and develops the policies which the executive puts into practice, points out that the British system is being used as a model by other countries.

The way it involves both sides of industry in forming its policies and executing regulations in detail certainly ensures that measures are workable and realistic. ‘We don’t tell people how to run their show’, Dr. Cullen says. ‘We are not seeking to be over-protective.

‘But a decade ago, health at work was peripheral. Today, it is part and parcel of management. It is considered at the highest level in companies’.