Making sense of the NHS. Monday 26th March.

I was going to entitle this blog, ‘Too Old’ Too Young’ to focus-down on the age discrimination that is inherent in the allocation of hip replacement surgery. But it turns out that the NHS is considerably more perverse than this simple issue, so it makes the scope of this blog hard to summarise. The theme that overrides me at the moment is the institutionalised cruelty, mostly of the impersonal kind that arises from the dishonest dealings of a failing bureaucracy.

I’m wiling to accept that I might not have a right to optimal treatment, or any treatment, if that is beyond the means of the state to provide, but I consider it to be dishonest for the service to deny it’s own limitations by turning them on the patients. People are told that they are not suffering to the extent that they believe they are; that they are contributing to their own disease through various kinds of non-compliance (unhealthy lifestyle usually); or that they have not exhausted the extensive list of less expensive treatments available – all in order to keep them off waiting lists for treatments that the state professes, through it’s health service, to be routinely providing.

This is a National Health Insurance scam, surely? It is the equivalent of the small print in the contract that is used against the powerless patient to either deny them appropriate treatment or shame them into not asking for it. It’s time for an honest policy document, and one that admits that the struggle to obtain treatment is the rule rather than the exception.

My (rather long-winded) Story:

In 2002 I fell down the stairs, landing painfully on the base of my spine. It must have been out of hours, since Andy took me to A&E. I had a deep pain in my groin, hip and buttocks. No imaging was taken. The consensus was that I had probably broken my coccyx, which is not treatable other than by rest.

For years afterwards, complicated by the pain from breaking my back, I struggled with pain in my right hip and leg. Pregnancy and child-birth was particularly hard.

By 2015 my hip had become so painful that I asked my G.P. For a referral to the Nuffield Sports Injury Clinic in Oxford, unsure of what the problem was and wanting my symptoms to be viewed holistically in the light of my sporting history. It was an assessment process that, in itself, knocked me about through it’s sheer speed and hands-on physicality.

The diagnosis came back of Osteoarthritis, along with a number of other features of the joint like synovitis (inflammation) and dysplasia (dislocation). This diagnosis precipitated a cascade of advice and information stemming from a basic premise of ageing. I was offered physiotherapy, which I did not take-up since I was in good physical shape and health, with good musculature, and a normal weight. Instead I decided to approach a private consultant, again in a sports specialty, for a second opinion on diagnosis and treatment options.

He made a similar diagnosis, but went on to specifically rule out any evidence of avascular osteonecrosis (AVN). In fact, this is exactly what the diagnosis should have been, though I don’t know the extent of visibility on the imaging at that time. After all, it was three years’ ago. We were told then, though, that the damage was long-standing (not of recent onset), meaning that it was appearing in my thirties/early forties. This seems to me to raise a case for questioning arthritis per se in a person who seems otherwise healthy. The treatment that I was offered was steroid injections, which provided temporary pain relief. “The damage has been done” he said, so I was free to engage in any activity, assuming that I could tolerate the pain. This I did. I pushed myself, agonisingly, to keep running and when this was no longer possible, to keep walking. I went from one walking stick to two.

At last, in August 2017, I saw my G.P. and asked for a referral for a hip replacement. I became, happily, aware that the NHS offer patient choice in terms of preferred surgeon and hospital, so I opted for Worcester and the surgeon I’d seen privately. Shropshire CCG (Clinical Commissioning Group) and Worcestershire bounced me backwards and forwards. We tried to find out what was happening and in January we were told that I was not on a waiting list. Eventually I got an appointment through for March 27th (tomorrow). When I called them today to cancel I was told there was no appointment, instead I had been stepped-down to physiotherapy, with an appointment in May (that’s 10 months after seeing my G.P.). Nobody thought to tell me any of this. Had I still needed the appointment I would have attended only to be sent away again.

I’ve described in my blogs my very different experience in France, including the diagnosis of AVN. The misdiagnosis of arthritis in the U.K. means that I’ve not been offered suitable treatment, and that my need for hip replacement surgery has been minimised and delayed. Physiotherapy is more likely to cause pain than relieve it. Moreover, the diagnosis of osteoarthritis (OA) has led me into some deep, dark places over the past three years. Of course, a degree of degeneration is probably normal in your forties and fifties, with progressively more in old age, but I’ve been struggling with amounts of pain to disable me through my forties. When the experts don’t question the diagnosis, you just have to accept their judgment that old age is setting-in. My daughter was only 9 years’ old, though, and I was until recently a functioning athlete when OA was diagnosed, so the idea of living in a chronic pain-management mode for the rest of my life was hard to hack. I did my best to argue with my own defeatism and depression, feeling that I must be making too much of a fuss. It should have been an unnecessary fight, since AVN is not a symptom of ageing at all, and the pain it causes is relieved by surgery.

My AVN has been painful, and driven me to try and save myself (most fortuitously, by turning to SurgeryInFrance), but the pain caused by the U.K. healthcare system is more pernicious. It is a dishonest system that can pull you to bits if you make the fundamental error of believing in what it promises. Though, it is probably an expression of a dishonest economic-political culture. I would like the healthcare system to admit that it has failed the population, in the sense that it can’t live up to it’s vaunted vision of itself. My feeling is that the patient is supposed to be complicit in the NHS delusion and take up the failure as their own. British people are good at that.

It is not justifiable, in my view, to deny younger people the opportunity to be pain and disability-free on the grounds that it might not last a lifetime. In any case, good quality implants, correctly fitted and well looked-after stand a good chance of lasting as long as they’re needed.

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