NHSCA June 2013 Harry Keen (1925-2013) Most NHSCA members will met him). At that time there was probably remember Harry Keen much competition in specialist primarily as a campaigner for and academic medicine; it was the NHS, as we are reminded the era of the time-expired by Paul Evans’ accompanying senior registrar. In academic memoir. Probably his most medicine it was widely regarded celebrated action, mentioned as a necessity to acquire the by Paul, was his attempt to BTA (Been To America) and challenge in the high court the Harry duly went to the National secretary of state’s power to act Institutes of Health, Bethesda, in advance of parliamentary to work with James B Field, approval of legislation, whom he had met when Jim something which incurred Field spent some time in the potential financial risk for Diabetic Department at King’s. Harry. Here I will concentrate Here he learned the techniques on his professional career. of measuring insulin action using preparations of the rat diaphragm and the rat epididymal Harry was born in London in 1925 and studied fat pad. He also did some exploratory work on medicine at St Mary’s Hospital. He qualified in isolating islets of Langerhans from rat pancreata 1948 a few weeks before the inauguration of the following the tying of the pancreatic duct, NHS. These were the days before pre-registration borrowing from Frederick Banting’s experiments jobs and his first experience of clinical medicine prior to the isolation of insulin. was as a locum general practitioner, doing his visits on a bicycle. Later he worked in the After returning to the UK, Harry obtained a department of medicine at St Mary’s under lectureship in the Department of Medicine at Professor George Pickering, whose principal Guy’s Hospital under Professor John Butterfield, research interest was hypertension and who whose principal clinical and research interest engaged in a famous dialogue/dispute with was diabetes mellitus. Clive Sharp, then Medical Robert Platt about its nature and causes. Pickering Officer of Health for Bedford, was interested was a major influence on Harry and introduced in screening for disease and approached John him to a second major influence, RD Lawrence Butterfield for help in a diabetes screening at King’s College Hospital, where Harry worked programme in Bedford. John Butterfield for several years as a research assistant in the engaged Harry and Roy Acheson (Reader in Diabetic Department (where, incidentally, I first Social Medicine at Guy’s) in the planning of In the June 2013 issue of the NHSCA Newsletter. Editorial: David Levy, pg 2; Brian Jarman on counting the dead at Mid-Staffs, pg 3; Heather Wood on Francis’ missed opportunities, pg 6; Geoff Mitchell: reviving the culture of the consultant, pg 8; David Levy: The Francis report, ‘a case study in failure’: lessons almost certainly not learned, pg 11; Paul Evans: remembering Harry, pg 18 something more than a simple screening exercise that John Parsons had used subcutaneous – more of an epidemiological study. At that time infusions of parathyroid hormone for patients the criteria for diagnosing type 2 diabetes using with hypoparathyroidism and thought that this blood glucose levels were many and varied and might be a potential means of delivering insulin. were all quite arbitrary. Several experts were Together with John Pickup he set up a research consulted and were asked what levels of blood programme to investigate this. The result, CSII glucose they would regard as completely normal (continuous subcutaneous insulin infusion, and what levels they would regard as definitely usually called the insulin pump), now with diabetic. It was decided to identify people in sophisticated technology, has become a widely- this grey zone (called ‘borderline diabetes’) and used treatment for people with type 1 diabetes. follow them prospectively. Subsequently, Harry was invited by Geoffrey Rose to participate in Harry was also greatly concerned with treatment, the Whitehall Study (now Whitehall 1), which both in terms of therapy and of organisation, was more orientated to cardiovascular disease, of diabetic patients. He was a pioneer in the but which included a diabetes element similar to employment of specialist nurse practitioners in that in the Bedford Study. The two studies came the education and management of individual to broadly the same conclusions and helped patients and groups. He persuaded management rationalise the diabetes diagnostic glucose levels. to fund a ‘metabolic ward’ at Guy’s, with four They also showed that levels of glycaemia below inpatient beds, available for various metabolic those diagnostic of diabetes were associated with investigations, but principally for clinical, increased risk of coronary and cerebral vascular teaching and investigational procedures relating disease. to the diabetes service. He was involved in many national and international bodies concerned with Inspired by the simplified immunoassay for diabetes, not least the British Diabetic Association insulin devised by Nicholas Hales and Philip (now Diabetes UK). At Guy’s he headed the Randle Harry, with Costis Chlouverakis, devised directorate of clinical services for medicine when a similar assay for urinary albumin. This was the administration was reformed. He also played applied in a cross sectional study by Ron Hill. a prominent role in several notable clinical trials. Follow up of these patients showed that in both type 1 and type 2 patients, even moderately Harry was unusual in encompassing laboratory raised levels of urinary albumin predicted skills, epidemiology, clinical medicine and increased morbidity and mortality, later found administration, and he endowed each with to be true of non-diabetics also. extraordinary enthusiasm and energy. He will be missed by many. People with type 1 diabetes traditionally need to inject themselves with insulin one or more John Jarrett times per day. In the early 1970s Harry learned EDITORIAL A look back to the future David Levy As guest editor of this edition, I planned it with Francis’ herculean efforts has been muted and a Mid-Staffs theme. Three months after the long- shockingly uncritical, apart from the expected delayed publication of the report seemed the headline-grabbers (nurses to do bedside nursing right distance to lend some decent perspective as part of their training, an unresolved question to the latest in a series of crisis interventions after about minimum nurse staffing levels, and heads catastrophes in the NHS since Ely Hospital back that should have – but didn’t, and were never in the 1960s. To date, with a few exceptions, the really going to – roll ). An organisation like response (including the government’s) to Robert the NHSCA with clear views on the aberrant 2 direction of travel in the NHS and a membership academic medicine in the NHS since 1948. of extraordinary depth of national real-life Although we will all remember him for his experience should be generating thoughtful lifelong and unwavering support of the NHS and balanced views to contribute to the debate. founding principles, his medical career and We hope you will find a quartet of them in this his extraordinary contribution to the science issue. But the discussion must continue, and of diabetes and its epidemiology marks an we’d like to hear other members’ thoughts equally important pinnacle of the NHS ideals of as the enormously complex outcomes pick academic brilliance in the service of our patients. their hazardous way through the financial and The metabolic team at Guy’s under Harry’s political minefields. leadership produced breathtaking research over decades at the very highest levels. We won’t see It’s poignantly appropriate that at a crisis- a personality like him again, and I suspect in the induced crossroads of development of the new NHS research environment we won’t ever NHS we should also mark the passing of Harry see a body of clinically meaningful research like Keen. His life was a magisterial marker of his either. the high politics and the very best of clinical HSMRs and Francis – their role in Mid-Staffs and their future in the NHS Brian Jarman Introduction Hospital Standardised Mortality Rates (HSMRs) have been told that the adjusted death rate for were developed in the early 1990s, originally open heart surgery in children under one year when our unit at Imperial College was given the at Bristol was 29%, but they only need to have job of calculating the resource allocation formula driven about an hour up the motorway to find for England. The idea was to see if some hospitals a unit with a third of that rate. Adjusted death had particular problems that might require rates are important for patients and relatives additional funding. It was evident that adjusted and are factors that could be considered in any mortality was the only measure that could be reorganisation of paediatric cardiac surgery used reliably in this way and also for monitoring units, but the complexity of their interpretation purposes (concisely described as ‘bombproof means that more than a decade on from Bristol, and actionable’ by the medical director of a US controversy still surrounds the future of other hospital). Death is a definite event that has to paediatric cardiac units such as Leeds. be registered by law, and unlike morbidity, it does not have the problem of knowing if the HSMR and their meaning condition was present on admission. Hospital death rates vary with age, sex, diagnosis Although people may not like to think about and other factors and the HSMR is defined as death rates, they do understand them and the ratio of the number of observed deaths in a knowing the numbers could be important for hospital over, say, a year to the number expected patients and their relatives.