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Sunday 25 September 2016
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Healthcare choices: excellence … or NHS?

Quality Matters

STEPHEN J HUMPHREYS

Practice Manager
Dr Hanak & Partners
Welwyn Garden City

Stephen is a member of several committees, including the Advisory Committee on Clinical Excellence Awards and both an independent and NHS research ethics committee. However, his main job is as a practice manager in Hertfordshire

Whichever political party wins the next general election, public spending restrictions seem inevitable – yet demands on healthcare will not decline.

One way to deal with this mismatch could be to encourage people to "go private". Many people are opposed to the development of the private sector, and I do not actually wish to argue for private and against public. However, I do want to consider issues of choice relating to surgery, which I had not appreciated before – perhaps because undergoing surgery was an uncommon event in my usual routine.

We all know that the private sector can usually sell itself by offering prompt treatment at a time that suits the patient, in comfortable, almost hotel-like surroundings, and with consultant attention. Sometimes however, as I discovered, it also offers treatment excellence virtually impossible to obtain in the NHS because it can allow its surgeons to specialise in a limited range of procedures.

I had not appreciated what now seems so obvious, which is that specialisation in even "routine" surgery can really raise the standard of care. The implications of this on the government's agenda to encourage GPs with Special Interests (GPwSIs) and the like do not make for comforting thoughts. For no matter how interested a GP may be, he or she cannot be expected to reach the level of excellence attained by even a fresh-faced consultant, never mind a consultant who subspecialises.

I am not anti-NHS at all, but now that I have experienced one of its flaws I felt I should bring it out into the open for a revealing airing. Certainly that is what I hope to do in this article, which explores my experience, as a patient, of seeking treatment for an unexciting surgical problem.

I knew I needed an operation and read up on what to expect while I waited for the various health appointments that would bring me closer to the scalpel. I would do just the same if I was making any other important decision in an area I knew little about – like turning to Which? for advice about the best vacuum cleaner or washing machine. Doing this means I know the sort of questions to ask of the salesperson or consultant general surgeon.

Vigorous exercise
Having followed the chief medical officer's advice about vigorous exercise (ie, doing 60 minutes of vigorous physical exercise three times a week – enough to get the heart beating and to break out in a sweat), I failed to appreciate (or rather Professor Sir Liam Donaldson failed to warn me) that intense physical exercise can bring with it the danger of injury.

Sure enough, I occasioned a double hernia (a bit like double pneumonia I expect, except nearer the testicles) while engaged in a series of rapid sit-ups, burpees and bastedos. Sharp-minded readers will pick up clues from this nomenclature that my instructors have a military background, I hope not all spent in Colchester barracks.

Computer dating
Contrary to articles in the likes of the Daily Mail, I was able to see my GP promptly, and the Choose and Book system got me in to see a consultant within 10 days. So far, so good, I thought.

The consultant the computer had selected for me said he could do the required operation: a bilateral inguinal hernioplasty. However, he was unwilling to do it under local anaesthesia because I weighed too little – or too much, I'm not clear which – but rather than insisting on general anaesthesia, which I did not want, he could offer an epidural as a compromise.

Intestinal loop
I was just considering the idea of agreeing to compromise my healthcare when the consultant, commendably, decided to launch ahead with all the gory details. No doubt he wanted to shut me up and stop me asking questions.

I suppose I was expected to have felt privileged to be seeing the consultant rather than some newly qualified member of his team and just listen to him. Perhaps it wasn't going to be quite like buying a vacuum cleaner after all. He wanted to warn me of the outcomes of the operation – having already reminded me that not to operate was not an option because of the near inevitability of a strangulated hernia (this is when, as I understand it, anything from a few centimetres to the full five yards of bowel slips like an eel through a newly formed abdominal weakness, and the hole through which it protrudes then closes noose-like around the intestinal loop … I'm sure you get the picture) and the need for emergency treatment.

He guaranteed that I would be off work for between 2-4 weeks, most likely the full month. Presumably he thought this would be what I wanted as an "NHS" worker. I pointed out that in fact I am a practice manager in a GP's surgery, spend most of my day sitting and do not typically carry heavy weights – other than those I routinely have to bear on my shoulders for the practice of course – so perhaps the two- to four-week sick leave would not apply in my case?

He replied that not only would I be unable to work, I would not even be able to drive. The pain I would have in my groin after the operation would be greatly exacerbated by moving my feet and this would mean I would not be able to perform an emergency stop – even if my life depended upon it! There would be very considerable pain, he assured me, because he would have to cut, manipulate me internally and place stitches in the pelvic region.

Postoperatively there would be bruising. I would want to lie down a lot, as whenever I sat down I would crease the site of the operation and the pressure I brought to bear on it would be very painful. He would give me analgesia. I would probably get some kind of infection, "because of the nature of the site where the operation is". For this he would give me antibiotics as a
prophylactic measure.

I might have trouble urinating – but that would quickly pass (I don't think the pun was intended). I would also need laxatives to ensure that I did not involuntarily put pressure on my wounds (I wasn't clear if he would provide these or if I would need to make my own arrangements).

He would put a "mesh" into my groin, which I would always feel, especially in the first 12 months. It was going to be an area of my body that might be a bit uncomfortable for the rest of my life. In fact, it might affect my sex life (I took this to mean not positively). I should be aware of these sorts of issues, he said, and I agreed.

He could do the operation in a couple of months' time. His secretary would send me an appointment, perhaps next week, or whenever she got around to such things. As it transpired, I was to be grateful for this inability to book on the day because time allowed me to consider my options properly.

Genetics
This was not the sort of news I had expected to hear, having read up a little on the procedures. Inguinal hernias seem to have a genetic component that affects some 5% of men (but fewer women – possibly because evolution has eliminated many who suffered at childbirth or whose hips were the "wrong" shape).1,2 It is one of the most common elective operations, accounting for about 15% of general surgery cases.3 There are more than 100 recognised ways to repair a hernia, largely because the anatomy of the region is still disputed.4,5 I turned to Google for a second opinion.

Partial walletectomy
The British Hernia Centre (BHC) could do a repair under local anaesthetic and I would be able to exercise as much (or presumably as little) as I wanted just a few hours after the operation! If I wanted to go to work the next day, that would be fine too. They could operate within two weeks. The cost would be £2,300 (lunch included) and came with a lifetime guarantee against recurrence.

The price was to prove significantly cheaper than any private hospital I could get a quote from, and it was the only place I could find to do the procedure I wanted. By happy coincidence, this establishment was also the world centre of excellence, had an entry in the Guinness Book of World Records attesting to their ability to deal with patients promptly, and was just down the road. This all sounded a far better option to me.

The cost is about double the NHS Payment by Results tariff (version 4), but when the levels of pain and enforced sick leave that NHS procedures seem to involve are factored in I'm sure that many uninsured patients, or their employers, would happily pay top-up fees if such an option were presented to them. The side effects of NHS procedures being so much worse than the condition, it is a wonder that such procedures are regarded as morally acceptable at all.

Practiced-based commissioning
I made some other enquiries of the BHC and, yes, their CEO had tried to get interest from commissioners – but there doesn't seem to be any. This seems myopic to me. The cost saving from sick leave alone will surely make the cost differential affordable in many cases.

In fact, perhaps this could be worked up as part of a new health policy: everyone can go NHS (the safety net), or pay a bit more and have decent treatment. Yes, it's two-tier, but the NHS option is, it would appear, just so barbaric.

I asked my surgeon, on the day, why the NHS could not give me the same operation. He told me there was no reason why not, but so few consultants were comfortable doing the procedure under a local anaesthetic, probably because they did not get enough cases to hone their skills sufficiently. I could not help wondering if there was a lesson here for the NHS.

Covert operation
My operation took about an hour, and I walked out of the operating theatre with one partially shaved, but obviously very beautiful, leg, and straight in to lunch. Later that evening I went for a walk for about a mile or so. I needed no painkillers.

The next day, I was able to go to the pub for lunch and only felt a bit guilty that I was not in work. I had planned not to be, and had no intention of appearing to go back on my word, although such planning now seemed a bit overcautious.

On the third morning I woke to discover I might be a hitherto-undiagnosed somnambulist, because I appeared to have been involved in a road-traffic accident that night judging by the yellow, brown and red contusions covering my groin. Strangely none of this was at all painful and these autumnal colours soon faded away to reveal my own familiar flesh tones.

And there we have it: I had prompt and excellent treatment with virtually no time off work and minimal pain and disruption to my life. And all because my surgeon was, free of the NHS, able to specialise in the type of surgery I needed.

At the time of writing, I have still to hear from the NHS consultant about when he is proposing to do my operation – he'll have to do it on someone else now and I don't envy them. And if anyone thinks their legs might be more beautiful than mine I would be very pleased to see them – no appointment necessary.

After all, if this whole episode has taught anything it is the importance not just of a second opinion but also of the need to develop expertise by seeing enough cases and developing a specialist interest. I shall, however, leave it to you, dear reader, to consider the implications for notions such as a GPwSI. As Alexander Pope put it: "A little learning is a dang'rous thing; drink deep, or taste not the Pierian spring."

References
1. Gong Y, Shao C, Sun Q, Chen B, Jiang Y, Guo C, et al. Genetic study of indirect inguinal hernia. Journal of Medical Genetics 1994;31:187-92.
2. Zimmerman IM, Anson BJ. The Anatomy and Surgery of Hernia. 2nd ed. Baltimore: Williams and Wilkins; 1967.
3. Hill A, Darzi A. Inguinal hernia: background and history. In: Darzi A, Monson RT, eds. Laparoscopic Inguinal Hernia Repair. London: Taylor & Francis; 1994.
4. Spigelman, AD. Open repair of groin hernias. In: Darzi A, Monson RT, eds. Laparoscopic Inguinal Hernia Repair. London: Taylor & Francis; 1994.
5. Hill A, Darzi A. Open mesh repair: review of the literature. In: Darzi A, Monson RT, eds. Laparoscopic Inguinal Hernia Repair. London: Taylor & Francis; 1994.