Decision making in Orthopaedics. A reflection by proxy from Mrs Charnley. It is decentralisation that is leading to irrational decision making….

Centralisation of supply and decision making means that the larger mutual is considered before the local Single Interest Pressure Groups. This is a feature of the old National Health Service which has been destroyed by devolution, decentralisation and regional health services, and was an appropriate utilitarian response. Now we have many people (not doctors or GPs) on boards who do not have the high level ability to analyse the evidence…. It is decentralisation that is leading to irrational decision making, and post code rationing. Bear this in mind as the Welsh election debate builds up..

In 2011 James Meek in The London Review of Books wrote an essay entitled: “It’s already happened”.

Wrightington Hospital, in the countryside near Wigan, is an accretion of postwar buildings of different eras clustered round an 18th-century mansion. It was sold to Lancashire County Council in 1920 after the death of its last resident, a spendthrift, according to one writer, ‘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. Earlier this year 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 of the budget the private sector sets aside for corporate sheen, although it does have a museum dedicated to John Charnley, who, almost half a century ago, pioneered the popular benchmark of the NHS’s success or failure, the hip replacement operation.

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 fixed me with an intense, tired, humorous gaze. ‘The problem with politicians is they can’t be honest,’ he said. ‘If they said, “We’re going to privatise the NHS,” they’d be kicked out the next day.’

The Conservative Party’s 2010 manifesto promised: ‘We are stopping the top-down reconfigurations of NHS services, imposed from Whitehall.’ Two months later, the new health secretary, the Conservative Andrew Lansley, announced his plans for a top-down reconfiguration of England’s NHS services, imposed from Whitehall.

The patient whom Porter was about to operate on was a 60-year-old woman from the Wirral with a complex prosthesis in one leg, running from her knee to her hip. She’d had a fracture and Porter had had a special device made at a workshop in another part of the NHS, the Royal National Orthopaedic Hospital in 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 £5000. 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 1400 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 as if I’d somehow jumped forwards in time. Lansley has not yet, supposedly, shaken up the NHS. He’d barely been in power a year when I talked to Porter. 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 was to be universal: anyone and everyone would receive medical treatment whenever they needed it. It was to be comprehensive, covering all forms of healthcare, from dentistry to cancer. And it was to be ‘free at the point of delivery’: 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, including the present one, these principles have remained, along with another: that it’s never a bad time for a fresh reorganisation. Otherwise, much has changed.

The source of the money that funds the NHS is still, as in 1948, general taxation, and there are no plans to change this. For the first 30 years, civil servants in Whitehall and the regions doled out annual budgets to hospitals and GPs according to the size of the populations they served and an estimate of the scale of their health problems. 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 had 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.

It’s objectively hard to describe how money flows through the NHS now……..

…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 make one confident that 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 possibly be justified on medical grounds. Much of the cost of the latest medical devices, like the cost of a can of Coca-Cola, goes 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 £6100. 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 be 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.’….

…..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.

What sort of evidence do Trust Boards and CCGs listen to? The Single Interest Pressure Group and levels of evidence. Do Commissioners and Trusts have policies to cope with them? Case studies are not valid evidence.

Devolution of health to Wales was a mistake?

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