by James Meek
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-ed piece 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 for
m) 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.
6. No Vacancies
Privatised homes
A housing shortage that has been building up for the past thirty years is reaching the point of crisis. The party in power, whose late twentieth-century figurehead, Margaret Thatcher, did so much to create the problem, is responding by separating off the economically least powerful and squeezing them into the smallest, meanest, most insecure possible living space. In effect, if not in explicit intention, it is a let-the-poor-be-poor crusade, a Campaign for Real Poverty. The government has stopped short of openly declaring war on the poor. But how different would the situation be if it had?
Look at things from Pat Quinn’s point of view, for instance. What’s being done to her is happening quite slowly, over a period of months, and is not the work of a gang of thugs breaking down her door and screaming in her face, but is conducted through forms and letters and interviews with courteous people who explain apologetically that they’re only implementing a new set of rules. At the age of sixty, having worked for thirty years before being registered as too unwell to work, Pat Quinn is effectively being told that she’s a shirker, and that the two-bedroom council flat where she’s lived for forty years and where her husband died is a luxury she doesn’t deserve. She’s been targeted for self-eviction. Essentially, the government is trying to starve her out. Without the government allowance she receives in the form of housing benefit, she cannot pay her rent, and the government has cut the allowance so it’s no longer enough to cover the rent on a two-bedroom council flat. It’s just enough for a one-bedroom flat – a theoretical, but actually non-existent, one-bedroom flat. This is what the ‘bedroom tax’ means.
‘It’s just very, very hard to deal with,’ Quinn told me when I visited her. ‘This is my home, this isn’t just a council place where I live. They can only do it to me because I have nothing. I’m sure if they had their way they would cull us. I really believe that.’
It wouldn’t be so tough on Quinn if her municipal landlord, the borough of Tower Hamlets in East London, or one of the local housing associations – not-for-profit groups offering low-rent homes – or their counterparts in neighbouring boroughs, or the private sector, had affordable one-bedroom flats to spare. They don’t. As I write this, the cheapest one-bedroom private flats in Quinn’s area cost £240 a week including council tax, at the very edge of the new maximum the government is willing to subsidise for a single person. Demand is intense – they don’t stay on the market for more than forty-eight hours, as a rule – and since, under the new rules, housing benefit will be given to the tenant rather than directly to the landlord, private landlords will be warier than ever of letting to benefit claimants.
The old council house waiting list no longer exists. Now areas run waiting lists for ‘social housing,’ a pool of council and housing association properties at subsidised rents. In Tower Hamlets, there are 22,000 people on the list. A significant number of them will have families, so it’s hard to know how many individuals the figure represents, but it corresponds to a fifth of all households in the borough. Of this 22,000, 10,000 are waiting for a one-bedroom flat. Five hundred of them have been waiting twelve years or more. How many one-bedroom flats became available in Tower Hamlets in 2012–13? Just 840. Supply and demand have floated free of each other, and not only in the category of social housing. In the same year, the price of private flats for sale in Tower Hamlets went up by 5 per cent; in neighbouring Hackney, which has a similar demographic, it was a wild 15 per cent.
There aren’t enough homes in Tower Hamlets. There aren’t enough homes in London, in the South-East, in Britain. The shortage gets worse. Each year, population growth and the shrinking of average household size adds a quarter of a million households to the twenty-six million we have now. The number of new homes being built is barely above a hundred thousand.
To understand how it came to this, you have to go back to 1979, when Margaret Thatcher began forcing local authorities to sell council houses to any sitting tenant able and eager to buy, at discounts of up to 50 per cent. It was one of those rare policies that still seems to contain in its very name the entire explanation of what it means: ‘Right to Buy’. Cherished by Tories and New Labour alike as an electoral masterstroke, it offered a life-changing fortune to a relatively small group of people, a group that, not by coincidence, contained a large number of swing voters.
Right to Buy differed from the period’s other privatisations in many ways. It was tightly l
inked to the buyer’s personal use of the asset being privatised. If the Royal Mail had been sold on the same principle buyers would have got a discount on the share price based on the number of letters they’d posted over their lifetime. According to Hugo Young, Thatcher had to be talked into Right to Buy by a desperate Edward Heath, then her leader, who’d been persuaded by his friend Pierre Trudeau after his electoral defeat in February 1974 that he needed a fistful of populist policies. No wonder Thatcher baulked. Right to Buy violated basic Thatcherite values: that self-reliance was good, state handouts bad. Right to Buy was a massive handout to people who weren’t supposed to need handouts. In fact, that was why they got the handout – because they were the kind of people who didn’t need handouts.
It was Britain’s biggest privatisation by far, worth some £40 billion in its first twenty-five years. But the money earned from selling Britain’s vast national investment in housing – an investment made at the expense of other pressing needs by a poor country recovering from war – was sucked out of housing for ever. Councils weren’t allowed to spend the money they earned to replace the homes they sold, and central government funding for housing was slashed. Of all the spending cuts made by the Thatcher government in its first, notoriously axe-swinging term, three-quarters came from the housing budget.
