by James Meek
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 Service’s 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 who’d 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 mothballed. 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 ocean’s 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 café 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 mo
ney 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.
