Elective Surgery

Junior doctors​ , who make up half the medical workforce in England, went on strike for 72 hours this week in protest at their low pay, long hours and dismal working conditions. One told me that her father earned more as a junior doctor in London thirty years ago: not just more in today’s money – more in the bank each month. Expectations for change are low. Not only are there great numbers of vacancies across the NHS, there seems to be little urgency to fill them. In London, for instance, NHS trusts have formed a sort of cartel, capping the pay any of them will offer locum doctors. This has the effect of putting off potential candidates (who wants to work an extra 13-hour shift for little more than their standard pay?) and demoralising core staff, as well as making hospitals unsafe for patients. Doctors quit and aren’t replaced: managers simply leave the slot empty; eventually it disappears from the rota.

One effect of the strike – a larger iteration of which took place during the pandemic – was the cancellation of routine hospital appointments, including elective surgeries. The NHS stopped collecting data during the worst of Covid, but a study by the medical research unit at Queen Mary University of London estimated that at least 1.5 million operations were cancelled or postponed. The delays led to further delays: at the end of December last year, more than seven million people in England were waiting for elective surgery (numbers had been increasing steadily since 2011, but leaped up after lockdown). The statistic contains multitudes: ‘elective’ can mean anything from cancer to cataracts to hernias to kidney transplants to joint replacements. It doesn’t mean the person isn’t in miserable pain or hasn’t had their life drastically curtailed, quit their job, abandoned their pleasures; it simply means they won’t die – at least not immediately – without it.

I was 23 when I was first diagnosed with arthritis in my right hip. It wasn’t the rheumatoid kind, which is what usually affects young people, but osteoarthritis: plain mechanical grinding down. It took a while to get the diagnosis. My GP said to wait in case the ache was muscular; months later I returned, and then waited for a hospital referral, first to rheumatology, then to orthopaedics. My cartilage was gone, the orthopaedic surgeon told me as he held up the X-ray. On one side was a slick layer of grey between ball and socket, on the other nothing: bone on bone, and bone spurs where the body had tried to cope by producing yet more bone, growing out to the side in delicate shafts, like icicles. I was dumbfounded by the verdict, by the intelligent stupidity of my own body, and humiliated, too. Arthritis – an old person’s disease.

The symptoms aren’t serious at first. If it’s your hip, then perhaps a clicking sensation when bending down to pick up the newspaper. I wasn’t really in pain but often had the odd feeling that I couldn’t safely land my foot or that my leg was frozen in place or falling through the floor. That was all: I staggered or got stuck and had to be helped. The cold had to become warm, the solid liquid. Muscles got tight and needed to be stretched. Then it would go away.

The surgeon wasn’t sure why it had happened. My joints were badly shaped, he said. My ligaments were lax. Hypermobility, genetics, gender. I shouldn’t have taken up running, yoga. The only treatment was a hip replacement and he thought I would need it before I was thirty. He reassured me – though I wasn’t much reassured – that they were much better than they used to be. That was that. No other solution, just surgery, to be put off, as I saw it, for as long as possible.

Each year I would return to see the same surgeon. Our appointments were brief, jovial, unsatisfactory. He would tell me to let him know when I was ready for the operation. But how could I be sure I was ready? When the pain was bad, I thought I was ready; when the pain subsided, I would be glad I hadn’t acted. Joint replacements don’t last for ever and the second is never as good as the first (less bone to work with). You don’t get a third. I did the maths: if a new joint lasts twenty years, and I could have two, that was two score years of mobility, more or less. For someone aged thirty, did that mean a wheelchair at seventy? Would I get lucky? Would science overtake my grim predictions? I looked for advice and anecdote, but mostly I lived with my complaint. A broken hinge, a crack in the crockery. My surgeon said the operation was elective, and I was electing to manage as best I could.

Things worsened suddenly last year. One morning in March, I woke up and couldn’t move. In A&E, the doctors ran every test and concluded nothing new. It was the same arthritis, the same single surgical fix. They took my pain seriously but all they could do was to give me morphine and a pair of crutches. Symptoms don’t always worsen steadily, they told me. Your house can shift slowly for years, then one day it collapses.

A new routine. You sleep downstairs. In the morning, you can’t move, at least not at first. You have to push through: once you start, things will be easier. Can you get to the medicine cupboard? Perhaps not, so let’s keep paracetamol beside the bed, ibuprofen, water, heat pads, muscle rub, walking stick, grabber. Set your alarm early. Set it earlier. Now naproxen, codeine, tramadol on the pillow. Then gabapentin for the nerve pain – the pins and needles, the cold water sensation – and diazepam to relax the muscles and omeprazole because naproxen gives you stomach aches. Diazepam helps, but it’s addictive, so you’re switched to robaxin. Things start to improve. You can’t stop the pills but at least you can move. Then one day, you step onto a stool to get something from a high kitchen shelf and the stuckness returns. This time you fall and you can’t get up. You don’t have your phone and no one hears you shouting. You lie there like Thora Hird, looking at the crumbs and fluff on the floor until someone comes home, brings you drugs and helps you up and tells you never to do that again.

The world shrinks and expands with the pain. You’re only half alive – a corpse adjourned, as Pessoa put it – and the living half is desperate. The attractions of drugs, of booze, of cutting off your leg or selling your mother, become indescribably sweet. I noticed, as someone who often couldn’t walk without crutches, how many others there were: old and not so old, bent, shuffling, limping, leaning on lampposts or resting at bus stops, waving buses on. There aren’t nearly enough bathrooms, rails, benches, ramps or slopes. Nowhere has properly supportive chairs: a moratorium on chairs! Crutches invite conversation, and the people who asked me questions usually assumed I had been in a car accident, perhaps a skiing accident. They were kind because my condition seemed anachronistic. Door were opened, bags carried. Taxi drivers quietly reset their meters when I was slow to get in. I hated and appreciated their sympathy, their saying in not so many words that this was not the natural order of things. It’s hard to imagine finding it any more bearable at eighty.

After the trip to A&E, I tried to bring forward my annual check-up. The clinic’s phones were still set to answering machine: an out-of-date message said that everyone was working from home. I emailed, and got no reply. I left a message; the same. It took some time, but eventually I was offered an appointment with one of my surgeon’s junior colleagues. He was delayed by the train strikes so we spoke on the phone: me in the busy hospital waiting room; he on the slow train from Brighton. I said that I couldn’t carry on and wanted to have the hip replacement as soon as possible. He agreed and told me that because of my age and degree of pain my case would be treated as urgent. But, he added, the Covid backlog and cuts to the NHS meant that ‘urgent’ wasn’t what it used to be, and I shouldn’t expect to hear from anyone that year. It was May. In twelve months, eighteen months, he said, someone would offer me a date for surgery.

Twelve months seemed unfathomable. If I had been hit by a car, they would have treated me right away. But afterwards I thought that even eighteen lost months were less significant for me than they would be for someone much older. Strength depleted in later life is far harder to regain. Every month of not exercising, of getting fatter, weaker or more dependent takes you further away from life as it should be lived. I could understand, though it seemed unfair, that pensioners are less of a priority than workers and parents, than the woman I met on the bus who was waiting for a knee operation and had been signed off from her job as a post office sorter because she could no longer stand up. I could recognise, too, that we are lucky to have such fine, brutal expertise: our surgeons wrench open joints and saw off bones and stick in pins and screw in metal and sew us up and we walk again. Even a couple of decades ago, I wouldn’t have been eligible for a hip replacement until I was much older (fifty at least); go back further, and I would have been a lame woman for life. The first recorded joint replacement was attempted in 1891, by a German doctor, Themistocles Glück, but they only became commonplace after the 1960s. I’m not sure I would have been brave enough to undergo the operation without anaesthetic and antibiotics, but I might have been desperate enough to submit to the pioneering techniques of Dr Smith-Petersen, in the 1920s, who replaced joints with glass (which shattered), or Dr McKee, in the 1950s, whose steel prostheses sent shards of metal into the patient’s body.

Their patients volunteered for surgery because their lives were such agony. We are more lucky, but our good fortune means little if the treatments that can help us aren’t available. As the suffering increases so do the numbers who go private in desperation. I am sure that in doing so myself I contributed to what seems the unstoppable drift to a two-tier system. But there is a further distinction. Private medicine isn’t cheap if you don’t have health insurance. Operations cost thousands of pounds and one survey conducted last autumn concluded that of the five million or so people who sought private treatment in the previous year, the majority weren’t insured. More than half said they just couldn’t wait any longer for the NHS and a similar number used their savings or went into debt to pay for it. The surgeon I saw privately also worked at the NHS hospital I attended; his Marylebone clinic offered me a date for surgery the following week. The biggest cost, I learned, is the hospital stay, which was more expensive than the Ritz. The differences seemed mostly superficial – better food, private room – but of course there were others: nurses not dropping with exhaustion; physiotherapists with time on their hands; smooth enough day-to-day functioning. It wasn’t glamorous; it seemed the sort of care that ought to be available to everyone.

My operation took place last August. In January, I had a final check-up. Recovery successful; discharged for the foreseeable future. I have started counting down the years to the next one – nineteen to go – but nonetheless, I’m relieved. The same day, my NHS hospital rang up. Although I had asked them to take me off the waiting list, no one had done so, and the receptionist was phoning to tell me that, eight months after my operation was deemed urgent, they still didn’t have a date for my hip replacement. She apologised. Could they move me to another surgeon’s waiting list? Otherwise I might not get treated this year.

The timing was a coincidence but it made vivid the counterfactual. In the other world, I was still on crutches; in this one, I was free. There I was still racked with pain, sleep-deprived, drugged to the hilt; instead I am myself again. The last day of the doctors’ strike coincided with the spring budget. Around half a million teachers, civil servants, lecturers, Tube drivers and others were striking too. In his speech, the chancellor announced no extra money for the health service and said nothing about how the government intends to find more doctors or improve their pay and conditions. He said nothing about the anguish driving a private sector bonanza or the surgeons who earn thousands of pounds a day in private practice. While he was at the dispatch box, I was at the office, editing the LRB. In the other world, I was still lying on the downstairs bed at home, shaking my futile fist at the TV.

17 March