It’s already happened

James Meek

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 ‘now’ of the time of writing is not the ‘now’ of two weeks hence. 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 last year when the reorganisation itself was reorganised. Nonetheless, it still functions, halfway between the system it was and the system Lansley wants it to be. The way it works, crudely speaking, is this. Every so often – it may be every year, or every two or three – the Department of Health is asked to make its pitch to the Treasury for the amount of money it thinks it should get from the overall tax pot, and then is told how much it will actually get. Most of the money comes from general taxation – income tax, VAT, corporation tax, duties on booze and tobacco – but a proportion comes directly from National Insurance, a vitiated form of the link between NI and the Welfare State that its architects intended. In the most recent spending round Health got £101.5 billion for next year, a slight increase. Most of it – £89 billion – will be divided up between about 150 local agencies called Primary Care Trusts, or PCTs, spread around the country. PCTs act as the ‘commissioners’ of health services, ordering a community’s medical care from hospitals, GPs and mental health professionals and paying them accordingly.

PCTs can use NHS money to commission care from the private sector. They’re under no obligation to shop locally, either. The fact that NHS patients are now allowed to choose private or far-away hospitals for treatment means the PCTs are obliged to commission from them. NHS hospitals like Wrightington have become dependent for their financial viability on the money they make from selling their services to the PCTs. Competition already exists.

The amount of money that PCTs get from the government varies. The Department of Health has a panel of civil servants and academics called the Advisory Committee on Resource Allocation, Acra, which comes up with a formula for working out the health needs of each area – population size and density, the proportion of elderly people, life expectancy, the degree to which their health varies from the norm. In the poorer parts of Merseyside, for instance, where male life expectancy is 67, men can expect to be incapacitated by disability of some kind at the age of 44. The corresponding figures for the richer parts of West London are 89 and 74. The variation in the sums different PCTs get relative to their population is, accordingly, considerable. This year South Gloucestershire will receive £1298 per head, Islington in London £2268.

Primary Care Trusts were set up in 2002, but they’re on the brink of abolition already. If Lansley and the coalition prevail, the way money flows through the NHS will look different again in a few years’ time. It will still come from general taxation, but the money that now goes to the PCTs will be doled out instead by a new organisation, the NHS Commissioning Board, to bodies called Clinical Commissioning Groups, essentially clusters of GP practices. Across England, groups of family doctors will suddenly 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. It is anticipated that, lacking expertise of their own, many will pay private contractors to manage these funds for them.

By that time a series of other changes will have made ‘commission’ more of a euphemism for ‘buy’. At the moment, not everything a PCT commissions comes with a price tag. But within a few years almost all procedures, even those as seemingly amorphous and complex as caring for the mentally ill, will come in quantified, priced units. At the moment, hospitals aren’t allowed to compete with each other on price, and are rewarded with extra money from the commissioners if they do a particularly good job. Procedures are categorised as ‘healthcare resource groups’, each with a code and a price. Any hospital anywhere in England, NHS or private, that carried out procedure HA11C on an NHS patient last year – treatment of a routine hip fracture – got a base payment of £8928 from the outfit that commissioned it, and £9373 if it followed ‘best practice’. A maternity unit clocks £1324 for a regular birth, NZ01B; putting in an artificial heart, EA43Z, earns £33,531. But this isn’t the amount they actually get. The sum is adjusted according to a local ‘market forces factor’, which takes account of the variation in cost of labour and assets between different areas. The codes and prices are worked out, in turn, according to the actions taken and materials used by typical hospitals. The set tariff for treating a stroke might be calculated from the price of nine days being nursed in a ward at £170 a day, a couple of X-rays at £20 each, ten pathology tests at £6 each and six sessions of therapy for £235 – a total of £1865. If the hospital can treat the patient for £1600, it keeps the difference. The incentive to send the patient home as soon as possible is high.

Under the new system, state money will ‘follow the patient’ wherever the patient chooses to take it, even when that is outside the NHS. Patients with chronic conditions like diabetes will increasingly be given, not treatment, but money to spend on treatment. All NHS hospitals will be 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 will be legally binding. They will find themselves competing not only with other NHS hospitals and private hospitals but potentially with the GP groups themselves, which may set up local clinics to provide diagnostic tests or minor surgery. Alongside the NHS Commissioning Board two other quangos will 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.

Lansley chose 19 July, the day Rupert and James Murdoch had the media transfixed with their testimony to the Culture Select Committee, to let slip that from next April 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, will 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’. Throughout the latest 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 do not 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 last year’s Tory-Liberal pact. Labour, the party that created the NHS, which has pledged to defend it and has denounced the Lansley reforms, was in power for those 13 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? In fact, 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 Lansley and Cameron 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. The ‘internal market’ was rushed in, ignoring the views of the medical profession. It didn’t work. 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 one looks at what has happened over the last 25 years, the more clearly one can perceive 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 18 days a year advising Cinven, which owns 37 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, is now an executive vice president at UnitedHealth, one of America’s largest private health companies. Mark Britnell, a career NHS manager who rose to become one of the most powerful civil servants in the department, 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 3500 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.

It would be hard for a genuinely state-funded National Health Service to be as efficient as Kaiser Permanente because the NHS offers treatment to everyone, including the long-term unemployed and people with the rarest, most expensive conditions. Although it has a big charity programme, Kaiser only offers full, guaranteed care to those (85 per cent of the US population) covered by some form of insurance – the employed, those well-off enough to pay the premiums independently, and the over-65s who are covered by Medicare.

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, 12 and a half days after admission; Kaiser patients were home after four and a half. Kaiser doesn’t tie its consultants to its 35 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 (NHS lengths of stay in hospital have dropped 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. Earlier this year 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 is 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 still reflects the US model. Most people over 65 are eligible for Medicare, a kind of gold-plated American NHS for the elderly, but otherwise, if you have no insurance – you don’t have a job, you’re too poor, you’re gambling that you won’t get sick – you have no guaranteed access to Kaiser’s facilities. 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. President Obama’s healthcare reforms will make it easier to get Medicaid and will both compel and subsidise the earning uninsured to get insurance. But inequalities will remain.

If you’re insured in America, you have access to some of the world’s finest medical facilities, and if you have an employer to pick up most of the premium, it might seem to be a good deal. But just paying a premium each month doesn’t make healthcare free at the point of delivery. Two standard features of US health insurance 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. Kaiser’s Copayment 25 Plan, for instance, costs $487 a month for a 48-year-old living in San Francisco; that’s a high premium, and there’s no deductible. But every time you see the doctor, you have to pay $25; an ambulance is $100, a month’s supply of branded prescription drugs $35; you have to contribute $200 a day for a hospital stay, and so on up to a maximum of $2500 a year. At the other end of the scale, there’s a plan that costs $169 a month. That’s a bargain if you don’t get sick or pregnant (maternity isn’t covered.) But if you’re ill, you have to pay the first $5000 out of your own pocket. After that the copays kick in – $50 to see the doctor, and for hospital treatment, 30 per cent of the actual cost – until you’ve forked out $7500. As for prescription drugs, you’re on your own.

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 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). 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 78, two years older than American men; for women it’s 82 versus 81.

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 30 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 was 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.

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. 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 70 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 20 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 29, 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 told me. ‘The boat he was in was bombed or shelled. I remember him saying to me that 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 raisons d’être, 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 total hip replacement, 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 vile 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 one witness 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 device – 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. But it was private companies, rather than the NHS, that picked up much 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 Lime Street to Birkenhead recently, 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, only five years after opening, the Runcorn centre had just closed.

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. Earlier this year the centre’s 165 staff were made redundant and the ISTC closed. The building reverted to NHS control. It hasn’t been decided what will be done with it, but it’ll probably be some kind of primary care clinic – ‘like using a luxury hotel as a garage’, Interhealth’s boss, Fred Little, said to 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 15 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 said. ‘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?’

Dr Mantgani is a believer in the Milburn-Lansley continuum, and power is shifting to him. Page by page the websites of the PCTs that opened and closed the Runcorn ISTC are going dark. Health services on the Wirral peninsula will from 2013 be ordered up by three groups of general practitioners, and Mantgani is clinical leader of one of them. The Wirral Clinical Commissioning Group brings together 27 practices, covering 129,000 patients.

Born in India, Mantgani has been a GP in Birkenhead for 20 years. He is based in a smart new medical centre, light, bright and clean. Ambitious and articulate, he has an air of busyness and impatience with institutional inertia. He has been navigating local health politics for a long time. To GPs, patient choice is old hat already. He’s eager to move on. Being able to choose a hospital isn’t enough if you can’t also choose a consultant. Having the power to commission a certain number of hip operations isn’t enough, either. Mantgani wants 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 has any necessary adaptations and check on them regularly after the op, Kaiser-style. And he wants 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 wholescale 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.’

There’s 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 can choose from five hospitals within five miles and 59 within 50 miles. The closest is the Wirral’s NHS hospital, Arrowe Park, three miles away; just across the Mersey is the Royal Liverpool University Hospital; the closest private hospital, the Spire Murrayfield, is only slightly further away. The site suggests you’d have to wait 11 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.”’

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, where wind turbines seemed to scratch an eternal itch. In a chi-chi 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 65, and life expectancy was 67,’ 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, can get complacent, and can resist good changes; perhaps the general hospital is over-fetishised in this country. Yet past commercialisations and privatisations 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, five hospitals – Barts, the Royal London, Whipps Cross, Newham and the London Chest – are planning to merge. Merger or not, the London Chest is closing. But the rest are only a few miles apart. It seems unlikely they will all continue to offer all the services they now do after the merger. 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.

In late June 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 20 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 65. In fact he’s 80. 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 25 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 £2000 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 20 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 50 or 55 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 www.rediscoveryourgo.com, where to the accompaniment of a driving guitar track, strong, shadowy dudes with artificial hips ski, play football and climb rockfaces?

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 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.’

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.

[*] Merlin, 128 pp., £12.95, April, 978 0 8503 6679 2.

[†] Palgrave, 256 pp., £55, 2007, 978 0 230 55314 9.