Elderly patients suffering over delays in hip surgery
The Times
Chris Smyth
Health Editor
“Gerry Gajadharsingh writes: This one is close to my heart, with 2 of my family members having had orthopaedic operations this week! Both could not get an appointment on the NHS to see an orthopaedic surgeon, neither had Private Health Insurance and so both were self-funded. It has been a very expensive week!
My eldest daughter, now 22 years of age, was taken out by a snow-border when skiing when she was about 6 years old (the border skied off and did not stop!). I went over to get her and saw that her left leg was facing the wrong way! I gently picked her up and the leg swung back (the amazing plasticity of children), it was swollen and bruised for a few weeks and settled.
A few years later she had her first dislocation of her patellar, which reduced itself. It happened a couple more times over the years, again self-reducing. We treated her conservatively and she was stable for several years until about 6 weeks ago. She went to sit down and sustained her worst patellar dislocation. Sadly, I was in San Fran (father where are you when I need you?). Paramedics came, morphine, Entonox (by law they said that they are not allowed to reduce the dislocation?) so a visit to A&E, several hours later and it was reduced by a consultant and sent home. Luckily, she has a father who is an Osteopath and we spent the following 6 weeks getting her better whilst waiting to see an NHS orthopaedic surgeon for a surgical opinion for patellar stabilisation, the expected appointment never arrived.
I arranged a private MRI and private surgical opinion with a colleague (by the way no mate’s rates in this job, at £250 for a 15-minute consultation, I’m definitely in the wrong profession, financially at least). Because of complications with her work and sick leave (she works as cabin crew for an international airline, which she loves, but the job is physically demanding therefore not great with an unstable patellar, if you have to do CPR on a patient 37,000 feet up in the air, as they are trained to do, by the way she has never taken sick leave, I mean not even 1 day) we took the decision to have a patellar stabilisation percedure done privately at £6,100. I start the rehab on her tomorrow.
At the other end of the age spectrum my mother, 77 years of age, has just had a total hip replacement, the day after my daughter. She has always been fit and healthy and had never taken any regular prescription medication (unusual in the UK at that age and therefore never having been a burden on the NHS) but like many elderly people developed the rheumatological condition Polymyalgia Rheumatica (PMR) a few years back, managed by her NHS GP with prednisolone.
A few years later she then became very ill, the NHS ran lots of tests over an intensive two-week period. They concluded that she was very ill but did not know what it was, and therefore did not know how to treat her (she had an ESR of 150 and a CRP of 260 (both extremely elevated inflammatory markers and with anaemia of chronic disease). So, I took over, and with one of my lovely medical colleagues arranged a private PET CT scan, £3,000 later we had a definitive diagnosis of central vasculitis and so then we knew what to do. She was referred a Rheumatologist (NHS) who has managed her since, more steroids and DMARD’s.
She plays a lot of golf and bowls, a couple of months ago, she thought she pulled a muscle in her left hip, had an x-ray (NHS) and was told there was a bit of “arthritis”. The pain progressed over several weeks and she was very disabled and walking with a stick. I again took matters into my own hands, partly knowing that long term steroid use can cause complications, I arranged a private MRI to find she had avascular necrosis (AVN), essentially a compromised blood supply to the hip, causing collapse in the head of the femur. In NHS Bucks, where my mother lives, as do we, the average waiting time for hip replacement surgery is 6 months (for at least 9/10 patients). We expected AVN to be an urgent priority, again sadly an NHS orthopaedic appointment didn’t materialise and the family took a decision to pay for this privately (£12,000).
Had we not taken this expensive decision, I’m not sure what would have happened. To leave a young woman in limbo, unable to work and unsecure about her future was not something we wanted. She had ever been to hospital ever before her visit to A&E and had only ever seen the GP a couple of times during her lifetime. So, it’s not as if she has been a burden on the NHS.
My mother’s situation is more complicated and I know that an increasing burden on the NHS finances are elderly patients with complex medical problems, constantly using NHS resources. Most people simply have to wait in pain, until NHS surgery can be arranged. A colleague of mine up North had his mother on morphine for 4 months whilst she was waiting for her hip replacement.
£20,000 is a lot of money to find urgently (luckily family members rallied around to help pay for my mother’s procedure and she also used her savings). The problem is that when we get ill, for us our problem is a priority, understandably. We expect the NHS to be able to swing into action, sadly this has not happened in our case.
Both surgeons who performed the procedures work in the NHS as well as privately.
I’m sure my discussion will raise many questions. I suspect that in due course patients, clinicians and politicians will have to have a frank and painful debate about the priorities for the NHS. The model is broken (has been for many years), it is a nightmare for many of the NHS staff, patients, families and funders alike. There are no easy solutions.
We will as patients HAVE to start taking more responsibility for our own health and start to allocate some our own resources to fund our healthcare. The NHS NEEDS to be fair for ALL who use it, it CANNOT provide all solutions to all people. Keeping throwing tax payers’ money at it will not help. Prioritising what the NHS can and cannot do will be a wake-up call for the population, both with GP provision, community care and hospital provision. It also needs a complete re-think of its diagnostic model (patients are either under-investigated, over-investigated and inappropriately diagnosed, causing undue distress on all concerned and wasting a lot of valuable tax payers’ money). Many patients have functional problems at the root cause of their symptoms, often driven by lifestyle choices, the NHS and the pathological model of medicine in general tends not to do well with these patients.
The article below raises the complications of hip replacement after fracture in the elderly population. The cost of £2 Billion a year just on hip fractures alone! Rehabilitation is critical after an orthopaedic procedure, just because a surgeon has done their job DOES NOT mean you are fixed. My personal view is that rehab provision is extremely poor in the UK. I see many patients post operatively for second opinions normally because of ongoing pain, usually the procedure was fine but the rehab was not.
Four in ten elderly patients who break their hips suffer delays in vital treatment that increase their risk of ending up in a care home, a report says.
Seven patients a day also break their hips while in a hospital bed and the number appears to be rising, with some hospitals failing to do enough to keep patients safe, the study found.
Broken hips are a common injury among frail elderly patients and dealing with the aftermath is estimated to cost the health service £2 billion a year.
While death rates from the condition are falling, analysis of records of 65,000 patients, almost all those admitted to NHS hospitals over a year, found thousands not getting the care they should.
Almost one in ten patients were still immobile four months after an injury with “enormous variation” in rehabilitation rates at hospitals, the National Hip Fracture Database reported.
Patients are meant to get standardised care, most importantly surgery within 36 hours and a prompt review by a geriatrician. However, the review found 40 per cent of patients were not getting the treatments they should. “It’s truly terrible not to have early surgery. If you have to get on a bedpan with a broken hip there’s no dignified way of doing that and people just unravel,” Antony Johansen, clinical lead for the project, said.
“If 40 per cent of patients are not receiving this care — usually because they miss out on just one or two elements — this could compromise their rehabilitation and recovery.”
He said that while some hospitals had 80 per cent of patients back in their own homes a few months after injury, elsewhere it was “a tiny little number”. Hospitals are paid extra for good care and Dr Johansen said that there was no good reason for poor treatment.
“With care of frail older people, doing it well is cheaper than doing it badly. I know if I fail to rehabilitate someone and they go into a care home that’s a bill of £70,000 for them or the taxpayer.”
The audit also found that 4.1 per cent of all fractures happen while older people are in hospital, up from 3.9 per cent last year. Accidents peak during staff changeover times, it said.
“Seven people every day are breaking their hip in hospital and the slight trend for that to go up is concerning,” Dr Johansen said. “It’s something we need to challenge. It’s very easy not to have enough staff on the ward or have staff doing paperwork rather than being with patients.”
While saying that hospitals should not be overcautious and confine patients to bed, he said that some hospitals had only one fracture for each 700 beds each year, while others have as many as one for every 16 beds.
Patients in England are also spending a day longer in hospital than last year, at an average of 21 days.
Caroline Abrahams, of Age UK, said: “We are dismayed that 40 per cent of those who go under the knife don’t benefit from the best practice available. She added: “The numbers of hip fractures in hospitals are unacceptably high.”