meek nhs

5. Multiple Fractures
Privatised health
Wrightington Hospital, in the countryside near Wigan, grew in
fits and starts around an eighteenth-century mansion that
Lancashire County Council bought in 1920 after the death of its
last resident, a spendthrift with a fanatical attachment to blood
sports. The hospital promotes itself as a centre of orthopaedic
excellence’. National Health Service hospitals have to promote
themselves these days. In 2011 it survived a brush with closure.
It’s neat and scrubbed and slightly worn at the edges, unable
to justify to itself that few per cent private firms set aside for
corporate sheen, although it does have a museum dedicated to
John Charnley, who, almost half a century ago, invented a
reliable way to replace human hips with artificial ones, creating
a benchmark by which the success and failure of the NHS
would always be judged.
They still do hips at Wrightington, and knees, and elbows,
and shoulders. They deal with joint problems that are too
tricky for general hospitals. There’s a sort of blazer and
brogues testosterone in the corridors, where the surgeons have
a habit of cuffing one another’s faces affectionately. At the end
of a hallway lined with untidy stacks of case notes in wrinkled
cardboard folders Martyn Porter, a senior surgeon and the
hospital’s clinical chairman, waited in his office to be called to
the operating theatre. He offered me his intense, tired,
humorous gaze. ‘The problem with politicians is they can’t be
honest,’ he declared. ‘If they said, “We’re going to privatise the
NHS,” they’d be kicked out the next day.’
The patient Porter was about to operate on was a
sixty-year-old woman from the Wirral with a complex prosthesis
in one leg, running from her knee to her hip. She had a
fracture and Porter had got a special device made for her at a
workshop in another part of the NHS, the Royal National
Orthopaedic Hospital at Stanmore in Middlesex. The idea was
for the device to slide over the femoral spur of the knee joint,
essentially replacing her whole leg down to the ankle. ‘The case
we’re doing this morning, we’re going to make a loss of about
£5,000. The private sector wouldn’t do it,’ he said. ‘How do
we deal with that? Some procedures the ebitda is about 8 per
cent. If you make an ebitda of 12 per cent you’re making a
real profit.’ You expect medical jargon from surgeons, but I
was surprised to hear the word ebitda from Porter. It’s an
accountancy term meaning ‘earnings before interest, taxation,
depreciation and amortisation.
‘Last year we did about 1,400 hip replacements,’ he said.
‘The worrying thing for us is we lost a million pounds doing
that. What we worked out is that our length of stay’ – the
time patients spend in hospital after an operation – ‘was six
days. If we can get it down to five days we break even and if
it’s four, we make a million pound profit.’
I felt I’d somehow jumped forward in time. A year had
passed since the 2010 election that brought the
Conservative-Liberal Democrat coalition to power. The Coalition’s
programme promised: ‘We are stopping the top-down
reconfigurations of NHS services, imposed from Whitehall.’ A
few weeks after they gained power, a new health secretary, the
Conservative Andrew Lansley, announced his plans for a
top-down reconfiguration of England’s NHS services, imposed
from Whitehall. When I talked to Porter, Lansley had barely
been in his job a year, and hadn’t yet, supposedly, shaken up
the NHS. But here was a leading surgeon in an NHS hospital,
about to perform a challenging operation on an NHS patient,
telling me exactly how much money the hospital was going to
lose by operating on her, and chatting easily about profit and
loss, as if he’d been living in Lansleyworld for years. Had the
NHS been privatised one day while I was sleeping?
When the NHS was created in 1948, it had three core
principles. It would be universal: everyone would get medical
treatment whenever they needed it. It would be comprehensive,
covering all forms of healthcare, from dentistry to cancer. And
it would be free to use. No matter how much the system cost
to run, no matter how much or how little any individual had
contributed to those costs, no matter how expensive their
treatment or how many times they went to the doctor, they’d
never be billed for it. Through dozens of reorganisations since
then, these principles have remained, along with another: that
it’s never a bad time for a fresh reorganisation. Otherwise,
much has changed.
The main source of the money that funds the NHS is still, as
it was in 1948, general taxation. For the first thirty years of the
health service’s existence, civil servants in Whitehall and the
regions doled out annual budgets to hospitals and GPs
according to the populations they served. Money flowed down
from the Treasury, but it didn’t flow horizontally between the
different parts of the NHS. Each element got its overall
allowance, paid its staff, obtained its equipment and supplies,
and co-operated, sometimes well, sometimes not, with the other
elements, according to an overarching plan. The aim was
fairness, an even spread of care across the country. In a
monopoly healthcare system, competition has no place; on the
contrary, it seemed sensible to the planners to avoid duplication
of services. It was patriarchal and democratic, innovative and
hidebound, cumbersome and cheap. For the majority without
private insurance, if you were ill, you knew you’d always be
cared for; if you were cared for carelessly, you had nowhere
else to go.
Trying to describe in generally comprehensible terms how
money flows through the NHS today would be hard enough
without the shifting channels of policy In England – Scotland,
Wales and Northern Ireland have gone along divergent health
paths – the various parts of the NHS had already begun
altering or abolishing themselves in response to the
reorganisation announced in 2010 when the reorganisation itself
was reorganised. In 2012, the Coalition responded to the
clamour against Lansley’s reorganisation by sacking Lansley and
keeping the reorganisation. Truly you can’t step in the same
NHS river twice. The last period of relative stability was just
before Lansley came along, when, crudely speaking, the money
flowed like this. Every so often – perhaps every year, or every
two or three – the Department of Health made its pitch to the
Treasury for the amount of money it thought it should get
from the overall tax pot, and was then told how much it
would actually get. Most of the money came from general
taxation – income tax, VAT, corporation tax, duties on booze
and tobacco – but a proportion came directly from national
insurance, a vitiated form of the link between that levy and the
welfare state its architects intended. In the last pre-Lansley
allocation, Health got £101.5 billion for the following year, a
slight increase. Most of it – £89 billion – was divided up
between about 150 local agencies called Primary Care Trusts, or
PCTs, spread around the country. PCTs acted as the
commissioners’ of health services, ordering a community’s
medical care from hospitals, GPs and mental health
professionals and paying them accordingly.
PCTs could use NHS money to commission care from the
private sector. They weren’t under any obligation to shop
locally, either. Under Labour in the 2000s, NHS patients had
been given the chance to choose private or far-away hospitals
for treatment, which meant the PCTs were obliged to
commission from them. Even before Lansley’s changes, NHS
hospitals like Wrightington had become dependent for their
financial viability on the money they made from selling their
services to the PCTs. Competition already existed.
The amount of money PCTs got from the government varied.
The Department of Health had a panel of civil servants and
academics called the Advisory Committee on Resource Allocation
(ACRA), which came up with a formula for working out the
health needs of each area based on population size and density
the proportion of elderly people, life expectancy and the degree
to which their health varied from the mean. In the poorer
parts of Merseyside, for instance, where male life expectancy is
sixty-seven, men can expect to be incapacitated by disability of
some kind by the age of forty-four. The corresponding figures
for the richer parts of West London are eighty-nine and
seventy-four. The variation in the sums different PCTs got
relative to their population was, accordingly, considerable. In
2011 South Gloucestershire received £1,298 per head, Islington
in London £2,268.
Primary Care Trusts were set up in 2002; they were
abolished only eleven years later. Post-Lansley, money flows
through the NHS differently. It still comes from general
taxation, but most of the money that used to go to the PCTs
is doled out by a new organisation, NHS England, to bodies
called Clinical Commissioning Groups, essentially clusters of GP
practices. Across England, groups of family doctors have
become responsible for handling tens of billions of pounds of
public money, using it to commission most of the medical care
NHS patients receive, from major surgery to simple diagnostic
tests. Lacking expertise of their own, most are paying private
contractors to manage these funds for them, or hiring ex-PCT
staff to do the same jobs they used to do.
At the same time a series of other changes have made
commission more of a euphemism for ‘buy’. Not everything the
PCTs commissioned came with a price tag. But increasingly
almost all procedures, even those as seemingly amorphous and
complex as caring for the mentally ill, have been coming in
quantified, priced units – ‘healthcare resource groups’, each with
its own code. Any hospital anywhere in England, NHS or
private, that carried out procedure HA11C on an NHS patient
in 2010 – treatment of a routine hip fracture – got a base
payment of £8,928 from the outfit that commissioned it, and
£9,373 if it followed ‘best practice’. A maternity unit clocked
£1,324 for a regular birth, NZ01B; putting in an artificial heart,
EA43Z, earned £33,531. The sum was adjusted according to a
local ‘market forces factor’, which took account of the variation
in cost of labour and assets between different areas. The codes
and prices were worked out, in turn, according to the actions
taken and materials used by typical hospitals, with ‘best
practice’ bonuses – if a hospital gave a stroke patient a
prompt brain scan and had an acute stroke unit of a certain
standard, for instance, it would get an extra £475 on top of
the base payment of £4,095. If the actual cost to the hospital
was less – if the hospital managed to send the patient home
quicker than usual, for instance – the hospital would keep the
difference. The notion of the profitable hospital within the NHS
was born.
The new system takes this simulated privatisation, this
enactment of commerce, further. State money ‘follows the
patient’ wherever the patient chooses to take it, even when that
is outside the NHS. Patients with chronic conditions like
diabetes will not be given treatment, but money to spend on
treatment. All NHS hospitals are obliged to become ‘foundation
trusts’, turning them into semi-commercial operations, able to
borrow money, set up joint ventures with private companies,
merge with other hospitals – and go broke. The contracts they
make with GP groups are legally binding. They now compete
not only with other NHS hospitals and private hospitals but
potentially with the GP groups themselves, who may set up
local clinics to provide diagnostic tests or minor surgery.
Alongside the NHS Commissioning Board two other quangos
now supervise the new, competitive marketplace: the Care
Quality Commission, there to make sure the players in the new
marketplace don’t harm patients, and Monitor, which, among
other duties, will make sure that if a hospital goes bust
somebody takes up the slack.
In 2011, it was announced that a billion pounds’ worth of
NHS services, including wheelchair services for children and
‘talking therapies’ for people suffering from mild depression,
anxiety or behavioural awkwardnesses like obsessive compulsive
disorder, were to be opened up to competitive bids from the
private sector. The doctor and Daily Telegraph blogger Max
Pemberton described it as ‘the day they signed the death
warrant for the NHS’. Now the NHS must compete with
private outfits for MRI scans in Lincolnshire, glaucoma
treatment in Cheshire, continence care in Stoke-on-Trent and
psychotherapy in West Kent. Worried about the lack of
competition in flexi-sigmoidoscopy in Bassetlaw? NHS England’s
website reassures you: it’s coming soon.
Throughout the current debate on the health service’s future,
the Conservatives have praised it as an abstract concept,
pledging to uphold ‘an NHS that is free at the point of use
and available to everyone based on need, not the ability to
pay’. But it is quite possible to praise something even as you
legislate it out of existence. Changes don’t need to be advertised
as embodying a cumulative destructive purpose for that purpose
to be achieved. The fall of the Roman Empire was never
announced, yet its fate was sealed once its rulers, no doubt for
reasons of efficiency, introduced a choice of competing
barbarians to defend its borders.
In their book The Plot Against the NHS, Colin Leys and
Stewart Player argue that, having failed to persuade the public
and the medical establishment under Margaret Thatcher that
the NHS should be turned into a European-style national
insurance programme, the advocates of a competitive health
market gave up trying to convince the big audience and
focused on infiltrating Whitehall’s policymaking centres and the
think tanks. As a result the government and the cast Leys and
Player call ‘marketeers’ – private companies, lobbyists,
pro-market think tankers – publicly praise the NHS, while
taking incremental steps to turn it into an NHS in name only:
a kitemark, as one prominent marketeer puts it in the book.
Yet there was a huge gap between the end of John Major’s
administration in 1997 and the Tory-Liberal pact of 2010.
Labour, the party that created the NHS, that has pledged to
defend it and has denounced the Lansley reforms, was in
power for those thirteen years. So how did a surgeon like
Martyn Porter end up, in 2011, so accustomed to the world of
commercial competition and the bottom line? As Leys and
Player show, it was the governments of Tony Blair and Gordon
Brown that began replacing the public components of the NHS
with private ones, the effect concealed by large spending
increases, long before the Coalition took charge. If the
Conservatives and their Liberal allies are dismantling the NHS, it
was Labour that loosened the screws.
The first attempt to introduce market competition into the
NHS was made by Kenneth Clarke in 1990, in the dying
months of Thatcher’s rule. An ‘internal market’ was rushed in,
against the advice of the medical profession. It was watered
down; it had less effect than its critics feared or its supporters
hoped. Tony Blair’s first health minister, Frank Dobson, read its
funeral rites when Labour came to power seven years later.
Yet at the turn of the millennium, Alan Milburn replaced
Dobson, and Labour introduced a new, more radical version of
that market.
It was Labour that introduced foundation trusts, allowing
hospital managers to borrow money and making it possible for
state hospitals to go broke. It was Labour that brought in the
embryonic commercial health regulator Monitor. It was Labour
that introduced ‘Choose and Book’, obliging patients to pick
from a menu of NHS and private clinics when they needed to
see a consultant. It was Labour that handed over millions of
pounds to private companies to run specialist clinics that would
treat NHS patients in the name of reducing waiting lists for
procedures like hip operations. It was Labour that brought
private firms in to advise regional NHS managers in the new
business of commissioning. And it was Labour that began
putting a national tariff on each procedure.
The more closely you look at what has happened over the
last twenty-five years, the more clearly you can see a consistent
programme for commercialising the NHS that is independent of
party political platforms: a purposeful leviathan of ideas that
powers on steadily beneath the surface bickering of the political
cycle, never changing course.
A key source of those ideas was Alain Enthoven, an
American economist. Enthoven spent most of the 1960s in the
Pentagon, one of the cerebral ‘whizz kids’ on the staff of the
defence secretary Robert McNamara. McNamara was a wonk,
confident that no mystery could withstand statistical analysis,
and Enthoven was the chief wonk’s wonk, crunching numbers
to judge whether the new weapons the generals wanted were
worth it. In 1973, Enthoven reinvented himself as an expert in
the economics of healthcare. He believed the US health system,
as a whole, was a failure (he described tax relief for private
health insurance as a disaster), but thought one part of it, a
California-based outfit called Kaiser Permanente, was exemplary.
His ideal was something called ‘managed competition’, and in
1985 he wrote a paper for the Nuffield Trust suggesting it
could work for the NHS.
Enthoven himself seems to have been taken aback by the
speed with which Thatcher’s sunset coterie latched onto him. In
an interview with the British Medical Journal in 1989 he said of
the Conservative proposals: ‘I was very surprised by the lack of
detail... I thought that I was throwing out a general idea that
needed to be developed.’ It is eerie to read the interview now.
Everything that Enthoven prescribed then was either brought in
by New Labour or is being put in place by Labour’s supposed
opponents a generation later. ‘I recommended that the district
health authorities be recast as purchasers of services on behalf
of the populations they serve, with choice of where and from
whom they buy the services, rather than being cast as
monopoly suppliers’ – check. ‘Another very strong idea is that
money follows patients’ – check. ‘Pay hospitals prospectively by
diagnosis-related groups as our Medicare programme does’ –
check. ‘Self-governing NHS trusts’ – check.
What seems to have happened since 1985 is that Enthoven’s
ideas have become embedded in individual careers, financial
aspirations and personal relationships independently of the rise
and fall of parties. For individuals, there is money to be made
by promoting the market. In 2006, Accountancy Age reported
that the NHS was spending more on consultants than all
Britain’s manufacturers put together. The figure for 2007-08
was £308.5 million. The post-political careers of the Labour
cabinet ministers responsible for marketising the NHS don’t
make for comfortable reading. Alan Milburn became an adviser
to Bridgepoint Capital, a venture capital firm backing private
health companies in Britain, and to the crisps and fizzy drinks
maker PepsiCo; for eighteen days a year advising Cinven, which
owns thirty-seven private hospitals, Patricia Hewitt, one of
Milburn’s successors as health secretary, was paid £60,000.
The revolving door has become a blur. Simon Stevens, Blair’s
special adviser on health, became a senior executive at
UnitedHealth, one of America’s largest private health companies;
he is now back on the government payroll as head of NHS
England. Mark Britnell, a career NHS manager who rose to
become one of the most powerful civil servants in the
Department of Health, upped sticks in 2009 to become global
head of health for the consultants KPMG.
This last move did have the advantage of giving an insight
into what had actually been going on in Whitehall and Downing
Street. In 2010 Britnell was interviewed for a brochure put out
by Apax Partners, a private equity firm: it had organised a
conference in New York on how private companies could take
advantage of the vulnerability of healthcare systems in a harsh
financial climate. ‘In future,’ Britnell said, ‘the NHS will be a
state insurance provider, not a state deliverer... The NHS will
be shown no mercy and the best time to take advantage of
this will be in the next couple of years’ Responding later to the
dismay his comments had caused, Britnell said in an article for
the Health Service Journal that the NHS had saved his life in
the year he left government service, that he would always
support it, and that the quotes attributed to him ‘do not reflect
the discussion that took place’ at the conference. But he didn’t
deny making the comments. ‘Competition,’ he added, ‘can exist
without privatisation.’
Yet Britnell had topped his own ‘no mercy’ line in an article
he’d written for the same magazine the previous week. There
he made the unremarkable if contentious point that ‘all over
the world, the size of the state has been increasing.’ What
furrowed the brow was the base year he chose for the
comparison with today’s level of public spending: the year was
1870, when infant mortality in Britain ran at 16 per cent,
working-class men had just been given the vote, and four
years had passed since a cholera epidemic killed 3,500
Londoners.
Critics of the NHS often cite Enthoven’s favourite health
organisation, Kaiser Permanente, as a model for efficient,
integrated care. And yet from the British point of view Kaiser
stands out among American providers not because it’s better or
worse than the NHS but because it looks a bit like it. It’s
huge: it provides medical care to a mainly Californian
membership roughly the size of the population of Austria. Its
doctors are salaried and its hospitals are non-profit. It offers
patients a complete service of hospitals, labs and family doctors,
as the NHS does, although it also has its own pharmacies. And
one explanation for its efficiency, as with the NHS until a few
years ago, is that it actually limits choice. Most Kaiser members
have a health plan that offers them or their employers relatively
low premiums in exchange for using only Kaiser facilities.
Kaiser is doing a lot right. Its model of’integrated care’ –
where a single health organisation looks out for people not just
during treatment but before, after and between, and hospital
admission is seen as a failure – has long been a goal for
progressives in the NHS. It seems to have done a better job
than the NHS of getting medical information off paper and into
computers. A 2003 study in the British Medical Journal,
investigating the length of time the over-65s spent in hospital,
found that for hip replacements, British pensioners went home,
on average, twelve and a half days after admission; Kaiser
patients were home after four and a half. Kaiser doesn’t tie its
consultants to its thirty-five hospitals; those who deal with
chronic conditions are as likely to be in its 455 medical centres,
alongside family doctors.
Getting ideas from Kaiser is one thing (as alluded to by
Martyn Porter, NHS lengths of stay in hospital have dropped
sharply since 2003); using it as a template is another. The
major problem that militates against importing the Kaiser model
to the NHS is money. England isn’t the only country that has
studied Kaiser. In 2011 a Danish think tank, the Rockwool
Foundation, reported on its investigations. Its team, led by Anne
Frølich, found that Kaiser was better than the Danish health
service at getting its constituent parts to work together, at
getting patients to take responsibility for their own health and
at preventing unnecessary hospital admissions. Everything was
great, except that for every krone Denmark spent on
healthcare, Kaiser spent one and a half. According to the latest
OECD figures, Denmark outspends Britain on healthcare, head
for head, by 25 per cent. On the basis of the Rockwool study,
the Kaiser system could be reproduced in Britain only if health
spending were increased by 87 per cent. That is not going to
happen on any Tory or Labour planet in this galaxy.
The curious thing about the Lansley plan is that it was
supposed to save money, yet despite the increase in spending
on the NHS under Labour, the organisation remains a bargain.
The two foreign systems with which it is most often compared,
the American and the French, are more expensive, are coming
to be seen as unaffordable in their own countries and contain
elements that it would be hard for Britons to accept. Kaiser
works well and is cheaper than traditional American healthcare.
But it reflects the US model. Although that model is being
changed by the introduction of President Obama’s Affordable
Care Act, it remains idiosyncratic. Most people over sixty-five
are eligible for Medicare, a kind of gold-plated American NHS
for the elderly, but otherwise, if you have no insurance, you
have no guaranteed access to medical facilities, including
Kaiser’s. If you fall seriously ill in the US, aren’t insured and
aren’t rich, you have two main options: to go to a hospital’s
accident and emergency unit, where they’re obliged to treat
you, or to try to get Medicaid, a government programme to
help the poor and disadvantaged run on a state by state basis.
But the hospital will charge the full rate for treating you, which
it will then try to recover against any assets you have, while
Medicaid is means-tested. In other words, being uninsured and
having a serious car accident in the United States is hard to
make compatible with owning a house.
The Affordable Care Act (ACA) is a giant step towards
equality of opportunity in America, though it falls short of a
revolution. The new law proposes that all fifty states accept a
more generous means test for households trying to enrol in
Medicaid. The threshold depends on household size; in most
states, a family of four could be earning up to $32,500 a year
and still qualify. In many parts of the US, where the current
threshold is less than $12,000, this is a massive increase, and
should enable proper health care for the first time to millions of
low-paid working Americans whose employers are too mean to
cover them. But a swathe of southern and mid-western states
with Republican legislatures, including four of the five with the
highest poverty levels, Mississippi, Louisiana, Alabama and
Texas, are refusing, with the approval of the Supreme Court, to
implement the system.
For middle-class Americans, the new system is just as radical.
Individuals still aren’t forced to take out health insurance, but
they now suffer a stiff tax penalty if they don’t. In return, for
middle-income households earning up to $94,000, the
government offers hefty subsidies on a choice of health plans,
and has abolished the brutal pre-existing condition’ rule, which
allowed insurance companies to refuse coverage to people who
were already ill. All businesses above a certain size will be
obliged to start offering their employees health cover. Supporters
of the law believe it will more than pay for itself; its increased
costs will be offset by thinning out the armies of walking
wounded who throng hospital emergency rooms, and by
spreading risk more widely.
But as many as thirty million people will still be left without
medical cover – low-paid people in the pro-inequality states,
illegal immigrants and people who gamble that they won’t need
a doctor and prefer to pay a tax penalty rather than a
premium. And even if you are insured in America, and have
access to some of the world’s finest medical facilities, just
paying the premium each month doesn’t make healthcare free
at the point of delivery. Two standard features of US health
insurance, before the ACA and under it, are the ‘copay’, a fee
for consultations or drugs, and the ‘deductible’, an amount the
patient is expected to pay before the insurance kicks in, like
the excess on car insurance. The lower the premiums, the
higher the copays and deductible.
With the new subsidies Kaiser’s Platinum 90 plan, for
instance, costs $345 a month for a forty-year-old woman with
one child living in San Francisco and earning $40,000 a year.
Although much more affordable than it would have been
pre-ACA, that’s a high premium, and there’s no deductible. But
each year she has to pay $20 to see a doctor after the first
visit; $150 for a trip to the emergency room; between $5 and
$15 per prescription; $250 a day for a hospital stay, and so
on up to a maximum of $8,000 a year. At the other end of
the scale, there’s a Bronze plan that costs $123 a month.
That’s a bargain if she doesn’t get sick. But if mother or child
falls ill, she has to pay the first $9,000 out of her own pocket.
After that the copays kick in – two-fifths of the actual cost of
everything from chemotherapy to x-rays – until she’s forked
out $12,700.
A Harvard-led study found that 62 per cent of all
bankruptcies in the United States in 2007 were due to medical
bills, an increase of 50 per cent in six years. Most of those
affected were well-educated, middle-class homeowners.
Astonishingly, three-quarters had their finances destroyed by
medical costs even though they had insurance. In a significant
number of cases, it was paying to look after a sick child that
bankrupted parents. Among the common ailments were
neurological conditions like multiple sclerosis, which left
households $34,000 out of pocket on average, diabetes
($26,000) and stroke ($23,000). In his paper ‘Sick and (Still)
Broke’, the lawyer Ryan Sugden points out that while the ACA
puts a helpful cap on copayments, it doesn’t eliminate them,
and does little to help people who have to quit work through
their or a child’s illness. ‘While the Affordable Care Act will
reduce the overall number of bankruptcies, and arguably
eliminate the most morally objectionable causes of medical
bankruptcy, in a system based on market principles there will –
and must – be consumers whose own bad choices spell
financial trouble,’ he writes. ‘For society to “win” and receive
the benefits of a consumer-driven system, there must be some
who “lose”.’
Latest figures from the OECD and the World Health
Organisation suggest that the US spends 2.4 times more on
health per person than Britain, yet Britons live slightly longer,
on average, than Americans. British men can expect to live to
be seventy-eight, two years older than American men; for
women it’s eighty-two versus eighty-one.
The US healthcare system is unique, as is the NHS. Most
rich countries lie somewhere in-between the two, using
mandatory insurance, with a mixture of state, for-profit and
non-profit medical organisations providing the care. France, for
instance, spends slightly more on health than Britain, and
French women, though not French men, live slightly longer.
French people of working age, together with their employers if
they have them, pay into a social security fund that’s supposed
to cover healthcare, pensions, disability and child support. The
poorest French people get healthcare absolutely free under a
system called Couverture Maladie Universelle, or CMU. There is
also a list of thirty conditions, known as Affections Longue
Duree, which are treated free of charge for everyone: cancer,
HIV, diabetes, Parkinson’s, all the way to leprosy Otherwise the
relatively well-off, though shielded from ruin by the sickness
insurance system, Assurance Maladie, are faced with a system
of copays not much less onerous than America’s. Where in
Britain copays are restricted to dentistry and prescription
charges, in France patients pay a fee each time they visit the
doctor. They pay a percentage, known as the ticket
moderateur, of hospital costs, ambulance bills and medical
procedures. Each visit to your GP, for instance, costs €23 up
front, of which €15.10 will be reimbursed. A replacement hip is
free, but to get one put in you have to pay 20 per cent of
the cost of surgery, lab tests, consultants’ fees and the stay in
hospital.
The huge sums France spends giving its citizens free,
universal access to the latest cancer drugs and equipment are
popular, but the country’s lavish spending on extreme illnesses
doesn’t put it as far ahead of Britain as critics of the NHS
claim. One recent study led by Philippe Autier of the
International Agency for Research on Cancer in Lyon showed
that the number of people dying of breast cancer in England
and Wales fell by 35 per cent between 1989 and 2006, against
an 11 per cent fall in France. France is still doing slightly better
than England but the rates have almost converged.
Britons who idealise the French system imagine that in France
anyone can see any doctor they like and that the state will
pick up the bill, but if this were ever true, it isn’t true now.
The country’s social security fund is chronically in the red. To
see a consultant inside the Assurance Maladie system, patients
have to get a referral from a GP, as in Britain. And there are
two kinds of doctor. Only secteur 1 doctors charge the
Assurance Maladie fee. Secteur 2 doctors can set their own
fees, but the share reimbursed by Assurance Maladie doesn’t
change. An increasing number are taking out private health
insurance to cover the gap.
All the rich world’s diverse health care systems are struggling
with ageing populations, with the diseases of plenty – obesity,
diabetes – and new, ever more expensive ways to treat their
illnesses. But to speak in terms of ‘health care systems’ doesn’t
accurately represent what’s happening to the NHS. The NHS
used to be no more or less than a health care system; now
it’s a health care system into which a whole other system, the
system of competitive consumerism, is pushing. A system that
was concerned first with making people well and, as a
secondary preoccupation, looking after itself, is now trying to
accommodate competition. But competition between agencies for
business, even medical business, is easy to understand. The
more insidious novelty is competition between patients. Once it
used to be enough to get help for what ailed you. Now
patients are being encouraged to think about how the NHS
treats them in terms of the discontent-fostering narratives of
advertising: to imagine other patients who are getting better or
worse treatment than they are, in prettier or uglier hospitals,
with therapies that are not necessarily more effective but are
faster, more fashionable, that come in a wider range of colours.
The blurring of the distinction between health care and the
maintenance of lifestyle choices gives the enemies of the NHS
another means by which to accuse it of failure.
One dark Sunday afternoon in February 1982 fill Charnley
waited at the wheel of a car outside a hospital in Mansfield.
Through the storm she saw her husband bustling towards her
with a plastic pail containing the haunch of a woman who’d
just died. ‘Down the road he came with a triumphant smile on
his face and this bucket with a hip in it,’ she told me not long
ago. ‘He put it in the boot of the car. I remember saying: “My
God, I hope we don’t have an accident, if they look in the
boot of the car to see what’s there...”’
John Charnley, Sir John as he was by then, managed to
restrain himself from dissecting the specimen, preserved under
formalin, until the next day. The dead patient’s hip was, in a
way, as much his as hers. It was implanted in 1963, one of
the world’s first successful total hip replacements, performed by
Charnley using a hip of his own design. ‘This is truly a
marvellous climax to my series of more than seventy cases,’ he
wrote in his journal, referring to post-mortem examinations he’d
already done on his early patients. To have his prototype hip
work smoothly inside someone for almost twenty years and still
be, as he described it, in perfect condition, gave him joy.
The first generation of NHS surgeons were front-line surgeons
in a literal sense. In 1940, aged twenty-nine, Charnley went to
France as a military medic with the makeshift flotilla evacuating
British troops from Dunkirk. ‘He didn’t expect to survive,’ his
widow said. ‘The boat he was in was bombed or shelled. I
remember him saying to me that this was the point when he
believed he’d been saved for a purpose.’
The foundation of the NHS in 1948 coincided with a golden
era in the struggle against infectious disease. In postwar Britain,
orthopaedic surgeons earned their spurs in hospitals built in the
countryside as sanitoria, designed to deal with the bone and
joint problems caused by tuberculosis and polio. But the
incidence of these infectious diseases was dropping. Casting
around for new reasons to be, the bone doctors fastened on
arthritis.
Up to this point, the options for people with a dodgy hip
were limited. Basic human actions – walking, getting up, sitting
down – require smooth movement of the femoral head, the
ball-like top of the thigh bone, against the cup-like socket in the
pelvis known as the acetabulum. When it works as evolution
made it, it is because socket and head are sheathed in a
smooth layer of cartilage that secretes a natural lubricant called
synovial fluid. Inflammation, fractures and swelling make the hip
jam and chafe like a rusted-up hinge. The result is immobility
and pain. By the 1950s, it was becoming fairly common to cut
off the degraded top of a patient’s thigh bone and replace the
femoral head with one made of metal or ceramic. Other
surgeons focused on the acetabulum: they lined damaged hip
sockets with cups made of steel, chrome alloy or glass. What
was missing was a reliable way of replacing both head and
socket. It had been tried in the 1930s, with the two parts
made of metal, but it had never really worked.
Charnley charged at the problem with zeal. A grammar school
boy from Bury, he was a charismatic dynamo, a brilliant
explainer given to anger when thwarted. He was so obsessed
with bone growth that he got a colleague to cut off a piece of
his shin bone and regraft it, just to see what would happen.
(He got an infection and needed another, more serious
operation.) Imbued with technocratic patriotism he carried a
torch for the British motor industry and saw parallels between
car and human engineering. Jill Charnley remembers him
roaring down to London in his Aston Martin – a brute of a
car, a good engineering car’ – to visit her. He told her he was
redesigning nature, and illustrated his theories with ball bearings
from the British Motor Corporation’s new Mini.
They were married in 1957 and Jill moved into his medical
digs in Manchester, where the wallpaper had a bone motif.
Keen to avoid the communal dining-room, with its clientele of
fusty bachelor surgeons, she tried the kitchenette. ‘I went in
and opened the first cupboard,’ she said. ‘I was literally
showered with old bones and all sorts of screws and bits and
pieces’
Human bones?
‘Oh Lord, yes.’
After noticing that a patient with a French-made acrylic ball
fitted to the top of his thigh bone gave off a loud squeaking
whenever he moved, Charnley realised that a complete hip
replacement would work only when the head was firmly held in
place and when materials were found that mimicked the
low-friction, squeak-free movement of a natural hip joint.
His first attempt was a steel ball, smaller than the usual
prostheses, attached to a dagger-like blade that was pushed
through the soft core of the thigh bone and held in place with
cement, like grout round a tile. For the socket, he used a
Teflon cup. He put the experimental hip in about 300 patients.
It was a disaster. After a few years tiny particles of Teflon
shed by the cup caused a cheesy substance to build up
around the joint. The blade came loose in the bone. Pain
returned. Each one of the Teflon hips that Charnley had so
laboriously put into his patients had to be removed and
replaced. He did the work himself. His biographer, William
Waugh, quotes a colleague as saying the sight of Charnley
going to each operation was ‘like observing a monk pouring
ashes over his own head’. Punishing himself further, Charnley
went around for nine months with a lump of Teflon implanted
in his thigh to observe its effects.
In May 1962 a salesman turned up at Wrightington trying to
flog a new plastic from Germany, a kind of polyethylene, used
for gears in the Lancashire textile mills. It proved many times
more hard-wearing than Teflon. Only after implanting a chunk
of polyethylene into his much-scarred legs and leaving it there
for months was Charnley prepared to risk putting it in patients.
It worked. The procedure was taken up around the world.
Now, each year, hip replacements free millions of people from
pain and immobility. The operation has a success rate of about
95 per cent. It lacks the life-saving glamour of brain surgery,
resuscitation of car-crash victims or new cancer drugs. It is
something more remarkable, a radical and complex operation –
involving the sawing of bones, the deep penetration of skin and
muscle, extreme measures to prevent infection and the
replacement of a vital body part with a synthetic substitute –
that transforms the lives of its beneficiaries, yet has become
routine.
Making artificial hips – and knees, and elbows, and shoulders
– has become a multi-billion-pound global business. But it was
in the austere conditions of an old TB hospital in Lancashire, in
the state-run NHS, not in the well-funded, commercially
competitive world of American medicine, that total hip
replacement was pioneered. To make the first machine to mass
produce polyethylene cups, Harry Craven, a young craftsman
who worked for Charnley, scavenged odds and ends from a
local scrapyard. In their book A Transatlantic History of Total
Hip Replacement Julie Anderson, Francis Neary and John
Pickstone argue that by putting surgeons on state salaries, the
NHS freed them from dependence on private patients, giving
the innovative among them the security to experiment. Charnley
was only the most successful of a string of British
surgeon-inventors who designed effective hips in the 1960s and
1970s.
Born in the NHS, routine hip replacement, the small family
car of medical procedures (the first Morris Minor went on
show two months after the NHS began), became the marker
of the Health Services life stages. Stoical postwar patients,
grateful to have their pain relieved and used to rationing and
queues, gave way to a less accepting generation comfortable
with the label consumer’. Charnley described his first patients as
pitifully grateful’ for the relief from pain his short-lived Teflon
hips gave them. By the end of his life, he was ranting against
the crass ignorance and stupidity’ of Britain’s consumerist
peasants’.
People were living longer, so they were older for longer.
Demand for the procedure rose faster than the number of
surgeons and hospital facilities to carry it out. In 1982 a fifth
of patients waiting for a hip replacement had been waiting a
year or more. Supporters of the NHS pointed out, correctly,
that the service wasn’t getting enough money to satisfy patients,
and was underfunded compared to its European peers; yet the
huge waiting list for hip surgery, much greater than for any
other procedure, was used by Thatcherites throughout the
1970s, 1980s and 1990s as evidence that the NHS was
inefficient. When New Labour came in and hosed money at
the problem, waiting times fell. Private companies, rather than
the NHS, picked up a significant portion of the extra work. Hip
replacements, the life-enhancing procedure that came out of the
Welfare State, became one of the main points of entry through
which private health firms were undermining it.
Once you start writing about hip joints, you begin to notice
the number of people hobbling and limping. Everywhere you
look there seems to be an aluminium walking stick. On the
train from Liverpool to Birkenhead one day I got into
conversation with a couple of women in their forties whod got
onto the train with the help of sticks. One of them was waiting
for a hip operation. The procedure was delayed longer than
usual because she was trying to align two specialists. She
couldn’t get an orthopaedic surgeon to do her hip until she’d
seen an endocrinologist to sort out another problem. I asked
her whether she’d heard of the new centre in Runcorn
specialising in joint replacements. Her eyes lit up: brand
recognition. ‘People tell me I should go there,’ she said. I had
to tell her that the Runcorn centre had just closed, only five
years after opening.
The costly fiasco of the Cheshire and Merseyside NHS
Treatment Centre, to give the Runcorn clinic its proper name,
was a typically post-Thatcherite episode. Governments now so
idealise the private sector that just allowing private firms to
compete isn’t enough. New Labour believed it had to pay
private companies to compete with their state rivals. The
Runcorn clinic was one of a wave of ‘independent sector
treatment centres’ – ISTCs – masterminded by a Texan private
bureaucrat called Ken Anderson, recruited by the Department
of Health in 2003 to shower private firms with gold in order
to bring down NHS waiting lists.
A firm called Interhealth Canada was given a five-year
contract to run the Runcorn ISTC, starting in 2006. It built a
state of the art joint replacement clinic, designed and equipped
to the highest standard, but it didn’t have to pay for it: the
entire £32 million cost was refunded by the taxpayer. In case
this wasn’t enough to keep the entrepreneurial tiger of
Interhealth happy, the PCTs in Cheshire and Merseyside who
were supposed to send NHS patients to the centre had to pay
Interhealth 25 per cent more than the NHS rate to carry out
the operations. If an operation went wrong, however,
Interhealth wouldn’t be expected to put it right. Initially, it
wasn’t asked to take any responsibility for training doctors
either. The cherry on the cake was that it would be paid for a
minimum number of procedures, no matter how many it
carried out. Over five years, the firm happily accepted about £8
million for work it didn’t do.
Once the five years were up, the PCTs decided they’d had
enough, and told Interhealth its contract wouldn’t be renewed.
In 2011 the centre’s 165 staff were made redundant and the
ISTC closed. The building reverted to NHS control and was
moth-balled. When I spoke to Interhealth’s boss, Fred Little, it
hadn’t been decided what would be done with it; Little said it
would probably end up as a primary care clinic – ‘like using a
luxury hotel as a garage’, he told me bitterly, denouncing the
NHS as a Soviet relic. According to a spokesman for the PCTs,
Interhealth was offered a contract extension in 2009 provided it
accepted the NHS rate for operations. It declined.
Dr Abhi Mantgani, a GP in Birkenhead, used to send patients
to the Runcorn centre. It was fifteen miles away but his
practice laid on transport for patients. Mantgani didn’t like it
that local GPs weren’t consulted before it was opened; nor
does he like it that, just when patients were getting used to it,
the place was shut down. ‘The service at the ISTC was
fantastic,’ he told me when I visited him in 2011. ‘Patients only
had to go twice, first as outpatients for all the diagnostics, then
they got a date for the operation and went in for surgery.
Why can’t NHS hospitals provide the same level of quality
service?’*
Mantgani, who was born in India, had been a GP in
Birkenhead for twenty years. His base was a smart new
medical centre, light, bright and clean. Ambitious and articulate,
he had an air of busyness and impatience with institutional
inertia. He’d been navigating local health politics for a long time.
To GPs, patient choice was old hat already. He was eager to
move on. Being able to choose a hospital wasn’t enough if you
couldn’t also choose a consultant. Having the power to
commission a certain number of hip operations wasn’t enough,
either. Mantgani wanted to be able to commission packages of
care’: to get a hospital to assess a patient, take them in for
surgery, make sure their home had any necessary adaptations
and check on them regularly after the op, Kaiser-style. And he
wanted to get more tests out of hospitals into local clinics.
‘Waiting six or eight weeks for an endoscopy is just not
appropriate in a Western democracy,’ he said. ‘I think the NHS
is a great system but I don’t think it can remain the way it
is... in vast parts of the country there is no proper choice and
it is a cartel. And that leads to patients being given what
clinicians think is the right thing to do. I’m not for wholesale
creating this into some kind of private industry. But I think if
various other models of working act as the grit in the oyster to
stimulate better performance, better competition and choice for
the patients, it’s not a bad thing at all.’
Actually, there was no sign of a cartel in the Wirral. I
punched the postcode for Dr Mantgani’s surgery into the NHS
Choices website, together with ‘hip replacement’. Under the
changes brought in by Labour, patients could choose from five
hospitals within five miles and fifty-nine within fifty miles.
Wrightington, nineteen miles away, was the twenty-first closest.
The closest was the Wirral’s NHS hospital, Arrowe Park, three
miles away; just across the Mersey was the Royal Liverpool
University Hospital; the closest private hospital, the Spire
Murrayfield, was only slightly further away. The site suggested
you’d have to wait eleven weeks from referral to treatment at
Arrowe Park, seven weeks at the Royal Liverpool and only five
if you went to Spire. On the other hand, Spire doesn’t have
the full range of emergency services should something go
wrong; nor is it likely to take difficult cases. If my hip was
hurting like hell, I’m not sure I would want to take these
choices on myself. Why should I? Like most patients, I’m not a
doctor. Dr Mantgani admitted: ‘The patient often says: “You tell
me where I should go.”’
Dr Mantgani was a believer in the new order, and since I
met him power has shifted his way. The websites of the PCTs
that opened and closed the Runcorn ISTC have gone dark.
Health services on the Wirral peninsula are now ordered up by
a body called the Wirral Clinical Commissioning Group, which
supervises three consortia of local GPs; Mantgani is chief clinical
officer, ultimately responsible, with his chairman, another local
GP, Phil Jennings, for a budget of £445 million. Just before the
group began its work, its board agreed a pay rise for the two
family doctors of 5 per cent, to £112,000 each. A few months
later Jeremy Hunt, Andrew Lansley’s successor, told rank and
file English NHS workers that a one per cent pay rise was
unaffordable.
After meeting Mantgani I got back on the train and went to
Hoylake, on the western coast of the Wirral. At the oceans
edge an immense beach stretched out towards the horizon. I
could just make out a line of wind turbines turning there,
scratching the air as if it held an eternal itch. In a cafe I met
John Smith, director of studies at Liverpool University Medical
School, a shy, rather noble-looking man with shoulder-length
grey hair. ‘I’m not sure in many ways what choice means,’ he
said. ‘Most patients might want to choose their consultant, but
they want them to be in the local area, so actually choice isn’t
nearly as great as it might appear. As soon as you start
introducing choice, you start introducing league tables,
short-term targets and less of an overall pattern of healthcare.
On the one hand, they want to say, “Let’s have a market
economy,” but on the other they want to say: “Let’s plan.”
Realistically, you can do one or the other reasonably well but
you can’t do both. As soon as you have freedom of choice the
market will decide the outcome. Even when you give GPs
budgets, what does the GP do if he gets several patients who
demand very expensive treatments?’
Whomever I spoke to, and whatever they thought of the
latest NHS upheaval, the conversation turned to the cruel
paradox of the Health Service: the more successful it is in
lengthening life, the more threatened it becomes. ‘When the
Health Service was started the average retirement age was
sixty-five, and life expectancy was sixty-seven,’ Smith said.
‘Much as I hate to say it, the issue of pensions is the issue
that pervades the whole political affordability question. Unless
people become surprisingly more productive, we are all going to
have to work longer in order to maintain our standard of
living. Someone is going to have to pick up the costs of looking
after people who are being kept alive but whose ability to look
after themselves is declining.’
To respect the NHS isn’t to love it unconditionally. There can
be few people who haven’t experienced a moment of
uncaringness or worse somewhere in the system. Monopolies,
state or private, get complacent, and can resist good changes;
perhaps the general hospital is over-fetishised in this country. At
Stafford Hospital, a small general NHS hospital, patients died
unnecessarily between 2005 and 2009 because they were
neither cared for nor cared about. Robert Francis’s last report
into the horror for the government began by describing a
culture focused on doing the system’s business – not that of
patients’ Patients went unwashed for weeks on end, went
hungry and thirsty, were left to soil their bedclothes, were sent
home before they were well. It was terrible. It was also
exceptional. And as Francis made clear, for all the terrible
failings of the NHS system and the personal sins against
human decency committed in Mid-Staffs, a significant factor in
the catastrophe was hospital management’s determination to
conform, at all costs, to Labour’s new competitive framework, a
framework the Tories and their Liberal allies have embraced.
Past commercialisations and privatisations of state monopolies
don’t give confidence that a commercialisation-privatisation of the
NHS would have a happy outcome. Competitive pressures can
reduce choice as well as encourage it. You can give patients
choice, but someone else chooses the choices. One of the
things businesses do is merge and consolidate and already
foundation trust hospitals are doing just that. In East London,
for instance, six hospitals – Barts, the Royal London, Whipps
Cross, Mile End, Newham and the London Chest – have
merged to create Barts Health, the largest NHS trust in Britain,
with a turnover in 2013 of £1.25 billion. The London Chest has
long been scheduled to close, but the other five hospitals are
only a few miles apart. It seems unlikely they will all continue
to offer all the services they do now. Foundation trusts often
consist of more than one hospital, and one of the hidden
implications of the Milburn-Lansley programme is that a strong,
solvent, ambitious foundation trust has as much incentive to
shut down one of its hospitals (in order to remain solvent and
grow elsewhere) as a financially weak one.
The more for-profit companies become involved in the NHS,
the more public money will leak out of the health system in
the form of dividends. And the government is taking a risk.
When it privatised the water industry, it effectively farmed out
to the water companies the tax increases needed to pay for the
renewal of the country’s Victorian water infrastructure. When it
privatised the electricity firms, it farmed out the tax increases
needed to fund wind farms and new nuclear power stations.
By commercialising the NHS, but promising to keep on paying
for it, it doesn’t leave room for manoeuvre in the health
marketplace when competitors start encouraging patients to
demand more expensive procedures.
One day I visited Edward Atkins, a retired bank manager, at
his home in East Molesey in Surrey. The modern redbrick
bungalow where Atkins and his wife live is about twenty
minutes’ walk from Hampton Court station, long enough for me
to appreciate the boon of properly functioning hips and knees.
Atkins answered the door, a tall, solidly built man with a full
head of hair who could easily pass for sixty-five. In fact he’s
eighty. He’d still be playing tennis if he could. As he describes
it, much of his life seems to have run on rails, making all the
stops and adhering to the timetable of respectable, decent,
middle-class life in the comfier corners of postwar southern
England. Born in Portsmouth, he did National Service, then got
a job as a trainee at Lloyds. He married, had children, got a
mortgage, rose through the ranks and retired on an indexed
pension at two-thirds of his final salary. His retirement began
well. He played badminton, golf and tennis. Then, in his early
seventies, he felt aches and pains in his right knee and groin.
A cyst was removed from his knee, but he was told the knee
was fine; perhaps the problem was his hip? In 2005, with the
groin pain getting worse, Atkins, who has private insurance,
went to see a consultant, Andrew Cobb.
Cobb, a distinguished orthopaedic surgeon doing a mix of
private and NHS work, recommended a hip replacement of a
new design called ASR, produced by the American company
DePuy, a subsidiary of Johnson & Johnson. Apart from being
more expensive, the ASR hip differed from the total hip
replacement pioneered by John Charnley in two ways. Both
surfaces, ball and cup, are made of cobalt-chromium – a
so-called ‘metal on metal’ hip. And instead of cutting off the
top of the thigh bone and pushing a spar deep inside the
bone to hold the ball of the joint in place, the ball is a hollow
hemisphere with a short stalk, like a mushroom, designed to
cover the ball at the top of the femur rather than completely
replace it. Hence the claim that the hip is not being replaced,
merely ‘resurfaced’.
Resurfacing means less bone is lost than in a full
replacement. Even the most successful conventional hip
replacements seldom last much beyond ten years, and it’s
easier and safer to put in a total hip replacement after a
resurfacing than to put in one replacement after another. In
other words, hip resurfacing is seen as ideal for the young and
the active, people who are generally healthy and are likely to
wear out at least one hip device. The DePuy ASR hip was
marketed aggressively as a hip hip. A device with its origins in
the basic need to eliminate pain and enable movement seemed
to be entering the realm of lifestyle marketing.
Cobb pitched hard for the ASR hip, as Atkins remembers it,
telling him the hip had ‘just come out’, that in a matter of six
weeks he’d be playing golf again, even tennis. ‘He said I
wouldn’t be able to play properly unless I had this operation.’
But the clincher, for him, was a marketing video from DePuy
showing a series of real people who were seemingly thriving
with ASR hips. ‘There was a golfer putting putts down from
twenty-five yards. At the end there was this guy apparently the
coxswain of a West Country lifeboat, at the wheel of the actual
lifeboat in very rough seas’
What Atkins didn’t know was that Cobb had helped design
the hip he was promoting. Impressed by the video, he signed
up for the operation. He was about to become a victim of
what has been called ‘one of the biggest disasters in
orthopaedic history’. From the moment he went home, he felt
something was wrong. ‘All I know is my hip started clicking
like mad after I got in a certain position. It was never really
right.’ The hip became inflamed, and the pain began. If he
exerted himself – went out on his bike, for instance – his hip
would swell up afterwards and start to hurt. He kept making
appointments to see Cobb, who would reassure him. Atkins had
already paid £2,000 for the operation, the part of the £14,000
procedure his insurance wouldn’t cover. But every time he went
to see Cobb, he had to pay more than £200 for a
consultation. In the end, on his GP’s advice, he ambushed the
surgeon at a walk-in NHS clinic he ran. Cobb agreed to
replace his ASR hip with a regular, Charnley-style hip, using
NHS money. By this time Atkins had been living with the pain
for four years: ‘Four years that blighted my life and that of my
wife. I couldn’t sit; I couldn’t stand. I was on 500 mg of
ibuprofen twice a day. Since that operation I really haven’t
played any sport at all.’
The ASR hip wasn’t the only resurfacing option for Atkins in
2005, but he didn’t know this. The John Charnley of hip
resurfacing is a Birmingham-based surgeon called Derek
McMinn. In 1997, after six years of trials, he put a hip
resurfacing device, the Birmingham hip, on the market. Now
made in Warwick by the British multinational Smith & Nephew,
it has been used with relatively few problems around the world.
The DePuy hip was designed explicitly to compete with the
Birmingham hip – a device that did the job perfectly well. It
could have been an improvement; it turned out to be anything
but.
In 2005, the year Atkins was given the ASR hip, McMinn
made a prescient attack on the rival product at a conference in
Helsinki. He warned that the groove DePuy had cut around
the edge of the metal hip socket meant greater pressure on
the rim as patients moved around, making it more likely metal
debris would shear off and enter soft tissue. It might have
been dismissed as the posturing of a rival, but disturbing
reports were beginning to come in from Australia about
problems with the hip.
The French authorities rejected the ASR in 2008, and though
US regulators never approved it, the rules allowed American
surgeons to implant it anyway. In Britain, the feeble agency that
is supposed to monitor medical devices, the MHRA, didn’t act.
An investigation by the British Medical Journal pinpoints an
early adopter of the ASR, Tony Nargol, a surgeon in
North-East England, as one of the first to question its safety.
He began getting bad feedback from patients in 2007. When
he opened them up to investigate he was shocked to find that
flesh and muscle around the hip had been destroyed; in some
cases bone, too, was damaged.
Just as McMinn had warned, the ASR was shedding tiny
fragments of cobalt-chromium, producing a devastating reaction
in some patients. Further trouble was caused by individual
atoms of cobalt and chromium leaching into patients’ blood and
spinal fluid. The evidence against the ASR began to escalate,
but it was only in August 2010 that DePuy admitted defeat
and issued a general recall of the hip. By that time the
company had sold tens of thousands of the devices around the
world. As lawyers began to gather clients for litigation, the scale
of the disaster became apparent. Some of those who had
signed up for the ASR in the hope of another twenty years of
dancing or running or tennis may be permanently disabled. In
March, British surgeons who had studied more data on the
ASR suggested that a second version of the hip, designed for
total hip replacement, would probably fail in half of cases after
just six years. About 10,000 ASR hips were implanted in the
UK. ‘The really unlucky ones are those about fifty or fifty-five
who had it done to extend their working careers,’ Atkins said.
‘There’s no way they’re going to work again.’
‘I never made any secret of the fact that I had been one of
the six surgeons contributing to the design of the ASR,’ Cobb
wrote to me in an email: ‘Certainly, most of my patients were
aware of this. I can’t remember exactly what was said to Mr
Atkins before his first operation but I usually discussed the
proposed use of the ASR, the advantages I perceived to be
offered by it over the Birmingham device, and the further
information available on the Internet. I have no knowledge of a
lifeboat coxswain featuring in any advertisements’
The disturbing issues raised by the ASR hip fiasco – why
was DePuy not obliged to test the device more rigorously by
the authorities in Britain? Are other metal on metal hips a risk?
– obscure a deeper question. Why are medical implants being
marketed like iPhones, as in Smith & Nephew’s video for the
Birmingham hip at rediscoveryourgo.com, where to the
accompaniment of a driving guitar track, strong, shadowy dudes
with artificial hips ski, play football and climb rock faces?
The progressive justification for the current changes to the
NHS, expressed by people like the former Blair adviser Julian
Le Grand, now on the board of trustees at the King’s Fund, is
that the only true recourse for patients who experience
incompetence, rudeness, slovenliness, patronising behaviour and
uncaringness by public servants is the power to send a
message to the offenders by taking their custom elsewhere.
Hence the ideal of ‘choice’. But the weakness of the British
authorities in the face of the ASR hip, and the ease with which
DePuy salespeople persuaded British surgeons to use the ASR
implant when tried and tested alternatives were available,
doesn’t suggest the people who run our health system have a
clear idea of the difference between ‘choice’ and ‘marketing’.
In 1993, an op-edpiece by three surgeons in the BMJ pointed
out that a significant cause of long waiting lists for hip
replacements was that hospitals blew their orthopaedic budgets
on expensive new kinds of joint implant whose increased cost
couldn’t be justified on medical grounds. Much of the cost of
the latest medical devices, like the cost of a can of Coca-Cola,
went towards the marketing propaganda without which it would
never occur to you to buy them. The article’s parting barb –
‘the implant industry remains a haven for all the excesses of
free enterprise’ – still applies. A recent report by Audit Scotland
(where the NHS more closely resembles its pre-Enthoven form)
noted that in Lothian, the average cost of a hip implant was
£858. In neighbouring Forth Valley, NHS joint buyers were
paying more than twice as much. In the US, a basic
Charnley-style hip implant will now set you back $10,000, or
£6,100. Another type of hip has gone up in price there by 242
per cent since 1991, when inflation has been only 60 per cent.
The authors of Transatlantic History point out that some of the
cheaper hips used in Britain aren’t sold in the US, even though
they’re made there. Many surgeons and consumers want the
best, they say, ‘but when that which is properly known to be
“the best” is ipso facto old technology, the best may come to
mean “the latest”, and the latest may prove to be expensive
failures’
‘There is no reason,’ Aneurin Bevan wrote to doctors as the
NHS came into being, ‘why the whole of the doctor-patient
relationship should not be freed from what most of us feel
should be irrelevant to it, the money factor, the collection of
fees or thinking how to pay fees – an aspect of practice
already distasteful to many practitioners’
I asked Martyn Porter how a place like Wrightington could
survive in the marketplace if Porter the commercial manager
failed to stop Porter the surgeon carrying out loss-making
operations rivals wouldn’t do. ‘I came into medicine because if
someone’s injured, I want to fix them,’ he said. ‘Someone’s
going to fix them. Why not us? Secondly, you never get good,
you get a little bit better. It’s necessary at my age not to get
bored. I’m just getting warmed up. However, the most
important issue is the finance. We get a lot of money from the
cheap and cheerful procedures, we take a hit on others. The
managers are cool with that, as long as we’re getting a
reputation as a centre of orthopaedic excellence.’
The phone rang. The patient was ready. Porter wanted to
talk some more about the Lansley project. ‘I think there’s a
model there, but it’s whether it can be delivered and won’t be
corrupted. I can see a very idealistic model, but by God, it’s
vulnerable to people ripping it off.’
Jill Charnley, now in her eighties, is the contented recipient of
two artificial knees. They’ve lengthened her life, she says. Her
shoulder gives her trouble and she could, if she wished, have a
prosthesis put in for that, too, but she’s made the choice not
to. She’s drawn the line, partly because of the physiotherapy
involved and partly because she knows there’s a limit to what
medicine can achieve. ‘We are all getting old,’ she said, ‘and
bits of us wear out.’
There is only money in more, or in getting something. There
is no money in less, or in getting nothing, even though less
and nothing is everyone’s eventual fate, and may be desirable
long before that. The NHS can’t avoid dealing with the financial
consequences of its own success in enabling people to be old
for longer and longer. But it can avoid becoming a victim of
marketing.
In The Charterhouse of Parma, Stendhal wrote: ‘The lover
thinks more often of reaching his mistress than the husband of
guarding his wife; the prisoner thinks more often of escaping
than the jailer of shutting his door; and so, whatever the
obstacles may be, the lover and the prisoner ought to succeed.’
In the governance of Britain, it is as if the marketeers have
internalised a modern version of this. The salesman thinks
more often of making a sale than the consumer thinks he is
being sold to; the lobbyist thinks more often of his loophole
than the politician thinks of closing it; and so, whatever the
obstacles may be, the salesman and the lobbyist are bound to
succeed.
* The Runcorn Centre was reopened in 2013 by Warrington
and Halton Hospitals foundation trust to provide the same
service as the ISTC, but within the NHS system.