A Patient Journey in a Fragmented Healthservice

This is the story of a patient and their tortuous journey through our now fragmented and dismantled ‘National’ Health Service. It is the story of a broken health service and the consequences that result from separating services, ultimately leading to an abolition of any sense of patient responsibility. It’s not an extreme case with dire consequences, neither is it particularly emotional beyond frustration, but it highlights everyday problems faced by patients that simply shouldn’t happen.

A close family member (we’ll call her Mary) has been suffering from carpel tunnel syndrome for a number of months now, that has slowly been getting worse. As a primary school teacher who does a lot of lesson planning and marking, she was often symptomatic because of the problem and it was becoming difficult to write or type for extended periods of time, especially as the problem was in her dominant hand. Carpel Tunnel Syndrome isn’t a particularly serious health problem, but it does affect everyday life and is also very common. Thankfully it has a simple treatment which involves a small operation to relieve pressure on the nerves traveling through the wrist by severing a tendon that wraps around them and can become tight when inflamed. It’s a straightforward procedure but requires a reasonable incision at the wrist that needs time and care to heal adequately. Symptoms are usually drastically improved following the operation.

Mary was referred for this operation by her GP in Kent (South East England). As a primary school teacher, she had to book a few weeks off work for the operation and recovery as well as arrange for another, older family member to travel a fair distance to help look after her son as she is a single mother. On the day of the operation, she arrived at the hospital to be told her operation had been cancelled as her notes had not arrived. A second operation date was scheduled for two weeks later (requiring a last-minute reshuffle of leave from work and rearranging cover for her school class). On arrival to hospital for the second operation, Mary was met with the same situation of lost notes and a cancelled operation. She was then told that next time they would go ahead with the operation anyway, regardless of whether or not the notes turn up (why this couldn’t be the case the first time round is anyone’s guess!).

Third time lucky, and now on unpaid leave from work having had to rearrange absence twice already, and the operation went ahead. Quick and simple, Mary was able to leave hospital later that day, although before she left she was informed that the hospital no longer offer any follow-up from a surgeon or even junior doctor after the operation, but a nurse would remove the stitches at a later date. Mary left hospital without any written information on wound care or what to do if a complication developed.

When it came to have the stitches removed, Mary was called into a cubicle by the nurse who immediately started to remove the stitches. Mary stopped her and asked whether her wound should perhaps be cleaned first as there was of course some pus and dried blood etc around the wound site (the incision for this type of operation is rather deep). The nurse simply replied that she was not trained to wash wounds, and was only paid to remove stitches. Turns out, on questioning that the nurse was actually an ‘axillary nurse’. She suggested Mary wash the wound herself and put some moisturiser on it! The dirty wound was then re-bandaged and Mary was sent on her way with no more follow-up at the hospital allowed as it was no longer funded.

Predictably, Mary’s wound was not healing adequately as the edges were not coming together at all. Her GP said there was nothing he could do as the surgery didn’t offer any service that could help anymore. Mary’s friend, an A&E nurse practioner from across the county, saw the wound and was amazed that nobody had taken responsibility for it yet. She suggested visiting her A&E department for it to be glued together.

Wound glue is incredibly expensive and not an ideal solution for this type of wound salvaging. It’s designed for head injuries that have just happened as an alternative to stitches. It wasn’t designed for poorly healing wounds that cannot be restitched. Mary’s scar is now very wide and hard, making movement of her wrist just as difficult as it was before when she was symptomatic.

This whole, ridiculous journey could have been avoided if the surgeon was allowed a follow-up clinic to review his own work. In a fragmented system where each service is commissioned to Any Qualified Provider, this cannot happen. It also absolves the surgeon from responsibility for complications like this as they cannot have a follow-up clinic even if they want one. Cuts from services meant an axillary nurse was only paid to remove the stitches and do nothing to clean the wound. It a comprehensive NHS that is appropriately staffed, an experienced nurse would have properly cared for the wound at the follow-up appointment, including cleaning and providing sensible advice for self-care. Finally, Mary’s GP should have been allowed to co-ordinate her care pathway without restriction rather than play by the AQP rules of referral.

AQP has started to be introduced across the country. In areas where it has not been introduced, cut to services are resulting in restrictions placed on care such as the ability to suitably follow-up patients. AQP will only make things worse in this sense, and the future of the NHS for everyday problems such as this looks very bleak indeed.

Mary’s lucky to have another close family member who was a matron for 40 years in the NHS, back when care was comprehensive and nurses were able to deliver care properly. Mary was pushed to seek further advice and was sensible enough to go on family advice for wound care and not the silly advice of the axillary nurse from the hospital. However many patient’s are not fortunate enough to have such input and the potential for complications become very serious indeed. Wound infection can be limb and sometimes life threatening and it can develop incredibly quickly. And the cost of this is massively higher in the long run than simply providing a better follow-up service.

A key part of the Act was to abolish the Secretary of State’s overal responsibility for the health of the nation and from the requirment to provide comprehensive care to all. Nobody in this care pathway has overall responsibility for Mary. Not the surgeon, not the GP and certainly not the Secretary of State. As long as each box is ticked at each stage of the patient’s journey, all is well for the government and they can claim that adequate care has been provided.

This shouldn’t happen in a healthcare system as good as the NHS but is happening everyday across the country as a direct result of the ConDem’s Health and Social Care Act 2012. At least Mary was able to have her Carpel Tunnel operated on, as in some areas of the country this service has been dropped completely!




  1. rathfelder · December 1, 2012

    Surely this is nothing to do with Any Qualified Provider – which hasn’t started in most places yet? This is just cost saving, of the most bureaucratic and short sighted kind. If you hadn’t rescued mary she could have sued for damages which would have exceeded all the cost saving.

    • fakethom · December 1, 2012

      I was under the impression the AQP had started in her area. If not then it will only get worse!

      • rathfelder · December 1, 2012

        AQP might work quite well for some things like physiotherapy. I haven’t seen it suggested that it be extended to surgery.

      • fakethom · December 1, 2012

        Surgery will still be a commissioned service, and the hospital offering it will be a qualified provider of that service.
        As far as GP services, a nurse to re-bandage wounds can be counted as an extended service, which are now being tendered out to AQP.

        The focus of the blog piece is that due to cuts and fragmentation of services under any guise has led to a loss of continuity and accountability. Old style NHS didn’t suffer such a problem.

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