Operation quick-fix

Patients in Southend don't always need to join the hospital waiting list for surgery: they just pop down to their local GP practice. Lynn Eaton reports

John Major would probably call it a "cottage hospital" - though the brick-built GP surgery nestling alongside one of Southend's busiest main dual carriageways looks a far cry from the traditional roses- round- the-door image of a cottage.

For 76-year-old Doreen Hayton, one of 150 patients who have had hernia operations at the surgery in the past 18 months, there is only one word to describe the Queensway practice: "Wonderful". In a purpose-built operating suite upstairs at the surgery, many other patients have had operations: from removal of skin cancers to vasectomies. Queensway is fast becoming a mini-hospital and, for all the criticisms that may be levelled at it by hospital consultants who fear it may undermine hospital work, the patients love it.

Mrs Hayton's hernia had been getting worse: "I'd started getting this terrible pain, like a very painful stitch," she explains. "It would bring me up sharp."

Her GP arranged for her to have the operation at the surgery, carried out by one of the other doctors in the practice, Philip Lafferty, a qualified surgeon. Within only a couple of weeks she was on the operating table. Normally, someone wanting a hernia repair can expect to wait on average three months - and that is only after they have been accepted on the hospital waiting list.

But the advantages don't stop there. Queensway uses a new hernia repair technique that is a vast improvement on the surgery performed in most NHS hospitals.

With a hernia, the internal muscles of the stomach weaken, allowing a part of the intestine to bulge through the weak point. The conventional method of repairing the weakened muscle is to create a patchwork of cross- stitches over the weak area, rather like darning a large hole in a sock. This operation usually involves a three- or four-day stay in hospital, a general anaesthetic and a considerable amount of pain for several weeks afterwards.

But the new technique, known as the Lichtenstein mesh method, uses a piece of gauze over the weakened muscle, almost like a bicycle puncture repair kit. The operation can be performed under local anaesthetic. The patient is up and walking within two or three hours, and the pain felt afterwards is dramatically reduced. Recurrence rates are much lower. The only proviso is there must be a carer on hand to provide a constant watch in the first 24 hours.

A survey of Queensway patients receiving the treatment carried out by the local community health council (CHC) confirms the service was generally felt to be efficient, effective and highly popular. The CHC recommended the service should continue, be supported by other health care providers and extended throughout the area.

"I thought it was wonderful," says Mrs Hayton. "I didn't feel nervous at all. They put you at your ease and explain everything. They give you a couple of pessaries to dull the pain, then I walked into the operating theatre."

Once there, she was given a local anaesthetic. An anaesthetist is always present. Some patients are offered music to listen to - a relaxing tai chi tape is now offered. Patients used to be allowed to bring their own, but their toes would start tapping to the beat, making it difficlt for doctors to perform the operation. One patient was so relaxed he was telling jokes throughout - until he was told to stop laughing because they couldn't get the mesh in place as a result.

"You don't feel anything and there is a screen in front of you, so you don't see anything either," says Mrs Hayton. "I got off the operating table, walked outside and sat in the chair for a couple of hours. I went home and within a couple of days I was back to normal. It was lovely not to have the pain and within 10 days I was swimming and was back at keep fit classes."

Patients are sent home with pain killers, detailed post-operative instructions and contact numbers for the surgeon 24 hours a day for the first few days. They have regular contact with the practice for the next year for check ups. "There isn't any institution in the world that will do that," says surgeon Philip Lafferty. He also says being on closer, first-name terms with the surgeon makes a difference to patients: "I've no doubt about it that they get better quicker."

Hernia repair is one of several operations and consultant clinics now carried out at Queensway. As a fundholding practice - one that is responsible for managing its own budget of pounds 3m a year - it can hire 22 consultants to come into the surgery to provide regular clinics in anything from gynaecology to ear, nose and throat. Although reluctant to discuss the costs of doing so - they even fly in one consultant from Edinburgh - the partners have cut nearly pounds 100,000 from their annual outpatient bill as a result.

"What we wanted is something a lot easier for the patients," says Dr David Pelta, one of the partners. "When you get to know the doctor and the consultant you get a much better rapport. It's much more difficult with hospital consultants. The GP loses control of what is happening. Here you are getting someone who specialises in a procedure, which means they are extremely good at it. Often in hospital it may be a junior doctor who does it."

Philip Lafferty, who performs the hernia operations and many of the other minor surgeries, is scathing of the attitude of many consultants towards operations at GP surgeries. "It's an intransigence because of history and because of unwillingness to change the established way of doing things. It's difficult to change anything in medicine."

From the hospital viewpoint, Andrew Pike, director of operations with Southend Health Care NHS Trust, is a little wary. "There is a tension for the hospital in terms of diseconomy of scale," he argues. "When you've got a big practice outreach clinics can be successful. For a population as dense as Southend I can see it happening. But hospitals don't want to be left without any work to do. Some consultants are concerned that perhaps the balance has swung too far."

The move is controversial, Dr Pelta admits: "Not all consultants can cope with coming out. They are not protected by the white coat. Some people think we should not tread on their territory. But what we are doing is moving secondary to primary care. Hospitals should be dealing with more specialised, complex cases.

"We are not saying we are Harrods, but we hope we can offer something like Marks and Spencer."