Private Island: Why Britian Now Belongs to Someone Else (24 page)

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 Durée, 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 modérateur
, 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 Jill 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 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'.