61
hepatopancreatobiliary
surgery have for many years attracted
Investigation of these patients and the treatment options are complex. Although in most patients stenting may be the optimum treatment, there are some for whom it is not and a small proportion (perhaps 10-20%) for whom surgical resection is the best option. It is only in the hands of specialist surgeons, endoscopists, and radiologists that this judgement can be made, and appropriate treatment provided. This is the first such experience I have had of what has been a worrying spectre for many of us since the inception of UK National Health Service (NHS) reforms. We are only three-quarters of the way through this fmancial year, and at least one hospital no longer feels it can refer patients for specialist treatment outside its own referrals of this
sort.
boundaries. I wonder wherein lies the much vaunted increased freedom of choice for this patient, or indeed for his consultant? If fmancial constraints of this type were applied universally, then a substantial number of patients with this and other complex conditions might be denied the best treatment, and indeed the prospect of cure from their cancer. There is another relevant aspect to the debate on NHS reforms. I have treated more than 200 patients with hilar cholangiocarcinoma in the past ten years, whereas most physicians or surgeons in non-specialist units may see 2 or 3 per year. This experience that I and my colleagues in the specialty have accumulated has allowed development of improvements in treatment and the evaluation of their outcome, as well as provision of essential material for research into the basic biology of the cancer. Without referrals to specialist centres this progress in management and basic research will come to an abrupt end. This is something that those of us working in specialist areas have long feared. Cancer of the biliary tree may be only a specific marker for a much more general process that is taking place in our health service, and one that I feel should be more carefully addressed. I wonder whether any of my colleagues in other specialist areas are beginning to have such experiences? ,
Day-case surgery SIR,-Mr Kirby and Mr Skilton (Dec 14, p 1529) report that 57% (of 44) of patients having varicose vein surgery and 91 % (of 57) of those having inguinal hernia repair were against the idea of discharge on the same evening of their operation. Such high levels of dissatisfaction might have arisen because the patients had not been prepared and admitted for day surgery. A second factor could have been the timing of the questionnaire. Data we collected during 1990 on several types of operations, while developing a questionnaire for the Audit Commission, revealed a much lower level of dissatisfaction-15% of day cases reported both one week and one month after surgery that they would rather have been an inpatient.’ Although this is still an unacceptably high proportion; we found that 17% of inpatients would rather have been treated as day cases. Day cases and inpatients were mostly dissatisfied with the same factors-lack of parking facilities, things to occupy them in the ward, and information about their treatment. The main difference between the two groups was greater dissatisfaction with postoperative pain control in day cases (20% versus 5%; p
hepatopancreatobiliary
surgery have for many years attracted
Investigation of these patients and the treatment options are complex. Although in most patients stenting may be the optimum treatment, there are some for whom it is not and a small proportion (perhaps 10-20%) for whom surgical resection is the best option. It is only in the hands of specialist surgeons, endoscopists, and radiologists that this judgement can be made, and appropriate treatment provided. This is the first such experience I have had of what has been a worrying spectre for many of us since the inception of UK National Health Service (NHS) reforms. We are only three-quarters of the way through this fmancial year, and at least one hospital no longer feels it can refer patients for specialist treatment outside its own referrals of this
sort.
boundaries. I wonder wherein lies the much vaunted increased freedom of choice for this patient, or indeed for his consultant? If fmancial constraints of this type were applied universally, then a substantial number of patients with this and other complex conditions might be denied the best treatment, and indeed the prospect of cure from their cancer. There is another relevant aspect to the debate on NHS reforms. I have treated more than 200 patients with hilar cholangiocarcinoma in the past ten years, whereas most physicians or surgeons in non-specialist units may see 2 or 3 per year. This experience that I and my colleagues in the specialty have accumulated has allowed development of improvements in treatment and the evaluation of their outcome, as well as provision of essential material for research into the basic biology of the cancer. Without referrals to specialist centres this progress in management and basic research will come to an abrupt end. This is something that those of us working in specialist areas have long feared. Cancer of the biliary tree may be only a specific marker for a much more general process that is taking place in our health service, and one that I feel should be more carefully addressed. I wonder whether any of my colleagues in other specialist areas are beginning to have such experiences? ,
Day-case surgery SIR,-Mr Kirby and Mr Skilton (Dec 14, p 1529) report that 57% (of 44) of patients having varicose vein surgery and 91 % (of 57) of those having inguinal hernia repair were against the idea of discharge on the same evening of their operation. Such high levels of dissatisfaction might have arisen because the patients had not been prepared and admitted for day surgery. A second factor could have been the timing of the questionnaire. Data we collected during 1990 on several types of operations, while developing a questionnaire for the Audit Commission, revealed a much lower level of dissatisfaction-15% of day cases reported both one week and one month after surgery that they would rather have been an inpatient.’ Although this is still an unacceptably high proportion; we found that 17% of inpatients would rather have been treated as day cases. Day cases and inpatients were mostly dissatisfied with the same factors-lack of parking facilities, things to occupy them in the ward, and information about their treatment. The main difference between the two groups was greater dissatisfaction with postoperative pain control in day cases (20% versus 5%; p
