Nobody doubts the fact that the NHS is in crisis. And it seems clear that in reality the NHS’s problems started a long time before Covid-19. My partner’s death was a harsh reminder that ‘private’ hospitals aren’t the magic solution some might think.
Investment in the NHS dropped from an average 6% annual budget increase during Labour’s 13 years (1997–2010) to 1.1% under the coalition (2010–2015). It increased slightly to 1.6% under David Cameron and Theresa May until 2018/9, when Theresa May announced a new funding package to mark the 70th anniversary of the health service, promising an increase of £20.5 billion per year. In real terms, this was only 3.4% of annual growth.
The pandemic: inexorably growing waiting lists
Covid-19 arrived on top of a 10-year struggle by the NHS, and demand was already outstripping capacity. To deal with the pandemic, the NHS was forced to reduce or shut down many of its non-Covid departments. In addition, a significant number of potential patients were unable to seek attention during lockdown between April and June 2020. Inevitably, waiting lists grew rapidly, from 4.4 million before Covid-19 to over 7 million in August 2022; nearly 400,000 of those patients have been waiting for over a year. It will take years to clear this backlog.
Can private hospitals help?
Given these waiting lists, desperate patients in pain may well turn to a private solution they can (very) ill afford. In these circumstances, it is important to assess realistically what the private hospital of your choice can offer.
Perceptions and realities of private hospitals
Many people think of private hospitals as highly equipped centres of excellence, where those who can afford it or have health insurance, get better treatment than that provided by the NHS. Many perceive that private means ‘better’, even ‘much better’. This is not always true. The reality is different when it comes to equipment as opposed to comfort. A report for the Centre for Health and Public Interest found that going private could in fact add an extra layer of risk.
Prof Colin Leys wrote that most private hospitals are smaller than their NHS counterparts and lack intensive care beds or appropriate nursing staff to address complications. In most, local NHS surgeons carry out a limited range of relatively straightforward elective surgery, such as knee or hip replacements, for mainly low-risk patients. In actual fact, most private hospitals depend on the local NHS for resources, including blood and access to high dependency units. It is no coincidence that many private hospitals are located either on the grounds of an NHS hospital or very close to one; in an emergency, a patient can quickly be transferred to the NHS hospital for access to proper care and necessary equipment.
The implications for choosing to go private
A private solution can be appropriate for low-risk patients who need relatively straightforward surgery. However, as I learnt to my cost, the issues are different for high-risk patients. Knee and hip replacements are most often required for older patients. Yet such patients often have at least some co-morbidities, making their operations more risky.
Assessing risks when opting for a private solution
The doctor/patient role is complicated and needs to be considered.
- The professionals: Surgeons focus on alleviating a person’s pain and enabling a more complete lifestyle. For relatively low-risk operations such as a hip replacement, they often reduce their description of risks to: All operations carry risk.. They see the operation as their responsibility, while anaesthetists take on the patients’ wellbeing.
- The hospital As more patients start to seek private operations, private hospitals need policies and procedures to assess their ability to properly treat higher-risk patients?
- The patients: Who really knows best? Patients see their surgeon and anaesthetist as the experts whose primary concern is the patient’s best interests. But pain can often obscure the patient’s ability or willingness to understand any real risks described. Any risks may seem worthwhile for a fuller, less pain-ridden life; yet how often is the possibility of dying considered? Issues of risk and consent need careful negotiation.
Assessing and mitigating against risk
My partner, a high-risk patient, decided to accept the risks involved in having a hip replacement – a low-risk operation that could, if successful, give her last months of life some meaning and fulfilment. But neither of us had closely examined all the risks. I believe that neither the surgeon nor the anaesthetist had done so either. Although the risks were identified in general terms, their implications were not listed or discussed. And crucially, they were not linked to contingencies. Consequently, these were not in place when needed.
In any situation of risk, especially risk to life, it is vital to do a thorough risk analysis and to put everything in place to mitigate those risks. This will be different in each patient’s situation. In our case, the hospital was irreproachable in its pre-operation assessment. All my partner’s co-morbidities were listed, various blood and other tests were done and her stats measured to ensure her readiness for the operation. The necessary pre-op blood transfusion was arranged and it was agreed that if her haemoglobin levels were too low, the operation would not go ahead. On the day of the operation, despite nursing staff voicing concern at the level of risk my partner presented, these concerns were brushed aside with the assurance that she could be sent to the Norfolk and Norwich University Hospital (NNUH) across the road if anything went wrong. When things did start to go wrong, contingencies hadn’t been identified, weren’t in place, and were not applied in time. My partner was the first patient to die at the Spire Hospital in Norwich. A second person died there soon after, under similar circumstances.
Risk analysis: what to do before an operation
- Speak to the surgeon and anaesthetist; understand the procedure and what kinds of things could go wrong.
Make a list of potential problems and how they will be addressed. For example:
– If there is a bleed during the operation, will appropriate blood be available immediately?
– Who arranges for the correct blood to be ordered and on hand?
– Who checks that it is in the fridge before the operation?
– Who administers the blood?
In my partner’s case, a blood check had not been done and blood had not been ordered from the NNUH. This caused a delay of 2 hours before the blood could be collected and administered.)
- What happens if things deteriorate during the operation or the patient has a heart attack?
– Does the hospital have facilities with trained staff on hand to respond appropriately?
In my partner’s case, although there were some high dependency beds, these were not staffed on the day and not available for use.
- Understand what happens in the recovery room.
– Who is responsible for ensuring the patient recovers well?
– Are the staff trained to identify when things are going wrong?
The anaesthetist took charge and the nurses were faultless in their attention, but there was significant panic and my partner was obviously highly distressed.
- Make sure you know what will happen if things go wrong.
– What happens if intensive care is required following an operation?
– Has the NHS hospital been forewarned that a transfer may be necessary?
– Is an NHS ambulance on hand? If not, does the hospital have its own?
The ambulance called for my partner took 2 hours as it was stuck in queues outside the NNUH hospital, waiting to discharge its patient. Given the current situation in the NHS, this is could have been predicted.
- Make sure the family has a named hospital staff member to keep you informed about progress throughout.
– Ensure that you have that person’s correct phone number.
In my case, I couldn’t get hold of anyone at the hospital and was not informed about the situation until very late in the emergency.
Private hospitals depend on the NHS
Given that private hospitals depend on the NHS for some of their services, facilities and consultants, it is imperative that conditions in the NHS be taken into account when assessing a patient’s risks. And it is vital that the hospital, doctors and patients learn to have a realistic and full discussion on all the risks, so that patients can make an informed decision.