UK: A Tale Of Two Systems

Last Updated: 29 August 2014
Article by Karen Taylor

Most Read Contributor in UK, August 2017

Knee replacements are the most common joint replacement operation in Britain, with 90,000 performed each year. A few months ago I had a total knee replacement (TKR) operation in an attempt to relieve the pain and improve mobility of the joint, which had become seriously arthritic following a hockey injury several years ago.

In the United States of America (US), Dr Paul Keckley, the former Director of the US Center for Health Solutions underwent his own TKR operation a few weeks after me. Having read Paul's account of his experience in his weekly blog 1 I decided to compare and contrast our two experiences as a salutary lesson on the value we get from the NHS.

In the US, Paul's operation took place in Nashville, where he spent 55 hours as a 'guest' in his local hospital. His operation, on a Thursday, saw 39 different caregivers involved in his care. The care is complicated and the service capital-intense, labour intense and scientific. Paul rates his care as exceptional and the prognosis, as far as he can tell, is favourable. The week after his discharge Paul started getting the bills; a whopping $51,829.35 from the hospital for his 55-hour stay (which doesn't include professional fees for his surgeon, internist and anaesthetist or the three medications he needed, the crutches and walker he bought, and the over-the-counter aids he purchased). He estimates that the final tally will be close to $60,000.

Contrast that with my NHS experience in Kent in England. My operation was also on a Thursday morning, I was second on the surgical list and, following a question and answer session with the registrar and anaesthetist, I was wheeled into the theatre where the anaesthetist inserted the spinal block and started to administer sedation. After the operation I was then wheeled to my single room met by my nurse who made me comfortable in my hospital bed and handed me the TV remote. My observations were taken hourly and then at four hourly intervals by a succession of nurses and healthcare assistants when I was also given my pain medication and a daily injection to prevent thrombolysis.

To my surprise I was up and walking, albeit with a walking frame, within a few hours. The next day I was visited by the physiotherapist and occupational therapist who explained what I could expect in the near term. I was given two walking sticks and assessed for what equipment I might need at home (a chair for the shower and a raised toilet seat). The following day, Saturday, the physiotherapist put me through my exercises, including how to walk up and down stairs using sticks. Meanwhile, the occupational therapist checked my mobility and delivered the equipment that I would need for home.

On the Sunday morning, the physiotherapist assessed me and gave me exercises to do at home, the pharmacist prescribed the medication I would need for the next two weeks and that afternoon my husband took me home - some 74 hours after the operation. I started commuting again three weeks after being discharged. I saw a physiotherapist once every two weeks for six weeks and had a follow-up with the surgeon after six weeks. My final follow-up is in three months' time. My knee hurts a little if I stand for too long but for the most part it's pain free and mobility is already much better than before.

Whilst the care, medication, equipment and physiotherapy was provided free, for me, a search of NHS websites suggests the tariff for a knee replacement is around £6,000 (the average cost of a TKR in a private hospital is £11,2152 ). A 2012 research study demonstrating the cost-effectiveness of knee replacement operations in the UK found that on average, a TKR and 5 years of subsequent care, cost £7,4583per patient. Both private and NHS costs are significantly less than the $60,000 cost of Paul's operation.

Luckily for Paul and I, our knee operations went as planned with no unexpected or adverse effects. Our prognoses appear good, accepting that the outcome will be affected by our own attitude and behaviours, and how well we adhere to exercise regime. For both of us the partnership we had with the care team was the most important aspect of our operation and in both cases was excellent. This leaves me reflecting on the huge difference in costs and consequently affordability.
As Paul said in his blog, it's impossible to place a value on walking with confidence and without pain. However what is different in the US is that the high cost seems difficult to justify and may well deter people from seeking treatment. In the NHS, no one is deterred from seeking treatment because they cannot afford to pay; rather the concerns are about time spent waiting for an appointment or operation.

To me this tale of two knee replacements suggests that if people had more information about the value offered by the NHS then they would have more evidence on which to decide how much they might be prepared to pay in taxes to maintain it, or whether co-payments or some form of insurance system or charging might be appropriate in certain circumstances.


1.My Take -The Keckley Report. See also:

2.Private Healthcare UK. Private Healthcare UK Self-Pay Market Study 2013. See also

3.Rationing of total knee replacement: a cost-effectiveness analysis on a large trial data set.  Dakin et al (The KAT Trial Group) January 2012.  See also:

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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