I've had a good election - recovering from heart surgery
During an election dominated by Brexit and the NHS, Anthony Barnett has been reflecting on what his open heart surgery has taught him about Britain's best loved institution.
A year ago I discovered that one of the valves in my heart was massively backfiring with potentially fatal consequences, a discovery I described here. Soon after this was published I was wheeled into the hands of a team of NHS anaesthetists, who ensured I have no recall whatsoever of the five and half hour operation that followed, as world-class surgeons opened up my chest and got to work.
Healing the heart
There are three interlinked processes to recuperation after a major operation. There is the biological healing of the body itself. Then there is the medical and scientific management of the process, which has to work with not against the body. And then there is the social – the healing of the person, and his or her reintegration into society. My own healing was hugely helped by messages of support and acts of solidarity, acts which became a modestly international health service – acts which, just as important, fortified my ‘primary carer’ in what can be a thankless task.
Each one of the three process can fail. The body can give way, doctors make mistakes, the social can be hollowed out. Only when all three combine together successfully do you have that wonderful transformation: a human being fully restored to life.
With open heart surgery your body faces quite a challenge. As soon as the operating team start to put you back together they turn off the by-pass machine and heart and lungs must then go straight to work. Your heart, the body’s emperor, has been stitched and mended and improved and now needs to get used to its new configuration. Your lungs have been collapsed so that the surgeons can work on the heart. That’s why you feel as if you have been hit by a bus when you come to. All the air has been taken out of you as well as a lot of blood. But your lungs emit vapour with your breath and five hours of fluids now needs to be drained, or your hands and ankles swell. I’m simplifying. But I emerged into the intensive care unit with twelve tubes and wires attached to, or going into, me. When you leave the operating theatre you are not ‘in’ hospital, you are built-in to it: attached to its infrastructure of alarm systems and monitors, and the lines that supply blood and morphine and extra oxygen and drain waste.
Over a period of five or six days, if you are fortunate as I was, the tubes, wires and attachments are pulled away and you are released, able to walk slowly into the hands of your ‘primary carer’. Provided you are lucky enough to have one.
A long process of healing begins. This is both helped and hindered by a mixture of chemicals: pills to thin your blood to prevent clots or a thrombosis, beta blockers to calm the heartbeat, iron pills to restore your haemoglobin, powerful diuretics to rid you of excess fluids. All can have side-effects. Together they impact on a weakened body seeking to return to strength.
Most obviously, your breastbone, the sternum, that holds your ribs, has been severed from top to bottom. Now the bone needs to fuse and mend, held together at first by wires. The muscles down the length of the wound have to re-bind and dissolve the stitches that have tied them, while your skin regrows. The first time I sneezed I wasn’t thinking and I really knew I’d been opened up!
Recovery is a form of work. It demands determined patient effort; learning to breath properly is surprisingly hard, walking is exhausting but essential. Equally important and more enjoyable is not working but instead dozing, reading and listening.
The value of healthcare, and the price of everything
It meant that as I started healing, Johnson got Parliament to pass his Brexit Bill. But I didn’t mind for I was starting to feel better. When the opposition parties foolishly agreed to an election I was taking pleasant, short walks outside my home. As the dire campaigns followed, filled with negativity and evasion, I was thankful not to be part of it, despite the threats to democracy promised in the Tory manifesto – voter ID to suppress turnout, and a re-assessed “relationship between the Government, Parliament and the courts; the functioning of the Royal Prerogative; the role of the House of Lords”.
The determining issue may be Brexit. But Brexit has never been about Europe. Which is why its key advocate, who unbelievably is Prime Minister, is pitching his campaign on getting it “done” so we can focus on the “really important issues” that we face as a country. It’s a paradox Lewis Goodall tweeted neatly. After Brexit, way above all the other issues voters care about is the NHS. Once scorned by Johnson as a religion he now presents himself as its most zealous believer, while Jeremy Corbyn commits the last days of his campaign on the need to save it from Trump and privatisation.
Well, I’ve just experienced the very best of the NHS. I’ve also seen at first hand a culture which could open the way to undermining it. There is no doubting its fundamental magnificence. The heart of this is that it is driven by human need, not the profit motive or concern over costs. You know this the moment a hospital gets to work. I had an angiogram a few weeks before my operation. It’s a procedure where a nurse inserts a tiny catheter into your wrist and up through your arm’s artery until it gets near your heart. A dye is then injected which can be X-rayed so that specialists can assess the state of the blood vessels around the heart in advance of surgery. You are conscious throughout. Two people worked on my other wrist injecting blood thinners to ensure that the procedure itself does not trigger a heart attack or a stroke, and an emergency team is on hand in case it does. Along with radiographers, it meant there were eight people in scrubs in a gleaming operating theatre with a huge X-Ray machine and multiple screens, for this simple check-up. The ‘market’ cost of just this 20 minute procedure not to speak of the administrative outgoings of billing the charges would have been unspeakable. But it was needed, so it was done.
You don’t realise the cost-effectiveness at the time. But others were coming in after me with conditions that were perhaps more complicated. With good management it is a very efficient use of the team that was in place. In the US, because of all the insurance, billing, and the disputes over charges, just the administrative costs of health care alone came to an estimated $496 billion in 2019. This is considerably more than the total expenditure on the NHS this year which was £143 billion.
The costs would have been far-greater for the surgery itself. But in my heart unit there were fellow patients from every class and walk of life, sharing a battlefield equality in our farting and groaning, as we were all treated equally with state-of-the-art operations, free from financial fear. The extraordinary human return means so much to our families we forget that elsewhere such a medical emergency could have bankrupted us. In the United States, between 2000 and 2012, over 40% of the nearly 10 million people diagnosed with cancer “depleted their entire life's assets” to cover its treatment, according to the American Journal of Medicine. It’s not flippant to suggest that fear of such an outcome is itself enough to make you ill.
The NHS’s good value makes the UK’s underspend on it more shocking. A recent, careful comparative analysis reports that the UK invests less than 10% of GDP on health compared to over 11% in France and Germany. But it’s not just about expenditure. In the madness of the privatised USA, total health care expenditure is nearly 18% of GDP while the death rate is rising – its system literally killing people.
Care can’t be measured – so what is the market doing to it?
It seems to me that the principle argument about the importance of the NHS as a public good has been won. If the Tories need to spend more money on it to stay in power, then they will; one of the paradoxes of Brexit being that it is making us more European. But aside from the threat of cuts, there is another danger. The headline is ‘marketisation’ - the selling off of parts and processes of the NHS to the for-profit sector. Resisting this is more difficult than merely demanding more funding, as it leads into arguments about efficiency. And this poses a fundamental question of a different kind: what is being measured?
In a recent openDemocracy article, David Zigmond, a GP for 40 years, warns of how ‘care’ is being overly displaced by ‘treatment’. “Care comes from ethos, while treatment comes from technology. Care is about whole people and relationships, treatment is about parts and mechanisms… Treatment may fix, but it is care that heals”.
If you have a dangerously faulty heart valve you really need treatment – you want it fixed. But the recovery after the operation demands a different kind of approach: care, which is a social process where love and consideration and conversation and sharing with others is intrinsic to the biological recovery. Instead, the current direction of medical culture, it seems, is going the other way, towards measurable treatment of identified problems that can be prescribed treatment, while the more difficult to measure wellbeing of human care becomes a side-issue.
Zigmond also sees this as a problem for medical professionals themselves, saying that the “loss of conviviality and humanity” and its replacement by “centrally managed treatment” is leading to the “demoralisation of doctors as well”.
I felt it in my guts. Literally.
For eating and the love of others are entwined.
To say that Serco’s hospital food tastes like cardboard would be unfair to cardboard
As you are given anti-biotics to prevent internal infection, a major operation blasts the good bacteria in your stomach that aid digestion. Weakened, you need food, but managing to eat it and keep it down is not easy. In my hospital, catering had been contracted out to Serco which also provides all “soft facility management”. Generally known for prisoner escort and custody, it’s a global conglomerate. To say that its sautéed potato tastes like cardboard would be unfair to cardboard. The relationship between nursing and your being fed, a crucial part of healing, has been broken and can't be compensated for by pills.
Nurses were spending more time form-filling and box-ticking than, well, what I think of as nursing. I was shocked by what seemed to me to be over-medicalisation that concentrated on identifying measurable problems that could be treated with chemicals.
This then leads into support for post-hospital recovery. The well laid out booklet I was given states, “Cardiac rehabilitation… is as much part of your treatment as your medicines are”. But there is much less of it and I have been lucky enough to organise my own rehabilitation, helped by a friend who is a GP and has experienced a heart operation and who talked me through various anxieties.
The larger point is that the more that medicine becomes specialised and centralised the more it becomes culturally like a marketplace, a domain of transactional maximisation that also generates anxiety and much mental distress in the wake of its towering achievement. In these circumstances making the best of the NHS becomes a challenge for us, its deeply grateful beneficiaries, to ensure that it remains a human service.
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