Approach to surgery in United Kingdom should be shaken up

EDITOR—With respect to the article by Wilmore and Kehlet on the management of patients in fast track surgery, the NHS needs to overhaul its surgical model completely.1 Although there will always be a need for hospital based surgery for major procedures and for less major procedures in higher risk patients, many procedures could be performed more efficiently in outpatient surgical facilities.

When my father reached the top of the waiting list and had elective wrist surgery in an NHS hospital, he spent a night in hospital before surgery to provide for an anaesthetic preoperative assessment, which took place the following morning, and another after surgery. And the procedure might still have been cancelled on the day because of a lack of inpatient beds or theatre space. This experience is not uncommon.

In the United States someone would be asking: “Who is paying for this?” Freestanding, often independent, ambulatory surgery centres have increased in number, to the point where they often threaten the viability of nearby hospitals. But the NHS model of centrally funded care renders this competition financially irrelevant and would allow hospital surgical units to focus on true hospital cases.

I codirect and provide anaesthesia and acute and chronic pain management services in one such facility. It is extremely efficient (and profitable for the shareholders), and the care provided is of the highest standard that I have seen in 19 years of medicine and surgery, much of it in the United Kingdom. The range of care includes orthopaedics (joint arthroscopy, cruciate ligament and shoulder reconstructions, extensive arm surgery, and lumbar and cervical spinal surgery), general surgery (“lumps and bumps,” laparoscopic cholecystectomy, and hernia repair), cosmetic surgery (mostly reconstructions after mastectomy), and invasive pain management. Similar facilities nearby cater for most of the common ear, nose, and throat, gynaecological, and ophthalmological procedures. In four theatres and one fluoroscopy room we conduct 250 surgical and 200 interventional pain management procedures per month, without operating weekends or evenings or yet running at maximum capacity. Our high response to mail surveys of patients and our routine follow up telephone calls tell us that patients and families appreciate the excellent care; the doctors enjoy operating here because things work well and their patients like it; and there is a low turnover of staff because they are content, working in a small, non-hospital environment where high standards of care are demanded. The NHS leadership should rethink surgery: the ambulatory surgery centre model works in terms of cost and quality of care and should be where all suitable surgery is performed in the United Kingdom.