How far must we go for a cure?

Four-year-old Chelsea Burke from Herne in Kent was yesterday recovering from treatment for a brain tumour in New York. She had been sent there this week after British doctors said they were unable to do anything more to help her. Two years ago Laura Davies was flown to the US for two multi- organ transplants that failed, leaving her dead and her parents sundered. Last October Alicia McCluckie, a three-year-old from Cheshire, successfully underwent the same treatment as Chelsea, at the same clinic, for which the NHS paid £32,000.

Including Alicia, the Department of Health has allowed the funding of four patients in the US in the past year because the equivalent treatment was not available in the UK. Is Britain falling behind on the cutting edge of medicine?

Bryan Jennett, emeritus professor of neurosurgery at Glasgow University, doubts it. In the two brain tumour cases, it appears that all the elements of the treatment the little girls required are available in Britain - but not combined in one centre. New treatments have to start somewhere, Professor Jennett says, and New York is ahead.

But in other cases, such as Laura Davies, "the Americans tend to have more nerve, be more heroic and take more risks, to put people through operations where British doctors would judge that things are best left alone. It is partly cultural, partly their system: a more entrepreneurial society with private facilities, less regulation and more aggressive doctors and patients.

"Americans tend to believe that death is optional. And with their private system, if you shop around enough and are prepared to pay, and to go through whatever it takes, you can usually find someone willing to have a go."

Britain has a long track record of innovation in medicine, pioneering hip replacements, heart and liver transplants and inventing CT scanning and magnetic resonance imaging, the modern equivalents of X-rays - although the old jibe of "invented in Britain, developed in America, made in Japan or Germany" applies to the last two. Today Britain remains ahead in gene therapy for cystic fibrosis and leads the world in developing transgenic pigs as possible sources of organs for transplant, for example, although the sheer scale of research elsewhere dwarfs Britain's contribution.

Innovation is driven by individuals, ambition, research facilities, money and culture. South Africa would have been at the top of no one's list for the frontiers of medicine in 1968; yet Christian Barnard was determined to undertake the world's first heart transplant. In hi-tech Japan, says Robert Maxwell, secretary of the King's Fund health think-tank, treatments requiring lasers are ahead of the world. But their transplant programme lags behind because of cultural objections to the use of organs.

The Soviet Union developed eye surgery to remove the need for spectacles, the one medical area where it led the world - to scepticism in the West and worries about the long-term results.

Caution, and a growing concern about cost-effectiveness, informBritain's approach: there have been too many examples of medical technologies, from foetal monitoring to new surgical and investigative techniques, adopted wholesale before their real value - and side-effects - were fully known. One of the key gains from the NHS reforms has been a new emphasis on "evidence- based medicine", working to establish which treatments work and are cost- effective, and attempting to discard those that are not.

Sir Terence English, the heart surgeon, says: "It is becoming more controlled now than in 1979, when I restarted the heart transplant programme. It would be more difficult to do that now because we demand that things be properly evaluated. I don't know whether this stifles innovation, but if it does, it is at the margin. We simply have to find out how best to use limited health budgets - and that applies everywhere, not just in Britain."

The scale of health spending and research in the US, and to a lesser extent Japan, Germany and France, means that many new techniques and treatments are bound to be developed elsewhere rather than in Britain. "For some conditions, it may be that a global market will develop, with patients having to travel for treatment," Mr Maxwell says. "If we were having this conversation somewhere other than in London, in a significantly poorer country, that would obviously be true now. As the health spending gap widens, that may happen between more countries. If you need a particularly expensive piece of kit to provide the treatment, that is a considerable barrier to a treatment spreading quickly."

Professor Sir Colin Dollery, dean of the Royal Postgraduate Medical School, is less certain. "For particular activities, at particular times, it may be true, but it is likely to be transient. Twenty years ago, Seattle was one of the major centres for transplantation, and I remember sending patients there for treatment. But new technologies and new techniques do spread out very quickly these days."

In the early Eighties, for example, patients from Scandinavia were coming to Britain for heart transplants as the British programme developed, and bigger volumes tend rapidly to cut the cost of new technologies, even of large items of equipment such as scanners.

What worries Sir Colin and Sir Terence is not so much Britain's competence but its capacity. The NHS has been slow to buy enough CT scanning machines, and needs more magnetic resonance imaging. For certain skin conditions, Britain has only two lasers available, both in London. Operations once seen as hi-tech but now routine - such as coronary artery bypass - remain lower in Britain than many other countries. "The Americans almost certainly do too many of these operations," Sir Terence says, "but we are doing too few."

But while there will always be somewhere in the world that for a time leads the way in new treatments, Sir Colin says that in general, "if I fell ill tomorrow, I can't think of any disease where it would be necessary to get on the first plane across the Atlantic to get the best possible treatment".