View from the ground, by Dr Heather Ryan

Ryan heather

I am fat, female, fair, and hopefully fertile (though this latter point is, as yet, untested) so it was hardly a surprise when, last year, I started to develop right upper quadrant pain after particularly indulgent meals. It took me a while to diagnose myself as the pain was somewhat atypical; a dull ache rather than colic, which radiated to my back, and was often pleuritic. I rather fancied that the first episode must be a pulmonary embolism until it resolved spontaneously and quickly after 3 hours, and I dismissed the second episode as musculoskeletal. After a couple of months, I accepted the inevitable, curtailed my takeaway habit, and booked an appointment with my GP. She agreed with my self-diagnosis, arranged an ultrasound, and 3 weeks later I was lying on a couch in a darkened room gazing up at the source of my malaise: two small gallstones.

Up to this point my patient journey had been relatively straightforward; I was able to arrange my GP appointment at a time that was convenient for me, my doctor was knowledgeable and courteous, and I did not have a significant wait for diagnostic imaging. I was well served by the NHS.

When my doctor phoned me to discuss the result, he warned me that he had heard unimpressive reports about laparoscopic surgery at the local district general hospital, and suggested that I take advantage of the opportunity to be treated as an NHS patient at a nearby private hospital. I hesitated for a moment (the part of me who spent her student years as a left-wing troublemaker rather disapproved of private companies making profit by cherry-picking easy cases, leaving complicated patients for the NHS) but the thought of a private room and convenient evening appointments won me over. I dutifully used my Choose and Book paperwork to arrange my first outpatient consultation, choosing an evening slot that fitted around my other commitments.

I needn’t have bothered as, a few days before my appointment, a clerk from the hospital rang to inform me that my appointment was being moved to earlier in the day, as some of the evening slots before mine were unfilled. The idea that I might have work commitments that could not be easily rescheduled at such short notice seemed like a novel concept to the hospital. This cavalier disregard for patients’ time resurfaced again later, when I received a phone call 2 weeks before my surgery asking me to come and see my anaesthetist the day before my operation. This was a normal working day for me, and I had patients to see. Thanks to the flexibility and kindness of my colleagues, I was able to take several hours out of my working day to attend, but had I been unable to, I presume my surgery would have been postponed. The hospital also waited until 2 weeks before my operation date to inform me that I would be on an evening list, would be staying in overnight, and would need collecting at 10am the following day by somebody who could stay with me for 24 hours. My other half is a GP, who could hardly cancel his booked surgery at the whim of the hospital, so this created further inconvenience.

Another annoyance was the lack of coordinated care. As I have a past medical history of scoliosis, I needed pre-operative spirometry. The private hospital did not offer this, so I was asked—again at very short notice—to attend a local NHS hospital, obtain a paper copy of my results there and then, and bring this to my anaesthetic appointment a couple of days later. The cardiorespiratory department at the NHS hospital had a much more conventional approach to results (namely, sending them to the requesting clinician, rather than handing them to the patient) and initially refused to let me have a copy of my print-out. Fortunately, as a doctor who knew the healthcare system, I was able to persuade them to help me, but as a patient it felt odd to be stuck in the middle with my operation date at stake.

There was much to commend about my patient journey. Despite the chaotic appointment process, the waiting list was short; my surgery took place 6 weeks after my first outpatient consultation. My surgeon, who also practises within the NHS, was fantastic: competent, efficient, and reassuring. The ward doctor issued a sick note, which was long enough for my predicted absence from work, and take-home analgesia of an appropriate quantity, without trying to delegate either task inappropriately to my GP. The private ensuite room was pleasant, and the food was palatable.

I must admit I was left wondering whether the NHS is getting a raw deal from independent sector involvement. Is commissioning private hospitals to deliver certain services the most effective use of the healthcare budget? Would the patient journey be smoother and safer if we were to centralise care in fewer, larger centres, rather than fragmenting it by subcontracting certain episodes of care? Indeed, has the purchaser–provider split had its day?