Second Opinion: Do you really need that operation?

It's safer to ask is the title of a HSE leaflet advising all patients to ask questions such as: "What are the different treatments for this condition and how will this treatment help me?" A better question, not in the leaflet, might be: "How do you decide when to refer me to a consultant?"

The Health Information and Quality Authority (Hiqa) recently published three health technology assessments (HTAs) of scheduled, or elective, surgical procedures, showing many people are inappropriately referred for hospital treatment. These HTAs advise on when people should be referred to a hospital within the publicly funded healthcare system.

Demand for hospital services far exceeds available capacity. There are almost 50,000 people waiting for more than 100 elective medical and surgical procedures including varicose vein surgery, tonsillectomy and cataract surgery.

Although the HSE's Elective Surgery Programme aims to "provide the right procedure for the right patient at the right time in the right way", rates for surgical procedures vary across the four HSE regions. This means that either some patients are having unnecessary procedures or others are not getting the surgical treatment they need when they need it.

Strict guidelines
The effectiveness of any procedure is limited unless undertaken within strict clinical guidelines. According to Hiqa, all interventions should offer significantly more benefits than harm, and patients most likely to benefit should be clearly identified.

Surely this happens already and nobody is offered a procedure that might do more harm than good? Not so. The UK Audit Commission has estimated that about 250 common hospital procedures are of limited clinical value to many patients. In Ireland, Hiqa has just begun to assess the value of common elective procedures and has produced HTAs for cataract surgery, varicose veins and tonsillectomy.

The HTA for varicose vein surgery shows that, although these are a common health problem in western populations with as many as one in four affected, there are no standardised referral criteria that are routinely used to prioritise such referrals. In most cases, varicose veins are unlikely to cause harm even if they look unsightly.

There is no Irish data on the cost-effectiveness of treatment. Accurate data for the average waiting time for an outpatient appointment is unavailable. There is a lack of data on the severity of varicose vein disease in those referred for outpatient review. Almost 3,500 varicose vein treatments are performed annually at a cost of more than €8 million. The majority (98 per cent) of those undergoing varicose vein procedures do not have significant complications such as inflammation or ulceration. Are they being performed for cosmetic reasons? Who knows? Not the taxpayer, that’s for sure.

Hiqa concludes that the presence of varicose veins does not in itself indicate a need for surgery and patients who are seeking treatment for primarily cosmetic reasons should not be referred. A 30 per cent reduction in referrals would get rid of waiting lists in one year.

Unnecessary appointments
The HTAs for cataract surgery (12,000 procedures a year, costing €2.6 million) and tonsillectomy (3,500 procedures a year, costing €11 million) found similar problems: no published data for waiting times; no standardised criteria to prioritise referrals; unnecessary outpatient appointments; and a lack of clarity on what thresholds are used and how consistently they are applied.

Cataracts and frequent tonsillitis do not in themselves indicate the need for surgery. A significant minority of people referred are not suitable for surgery. Bet- ween 2005 and 2011 almost 40 per cent of all outpatients were referred back to their GP without treatment or further tests.

Large numbers, up to 60 per cent in one hospital, do not attend their outpatient appointment. What a way to run a healthcare system. It is no wonder waiting lists are intractably long.

At the heart of the waiting list problem lurks the question: What are hospitals for? In an ideal world their job is to provide cost-effective procedures that cannot be provided by primary care.

In practice they mean much more to citizens, who think they are always lifesavers. Citizens are loyal to their local hospitals. Are patients referred because that is what they expect even if the treatment is unlikely to be beneficial? Do patients believe they have not received a good service unless they are referred to a consultant? Do citizens generally think hospital care is more sophisticated and, therefore, better than primary care?

I suspect the answer to these questions is yes because we are conditioned to think in this way. Until hospitals lose their exaggerated local hero image, waiting lists will remain as intractable as ever.

drjackyjones@gmail.com