Post-Op Highland Fling!

Progress in walking has been one of the most important indicators for me following hip replacement surgery.

I remember how badly I was walking before my surgery. After years of gradual decline, my gait was pretty dreadful. My limp was very pronounced, high heels became impossible, and the distance I could walk without real discomfort was minimal. To call my walking speed snail-like would be an insult to molluscs.

I’ve described in previous posts the early weeks of recovery. By about week six, I was able to walk without pain, though my style was tentative at best. Over the coming weeks, my walking definitely improved, and I was able to walk further and with growing confidence. I would highlight four occasions that signified real progress for me:

1. Hyde Park Yomp

In week 12 post-op, I decided to test out just how far things had improved when Annabel and I had to go to London. After we completed our errands, I suggested we walk to our hotel.

On the map, it did not look so far away, but after about an hour, we found ourselves in the middle of Hyde Park on a very windy, exposed day. We soldiered on (mainly because we had no alternative) and celebrated reaching the end of the park with a spree of selfies and a visit to the Mulberry handbags held captive and waiting for us in Harvey Nichols.

A long walk and a lot of selfies in Hyde Park

A long walk and a lot of selfies in Hyde Park

Eventually, we got to the hotel. I was completely shattered, but took comfort from the fact that the able-bodied 16-year-old with me seemed equally tired. I was pleased to notice no ill effects from my first big post-op hike.

2. St Cyrus Beach Cricket

Two weeks later, we were off for our annual Easter trip with our dear friends to Fettercairn in Aberdeenshire. We always enjoy our time there immensely. The fresh air and beautiful landscape are so relaxing. Even if the weather is rubbish, there is plenty to enjoy in such a picturesque place.

This year, we were lucky with the weather and enjoyed an outing on a windy but sunny day to St Cyrus beach. As usual, we enjoyed a game of beach cricket and this year added beach baseball. I stuck to batting and left the running in the sand to those still in possession of their original hips. Here is Annabel racing to score off a home run hit by Harry:

Baseball on St Cyrus Beach

Baseball on St Cyrus Beach


I was very pleased with my ability to traverse sand dunes and walk along the beach. My progress in similar conditions in the past few years had been pretty woeful so it was a nice surprise to be able to keep up so much better this year.

3. Edzell River Walk

On our last full day in Scotland, we decided to see how we fared on the river walk near Edzell.   This is a scenic, wooded spot full of wonderful sights. The terrain is quite uneven, and there are lots of tree roots and natural hazards making it quite treacherous for the unsure of foot.

In the last few years, my walking was so compromised that I was unable to make it too far beyond point A on the map below. Last year, I remember getting only to point B and needing to turn back because the pain in my hip was so bad.

Beautiful river walk near Edzell

Beautiful river walk near Edzell

This year, I was absolutely astonished to cope so much better. It was mud rather than hip pain that forced us to turn back just before we reached the final point, the Rocks of Solitude. The best guess was that we covered about three miles in total. I was thrilled to make it so far, at a decent clip and without any pain.

  1. Prom Dress Shopping

And finally, the ultimate endurance test – prom dress shopping in the Trafford Centre. Last week, Annabel and I traversed this most hostile of indoor tracks for four hours in search of the perfect dress. I’m pleased to report that the new hip managed this gruelling outing with success.

Posted in Hip replacement, Joint replacement, NHS, Orthopaedic surgery, Patient, Uncategorized | Tagged , , , , , , , , , , , , , | 8 Comments

Happy 12-Week Birthday To My New Hip

My new hip recently turned 12-weeks old.

I had expected to mark this milestone quietly with an x-ray and a follow up visit to my surgeon, but I had to rearrange my original appointment because of another work commitment. When I rang to rearrange, I explained that because my surgeon had done such an excellent job, I was back at work and busy making up for all those lost winter weeks spent goggling Sky Go box sets.

As the big day dawned, I celebrated the end of all the restrictions on my movement by joining some of my Steering Committee colleagues to speak at an NJR 10th Anniversary Regional Event. We were out in force, showcasing the work the NJR is doing to promote patient safety and positive clinical outcomes.

I was delighted to be able to show off my new-found mobility and pain-free state by joining my colleagues. And in high heels, no less. Whoop, whoop:

Family 118

The NJR fielded its A-Team including:

  • Elaine Young, NJR National Lead
  • Martyn Porter, Orthopaedic Surgeon and NJR Medical Director
  • Peter Howard, Orthopaedic Surgeon and Chair, NJR RCC Network.

The day was chaired by the very gracious Pedro Foguet, Orthopaedic Surgeon at University Hospitals Coventry and Warwickshire. Should he ever decide to retire his scalpel and bone saws, he would have a glittering second career in PR. He obviously used his persuasive powers to excellent effect in making sure the room was packed. It was standing room only with an impressive number of orthopaedic surgeons, clinicians, and managers attending.

We started the day with a comprehensive overview from Elaine on the work of the NJR, Martyn gave a pithy analysis of the Annual Report, sharing his insights on ten years of data, and yours truly shared the patient’s perspective.

I couldn’t resist relating some of the highs and lows of my own recent experience and was delighted by the very warm and generous response from the audience. They kindly laughed at all my jokes and asked loads of patient-focused questions during the Q&A panel session.

There was even a ‘lively’ exchange between clinicians who differed (aka nearly came to blows) over the question of whether it’s really necessary for patients to meet their surgeons. One audience member posited that having joint replacement surgery should engender the same level of confidence and trust as booking a flight to Malaga – a patient need not meet the surgeon before surgery just as a passenger does not ask to see the pilot’s licence before boarding. Yep, that one really got things going, and Pedro probably wished he had brought a referee’s whistle with him.

During the coffee break, I was very pleased to be approached by a dozen audience members – all surgeons – who wanted to chat further. It was clear to me how much genuine interest they had in their patients’ wellbeing and how much they wanted to make sure their own practice is as patient-focused as possible.

Posted in Hip replacement, Joint replacement, NHS, Orthopaedic surgery, Patient, Uncategorized | Tagged , , , | Leave a comment

On Being A Patient Patient

I apologise for the lack of blogging content in recent weeks.  In my defence, weeks three to six of recovery from hip replacement surgery are really boring if things are going to plan.  This makes for dull blog content, but, hopefully, long-term successful surgical outcomes.

I don’t think anyone would describe me as patient.  When asked to identify my weaknesses in a job interview, I have, in the past, put “prone to impatience” at the top of my list.  My mother reminded me frequently before my surgery that I would have to be patient during my recovery and be prepared to ask for help.

In recent years, I thought that I had improved in the patience department, not least as a consequence of having children.  When they were very young, my children would unintentionally test me by bellowing, “again” just as the favourite game or story was nearing the end.  Children really love repetition.

For Harry, it was endless readings of “Baby Bear”.  It is nearly twenty years ago, but I can still recite the first few pages of this epic from memory.  I cannot remember which kindly relative supplied this book; it may well have been the same sister who provided the birthday drum kit.

Anyway, I thought years of child rearing and managing large teams of people at work had taught me everything I needed to know about being patient.  Not so.  Recovering from joint replacement surgery really put me to the test.

Although I had received plenty of explicit warnings, I was still surprised to find that the post-op fatigue really is quite debilitating and that improvements are very gradual to emerge.  I found it very frustrating to sit around waiting for my oomph to return.  Unreasonably, I had hoped somehow to be exempt from the promised post-surgical pain, fatigue, inability to concentrate and boredom.

Phrased more positively, I should say that my recovery has been blessedly uneventful and full of slow and steady improvements.  Compared to those coping with complications such as infection, dislocation, loosening of their new joint, ongoing pain and trouble with medication, I have absolutely nothing to complain about.

I would characterise week 3-6 as being full of mini-milestones.  Each day or two, I noticed slight improvements.  These improvements tend to creep on you, and it’s important for your own sanity to recognise and celebrate them when you or someone else spots them.

Recently, my husband was away for a week working abroad.  When he came home, he identified significant improvement in the way I was moving and the things I was managing to do far more easily than when he left.  That was very encouraging and gave me a new perspective on my recovery.  Up until that point, I had been getting very frustrated with what felt like the glacial speed of healing.

Some of the key milestones during this period for me included:

Week 3:

  • Managing stairs better and more frequently
  • Able to sit and visit with others for longer than 20 minutes
  • Improving concentration
  • Less dependent on two crutches

Week 4

  • Able to concentrate much longer and resume work in bursts
  • More mobility
  • Able to walk easily with one crutch and to take a few steps with no aids
  • Reducing pain – no further need for ice
  • Sleep still disrupted but fatigue lessening

Week 5

  • End of blood thinning injections (hurray!)
  • Able to remove reminders for pain medication from phone alarm
  • Sleeping a bit better and experiencing no fatigue in the day
  • Improving mobility and ability to walk longer distances

Week 6

  • Pain free (apart from occasional aches after long walks)
  • Able to walk longer distances with ease and without aids
  • Able to work and concentrate well for long periods
  • Sleeping better
  • Able to say goodbye to the compression stockings (Hurray! But be prepared for the dry, flaking skin which is pretty disgusting).

For me, being free of one crutch made a massive difference.  Suddenly, I could carry items easily, cook and do laundry.  I never thought those would be tasks to celebrate, but it was such a relief to be free of the overwhelming fatigue and limitations of the first two weeks.  I also celebrated my first trips to the supermarket and the hairdresser as significant occasions.

And, when the magical 6 week date is achieved, the real excitement starts.  After week 6, my surgeon cleared me to drive and to sleep on my side.  These are two of life’s true joys.  Perhaps they can only be truly appreciated by those who have been denied them for a long time!

I just had my 6-week check and was told that I am making good progress – particularly in walking well with a good stride length.  I confessed to a few misdemeanours (like putting my socks on without the contraption, walking without aids and tying my shoes) and was absolved as long as I do not strain my hip.

In general, I was told that walking and exercising (but not to the point of fatigue) are fine, but I still need to be cautious until late March.  The danger in feeling well and pain-free is that it is tempting to overdo it and strain the still healing muscles and nerves.  I am determined to behave myself and follow any rules that will promote the health and longevity of my new hip.

Posted in Hip replacement, Joint replacement, NHS, Orthopaedic surgery, Patient, Uncategorized | Tagged , , | 42 Comments

Early Recovery From Hip Replacement Surgery

I was not entirely sure what to expect in terms of recovery. My surgeon warned me that the first two weeks would be a write-off, and I should expect to feel tired and unable to concentrate on anything for very long. After this, he predicted I would gradually have more energy and vim.

The hospitals’s pre-op education session was excellent for generic information and tips, but every specific question about recovery was answered with a catch-all reference to the rules with an acknowledgment that everyone is different and will be advised by their surgeon on what they can and cannot do.

The recovery information was definitely pitched at the most cautious level for the lowest common denominator. We were left with the impression that we were all facing the same 12-week endurance test.

And yet, looking round the room, I was struck by how different we all were in terms of size, age, general health and underlying fitness. Amongst others, there was a very young, healthy-looking chap in his early 40s, there was a wheezing octogenarian facing a third joint replacement operation, there was an older, very obese man in a wheelchair who was not able to walk. Although we were all facing the same operation – total hip replacement – it was simply counter-intuitive to believe that we would each experience an identical 12-week recovery given the variety of our start points.

Confession time. I am a devoted Strictly Come Dancing fan. When it was announced that judge Craig Revel Horwood would be having his hip replaced in late October, I became more interested in watching the progress of his hip action than the dancing. Who could fail to be impressed by the incredible speed and success of his recovery? Each week I was on Craig-Watch noting each bit of progress:

Week 1 – he stayed in his glittery, high-backed judge’s chair and looked a bit peaky. He was dressed, upright and coherent which I took as a good sign.

Week 2 – he joined the judge’s upstairs for “Len’s lens” using elbow crutches and sitting on a cushion with his operated leg out straight. He didn’t say much, but was clearly mobile and with it.

Week 3 – he was down to a diamanté-encrusted stick and still sitting on a cushion. He took part fully in the chat and seemed to have all his acerbic faculties back in place.

Week 4 – he was walking aid-free and was generally more animated and mobile throughout the show.

Week 5 – dressed as the Phantom of the Opera, he whirled and twirled his way across the dance floor as part of the opening sequence before taking his seat. Astonishing.

Craig Revel Horwood set the hip replacement recovery bar very high and seemed to make a mockery of the doom-laden warnings. It was my fondest wish to breeze through my post-op experience in exactly the same style. Well, maybe minus the orange tan and definitely less jazz-handsy.

I know it’s obvious, but the reality of recovery is completely individual. It’s probably not much use comparing yourself to others as their situation may be very different to yours. When I was still in hospital, many of my fellow Ward 5 inhabitants had had surgery many days and in some cases weeks before me, and yet many were quite bed-bound and seemed, to my ill-informed eye, slow to recover. There may be all manner of reasons, complications and individual experiences of pain that affect individual progress.

I do count myself as one of the lucky ones, having been set free on day 3 post-op, complication-free, and with a little bag of paracetamol and codeine tablets to take every six hours as needed.

I was thrilled to be home. My first experiences were very humbling, and it came as a massive shock to me (and my family) just how much help I needed at first. As soon as I got home, I managed to climb the stairs and then required a two-hour nap to recover from my exertions.

I quickly settled into a routine for the first week, but continued to be surprised by just how tired and debilitated I felt. Getting up every hour or so and promenading around a bit on my crutches was satisfying, but exhausting. I did feel quite vulnerable particularly if no one was home with me. I took to carrying my phone with me and making sure that friends with keys to my house were on standby in case of emergency. I was particularly concerned about falling or dropping my crutches and being stranded. I certainly didn’t feel sociable and found it too tiring to sit and chat with others for longer than 20 minutes or so.

And despite feeling so tired, the long, deep, restorative sleep I craved stubbornly eluded me. I slept in two or three-hour bursts with uncomfortable, achy stretches in between. My leg was still a bit swollen for the first week, and the golden rule of sleeping on your back didn’t help. After a few hours of remaining fixed in this position, my leg would begin to ache – around my knee and the outside of my thigh – badly enough to wake me and then to keep me awake.

I am hugely grateful to my lovely family who have looked after me superbly well and with great patience. I have tried to become a patient patient and to express my sincere gratitude for the many kindnesses Mike, Harry and Annabel do me on a daily basis. However, I have once or twice, felt really ratty and frustrated with my limitations. It is hard to wait for your body to catch up with what you want to be doing.

I am now at two weeks post-op, and, although I don’t feel back to normal, things have improved significantly. I am able to walk around easily and can manage on one crutch. Stairs do not hold the fearsome power to exhaust, and I no longer need a nap after climbing them. The District Nurse came to remove my dressing and to check my incision. She was very impressed with the “very small, very neat” incision and its healing. I celebrated by having a shower which felt marvellous. I am able to concentrate better and can visit with friends and family. Sleeping is still uncomfortable and patchy, but I am stringing along slightly longer bursts of sleep.

These were my week one and two recovery life-savers which I commend to you:

1. Ice packs – ah, the bliss of an ice pack on your operated leg is lovely. A friend recommended frozen peas as more malleable and less leaky than ice cubes. I have stuck with ice, but can confirm this requires at least two zip-lock bags, following an unfortunate but comical incident involving a leak, a hair dryer and an electric under blanket.

2. Pillows galore – have lots of pillows to help you sleep. I have two large bolster cushions and two normal pillows to keep me more upright. Mimicking a hospital bed makes the forced stay on your back slightly easier to sustain. I also have a firm pillow on its side for between my ankles to prevent me turning or crossing my legs. I will be so glad when I’m allowed to move around again in my sleep!

3. Have a table by the bedside with: drinks, painkillers, mobile/iPad charger, snacks and blood thinning injections all to hand.

4. Have a sturdy bin by the foot of the bed to hold crutches, the helping hand/grabber and shoehorn. Ideal for preventing your aids from falling to the ground. Have another bin by the toilet to make sure your crutches are always handy.

5. Set your phone alarms to remind you when to take tablets and injections. I found this important in the first week when I was napping a bit and could not remember when I last took a paracetamol. I became more sophisticated by assigning an apt song for each alarm. The time for painkillers is heralded by a rousing chorus of “Paradise” by Coldplay, and the loathsome, painful injection time is preceded by “Do The Bad Thing” from the Arctic Monkeys. I have not discovered a secret to pass on to help with the injections. My stomach is horribly bruised. Even after two weeks I have no idea why some injections are hideously painful and bruising and why some are only very painful and slightly bruising. My technique must be rubbish, but so far nobody else is interested in trying to do better.

6. Keep your mobile with you at all times, particularly if you are on your own. This is important if you have a fall and for peace of mind if you feel a bit unsteady.

7. Use travel mugs with a lid for hot drinks. The lid keeps the drink hot for longer and makes transport less leaky. I credit this tip to my friend from Ward 5 who is very inventive and creative. She has designed a tool belt for her Zimmer frame from which she can hang the handles of three travel mugs and assorted other items with ease!

8. If you build a rapport with fellow patients in hospital, exchange numbers so you can text once at home. I found it a great help to keep in touch with others going through the early stages of recovery at the same time as me. There is no pressure to reply, but we are able to check in, to swap ridiculous stories and to blow off steam.

9. If you have an iPad or a laptop, load it up with iPlayer downloads or, if you have it, Sky Go programmes. For me, this has been an absolute lifesaver, particularly given my intermittent sleep patterns. Whoever invented this technology deserves a medal and eternal thanks from house-bound, immobile insomniacs like me. Before my operation, I thought I had been rather clever in timing my recovery to coincide with The Ashes. The England performances have been so dire that had I been watching as planned, I might have relapsed. Anyway, Sky Go very thoughtfully provides countless films and box sets as an alternative to Ashes depression. I have enjoyed The Thick of It (absolute genius), Rescue Me, The Sopranos and The Wire so far. Thank you, Sky Go!

Posted in Hip replacement, Joint replacement, NHS, Orthopaedic surgery, Patient, Uncategorized | Tagged , , , , , , , , | 24 Comments

Excellent Care – Not So Excellent Facilities

Today, I am celebrating my first full week post-op. It has been an eventful time and quite the learning experience.

A week ago, I arrived on the pre-op ward early in the morning with my wheelie bag of nighties and clothes, some books, my iPad and my post-surgery aids. Mike was dismissed at the entrance to the ward, on the grounds that it is a small, single-sex area. Although this was not what we expected, it was the best thing for us. Some people – like Mike – are not naturally nurse-y and do not cope too well in the waiting. I was glad that his possible business trip to New York on the day of my op was rescheduled for February so that he could take me to the hospital, but it would not have been good for either of us to have him anxiously hovering by my side before I went in. I told him to go home, but he opted to work in the cafe until he could see me on the ward.

I only had a brief wait on the pre-op ward where I changed into the hospital gown and compression stockings. I was told to put my winter coat, scarf and socks on top to make sure my body temperature stayed in the acceptable zone for surgery. I did not realise there is a minimum body temperature below which your recovery is compromised and your surgery may be delayed or cancelled.

During my wait, I answered several times the questions that were to become the pre-cursor to most of my interactions in the hospital: what is my name, date of birth, procedure (right total hip replacement), allergies, medications.

I was visited by my surgeon’s registrar to discuss risks and to sign the consent form. He was lovely – very reassuring, calm and clear in making sure I understood each risk thoroughly. He explained the preventative measures to be taken during and after surgery (eg antibiotics and blood thinners) and the tests he would perform to make sure my sciatic nerve was not damaged (foot-flexing). He drew a large and artistic arrow and the letters ‘THR’ on my right thigh which was oddly reassuring and took his leave saying he would see me after the surgery.

Minutes later, two nurses appeared to bring me to the anaesthetic room. They informed me I was on the “Enhanced Recovery Programme.” I had never heard this term before and did not know what it meant. Beyond confirming I had attended the pre-op education session and being told that I should be discharged in 2-3 days, there was not time to discuss this any further.

Given the choice of walking or riding, I decided to have a last limp on my dodgy hip to say farewell and to attempt to warm up. We soon arrived, and then everything happened with lightning speed.

The anaesthetist introduced himself as he put a cannula in my right hand. As he taped it in place, he asked if I wanted a spinal or a general anaesthetic. “Spinal, please,” I said, adding that as nice as everyone was, I would prefer not to be chatting or aware of what was happening. “Don’t you worry,” he assured me. “I’m going to give you a good hit of a special mixture called ‘I don’t give a damn,’ and if you seem to be coming round, I will give you some ‘I really don’t give a damn.'” Now you’re talking, I thought. This was a man after my own heart. He was as good as his word – the last thing I recall is him asking me to press my back against his hand as he found the right spot for the spinal.

I did surface briefly during the final stage of the surgery. I was lying on my side and could see the blue towel drapes in my peripheral vision. I could hear my surgeon and his registrar talking and then heard vigorous hammering. I couldn’t feel anything, but I knew that din of panel-beating was going on inside me. A second bout of hammering led me to look for the anaesthetist. “I’m a little too here,” I said. “Don’t worry,” he said, “It’s nearly finished. I’m taking care of this right now.” Seconds later, it was good night, Vienna.

I came to in the recovery room feeling great. I especially enjoyed the ‘Bair Hugger’ – a gorgeous, hot-air filled warming blanket that moulds round your body as it raises your temperature. I would like to be permanently dressed in one of those all winter, please. Bliss.

The recovery room tests were as promised with frequent checks on what feeling I had in my feet. Strangely, the feeling came back in my good leg first, and there was a gap of two checks before I could feel a hand pressing on my operated side. I wish I had been told to expect this beforehand as it made me a bit anxious.

I did not have a long stay in the recovery room and was wheeled off to my new home on Ward 5 before I knew it. For the rest of the afternoon and evening, I felt great. I was sitting up and enjoyed visiting with Mike and Annabel and speaking to friends and family on the phone. I met my bed-bound neighbours and their families.

Although I was connected to a PCA – a machine that administered 1ml of morphine intravenously when I pressed a green button – I did not feel the need for pain relief. I gave a few, experimental presses throughout the evening when I thought I sensed the start of a background ache. All in all, I felt so well that I thought, “This is a doddle. What’s the big deal?”

Morphine Is Not My Friend

That smug sense of comfort evaporated at 3am when I was woken by extreme pain all over my right leg. I felt like I had fallen off a cliff. I pressed that green button. I tried to distract myself during the 5-minute intervals before I could press the button again. It was agony. I started to time the interval on my iPhone stopwatch as I simply could not imagine that 5 minutes could take quite so long.

In desperation I pressed the nurse’s call button. I explained I was in great pain and the morphine did not seem to be working. The nurse looked at the PCA which showed that in 12 hours I had only made 9 presses and that I needed to be patient while the pain relief built up to take effect.

I pressed that button with fervour every time I spotted that the green light was illuminated. Eventually, the pain became bearable, but the side effects of the morphine were incredible drowsiness (the sort where you conk out mid-sentence) and constant sickness. I spent all of the morning and early afternoon in a fog of sleep and sickness. I became a popular subject for monitoring as my respiration and blood pressure rates dropped significantly.

The highlight of my day was a visit from the physios who asked if I would like to have a go at getting out of bed and standing. Truth be told, this was not top of my wish list at that exact moment, but I am a compliant soul, and I knew that getting moving quickly after surgery was in my own best interests. “I’ll give it a go,” I answered. This was met with exclamations of delight and approval. The three physios were so encouraging and wonderful. They explained how to get my legs to the side of the bed safely. This took a lot of effort, but there I was sitting up with legs dangling. We paused so everyone could admire my slippers and I could let the room stop spinning.

My slippers - approved by Annabel and much admired by physios and nurses

My slippers – approved by Annabel and much admired by physios and nurses

Then I stood up and was amazed to find that it really was true that my new hip was safe to bear my weight. I was instructed on how to coordinate stepping forward with using my crutches and managed three steps forward and three back. I was told I had done very well but looked quite dizzy so that was probably enough for day one. I celebrated by getting back into bed, throwing up and dozing.

By the way, this experience was instructive in explaining how post-op patients stay on their backs when asleep – at least in the early days. That operated leg weighs a ton and is as immovable as granite. The chance of accidentally turning on your side appeared to me to be nil.

By the evening, I managed to perk up a bit with the help of an anti-nausea tablet and enjoyed a visit from my brother-in-law, a wonderful fellow who brought holiday pictures and M&S chocolates! I was looking forward to a good night’s sleep, but, unfortunately, it turned out to be a wild night on Ward 5.

Morphine Was No One Else’s Friend Either

From my bed-bound vantage-point, I had not experienced all of Ward 5. I could see that it was a huge, old-fashioned ward with beds arranged in three long rows (two rows along the outer walls and a row in the middle of the space. I was almost opposite the nurse’s station in bed 3 and looking across to the far wall, I could see the sign for bed 25. That’s a lot of people in one ward.

Every bed was occupied with a mixture of hip and knee replacement patients at various stages. I’d learned from my bed 4 neighbour that she had been in for 8 days since her hip surgery. My bed 2 neighbour was also a hip replacement patient who had been in for some time. She was physically doing well and was able to walk around the ward with a zimmer frame, but she was also confused and not always aware that she was in hospital.

The ward closely resembles a busy train station in terms of bustle, noise, fluorescent lighting and general aesthetics. There is very little space between beds, and the only privacy measure is to pull a flimsy curtain around a bed. This still means every patient is audible though not visible. There is a constant hubbub as the nursing and catering teams dispense medications, vitals checks, food and drink, sick buckets and commodes on a constant basis. Even at night, this activity continues unabated with only one set of the most glaring lights turned off at around 11.30pm. With patients, staff and visitors all talking, the din is quite overwhelming. Needless to say, Ward 5 does not provide a restful environment.

I dropped off to sleep when the big light was finally switched off, despite the continuing burble of conversation among patients and nurses including a long grumble about sluices not working properly.

So much for restorative sleep. At about 2.30am, Ward 5 became a madhouse. All at the same time, a new patient at the far end of the ward began shouting about going home, calling the police, having the staff arrested for kidnapping; another new patient, two beds away from me in bed 1, began plaintively shouting, “Help me. Somebody please help me,” which she repeated at top volume without a break; my neighbour in bed 2 announced she was just getting up to make her husband a nice cup of tea; and someone in the middle row fainted and fell.

Over the next several hours, the two shouters seemed to be in a competition to cause maximum disturbance. The poor staff ran between the beds of the shouters and wanderers trying to keep everyone safe while still trying to meet the routine needs of the other 20+ inmates. I’ve never witnessed anything quite like it.

It is incredibly eerie and disturbing to hear someone repeatedly shouting for help in the wee, small hours, particularly if you are bed-bound. Moaning Myrtle, as I named her to myself, had great stamina in sharing her repertoire of: “Help me. Somebody please help me. Ooh me knee. Ooh the pain. I can’t breathe. I’m frightened,” which she belted out for more than seven hours without a break.

Initially, I was very concerned for her. I caught the eye of one of the nurses at about 4.30 and asked if anything could be done. She assured me that the patient in question was being looked after but was not pressing her morphine button often enough. She said the other patients were also affected by morphine which was causing drowsiness, ravings, confusion and sickness.

I confess that once I witnessed Myrtle verbally abusing the day nurses who arrived at 8am when they tried to help her, my sympathies went out the window, and I just wanted her to pipe down! She was apologetic the next day, confessing she thought morphine was terrible stuff.

Despite the disturbed night, I managed to get out of bed, walk around, go to the toilet and get rid of the PCA. I promised the physios that if they would persuade the nurse to remove the cannula in my hand, I would walk the whole ward and take the stairs test. It was incredibly painful to use crutches with that needle in my hand, and I was thrilled when the nurse agreed. I was told that subject to various tests (walking, stairs, OT, blood tests and X-ray), I would be discharged the next day.

Once I was mobile, I was able to experience every aspect of Ward 5. Sorry about this, but I feel compelled to comment on the toilets. There were just four toilets for 25 patients. Each toilet had a commode frame over it to raise the height of the seat but which also covered the flush mechanism. In practice, the height was set wrong for a number of patients and, to put it delicately, they frequently missed. On most visits there were puddles all over the floor. In addition, there was nowhere safe to put crutches, and mine fell into the puddles more than once.

I found it astonishing that a hospital absolutely at the cutting edge of surgical practice and with an enviable record of performance on infection prevention had such primitive facilities. I found this aspect of my stay really awful. Surely it’s not beyond the wit of man to install toilets with an adjustable seat height, an accessible flush mechanism and a bin like the one below which I use to keep crutches from falling over?

Excellent tip from the education day - put your crutches in a tall bin by the bed and toilet. Surprised not to see  this on Ward 5.

Excellent tip from the education day – put your crutches in a tall bin by the bed and toilet. Surprised not to see this on Ward 5.

As a Non-Executive Director of an NHS Trust, I and my Board colleagues are always interested to understand the patient experience. It occurs to me that there is no substitute for direct experience, and I think all Directors (Executive and Non-Executive) should be encouraged to spend a night on a typical ward to appreciate what it’s really like for patients. From this experience, I have no doubt that many practical quick wins would be identified that would really enhance the patient experience.

When I was discharged, I was given a feedback card and asked if I would recommend Ward 5 to others. I found the tick box (with choices ranging from definitely would to definitely would not recommend) and small comment box a bit inadequate to sum up my experience. I received top notch surgery and excellent care from all the clinical and allied health professional teams. I found all the domestic and catering staff incredibly kind and helpful. That said, I felt the ward was too huge, too noisy, too bright, too unmanageable and too outdated to provide a good environment for rest and recovery.

Unlike many of my fellow patients who had stays of 10+ days, I was extremely fortunate to get sprung on day 3 and was eager to say thank you and goodbye!

Posted in Hip replacement, Joint replacement, NHS, Orthopaedic surgery, Patient, Uncategorized | Tagged , , , , , , , | 8 Comments

Home Now

May I present my new hip – ta da:


This is a copy of my post-op x-ray kindly presented to me by my surgeon on Wednesday with a detailed explanation of the component parts.

In essence I have a particularly dainty femur so am now sporting the smallest possible stem snugly cemented into my thigh bone with a rather natty ceramic cup secured with one metal screw and a bit of polyethylene covering my hip socket to boot.

The day after my surgery, the Registrar who visited me explained my surgery went very well although my small femur presented some complexity. I’m thinking this translates as: large hands, small bone, desire to keep the incision as small as possible.

I am recovering well and am delighted to be home. It is just day four so I’m not yet at full strength. I will continue to post details of operation day, life on what must surely be the largest ward possible and post-op recovery. Again, many useful pointers from other patients have been very beneficial, and look forward to passing these on.

Posted in Hip replacement, Joint replacement, NHS, Orthopaedic surgery, Patient, Pilates, Uncategorized | Tagged , , , , , , , , , | Leave a comment

More Daunting Decisions – What Surgeon

I was warned that I would have a long wait from diagnosis to consultant appointment, and it was several months before I received a letter from my chosen hospital.  This informed me that I would be under the care of Surgeon A.  When I received my appointment letter, I did a Google search of Surgeon A and was reassured by his depth of experience and accomplishments.

At the appointment, I found Surgeon A to be very kind and empathetic.  He explained that his approach was to take a long-term view of my care over the next 40 years and that I was really too young for surgery.  That was strangely flattering.  However, I was greatly taken aback when he said I should wait for surgery until I was 55-years-old because I would be lucky if a replacement joint lasted 6-8 years.

I was so surprised by this very limited life for a new joint that I struggled to take in much more of what he said while he gave me additional advice about movement and pain management.  In my head, the phrase “lucky to get 6 to 8 years” was on a permanent loop.  As I prepared to go, he mentioned that he would see me annually to check my condition and that, if at any time, I felt the pain was becoming unmanageable, he would do my surgery sooner.

Off I went home thinking that I should now focus on accepting the limitations I was experiencing with good grace.  I decided to embrace my high pain threshold and stop whining.

In the year that followed, before my next appointment with Surgeon A, I was appointed as a Patient Representative with the NJR and began to become much better educated on the subject of joint replacement surgery.  Having access to the data in the Annual Report, the Public and Patient Guide and, most importantly, to other patients’ experiences was an enormous help in giving me a better understanding of my condition and the options available to me.

It was my good fortune that an early meeting of the NJR Patient Network was held on the eve of my follow up appointment.  My fellow patients were very open in telling me about how they went about choosing their hospital, surgeon and even, in some cases, their precise replacement device!

I was given excellent advice on how I might frame my questions to understand my options in greater depth and I jotted these down on the train ride home.

On reflection, I know that I benefited enormously from the advice of one of the Network members who described her many surgeries.  Her view is that it is vital to have a surgeon-patient relationship where the patient feels able to ask questions and understand the rationale for any procedures.  She described the times she was unwilling to compromise when she just didn’t “click” with a surgeon.

Next day, I went to my annual review with a spring in my limping step.  Armed with my list of questions and the latest copy of the NJR Patient and Public Guide, I felt better informed and more optimistic about asking the right questions.  I was determined to listen carefully, to write everything down and to avoid getting unduly distracted by any single unexpected answer.

As I entered the waiting room, I was further buoyed by the site of these posters which covered every wall:

Njr poster

How wonderful that the message on this poster so succinctly captured the questions on my list!  My expectations were raised, and I was anticipating a much more informative discussion.

When I was called in, my first surprise was that I was not seeing Surgeon A, but his fresh-faced registrar.  He was perfectly pleasant, but did not inspire confidence when he asked how I was going on with my knee.  I replied that my knee was fine, but I was there regarding my hip.  “Your hip?  Are you sure?” he asked.  I promised him that I was indeed sure that it was my hip keeping me up at night and not my knee.  I gestured at the computer screen in front of us which was displaying an x-ray of my pelvis.

Once we agreed that it really was my hip we needed to discuss, I took out my list of questions and asked what was planned for me and what my options were.

The fresh-faced registrar said that, unfortunately, he really was unable to comment on my options.  He added that if I remained under the care of Surgeon A, I would receive a cemented ceramic hip and a type of incision with certain risks.  I asked if this was because these approaches represented the best option for my circumstances, and was told, no, these were the approaches Surgeon A felt most comfortable with, and, therefore, what all his patients received.

In the end, I resorted to the question that women of my age rely on: “If I were your Mum, what would you advise me to do?”  He said he would advise me to seek a second opinion with Surgeon B with whom he was also training.

I confess I felt a bit deflated by this meeting.  Putting posters in the waiting room exhorting patients to “Ask 3 Questions” should, at the least, be met with clinicians who are prepared to answer the 3 questions.

I discussed the meeting with family and friends and decided to follow the advice and to seek a second opinion via my GP.  I was told that I would have to undergo another orthopaedic assessment and that the current waiting list was several months.  I said that was fine, believing I had nothing to lose, particularly as Surgeon A wanted me to wait another eight years before having my joint replaced.

Eventually, I received an appointment with a specialist physiotherapist for the assessment.  This was a real turning point for me.  I was very fortunate to be seen by someone who was exceptionally caring and utterly determined that I should receive the right treatment.

She advised me of three things that made a massive difference to me:

  • I was doing the right thing in seeking a second opinion
  • Doing so was not, as I feared, a betrayal of Surgeon A
  • My increasing pain and decreasing mobility were relevant considerations.

What’s more, she advised me that if I were not happy with my second opinion, I should seek a third, fourth, fifth and so on until I felt completely confident.

Second Time Very Unlucky

Again, after a long wait, I received a date for my second opinion with Surgeon B.  A Google search yielded evidence of his extensive experience, and the nurse at the hospital (pre-consultation x-ray) advised me that he is an excellent surgeon.  Unbidden, she added that I should be prepared to answer his questions succinctly and should focus my answers exclusively on my hip as any irrelevant detail or venturing into trivia would be most unwelcome.

Heeding her words, I made sure I had my questions written down and rehearsed for pithiness.  I took heart in spotting that the “Ask 3 Questions” posters were still adorning the walls of the waiting room.

The meeting was a complete disaster.

Surgeon B arrived accompanied by a young woman physiotherapist who stared at the floor and did not speak before, during or after the consultation.

He asked me why I was there, and I explained I had been advised to seek a second opinion by his registrar as I had questions about the treatment planned for me and how long a new joint would last.  Before I could finish my first question about what my options were, he shouted, “Stop!  Stop there.  You have no business asking about such things.”  He clearly felt that my interest was inappropriate and that I was in some way challenging him.

It was a very uncomfortable ten minutes during which Surgeon B went on to tell me that although I was meddling and out of line, he would describe his practice and the approach he would take if he were doing my surgery.  On average, his patients get an average of 20 years from a new hip, he identified the surgical approach he would take and named the replacement device he would select.

I could not wait to leave and felt deeply upset.  I felt horribly embarrassed, as though I had been presumptuous and overstepped the mark and then got found out and was soundly told off.  It was awful.

I really did not know what to do.  I felt I had the choice of Surgeon A, a very kind person who was predicting a limited outcome or Surgeon B, who predicted a much more successful result, but who made me feel bad.

This choice rattled around in my head for weeks.  I decided to keep taking the codeine and avoided making a choice between Surgeon A or Surgeon B.

At the time, I had forgotten the sage words of advice from other patients and physios about continuing to ask for opinions until you feel confident in your choice of surgeon.  I’m not sure why I forgot about this advice, but I was stuck in a mental holding pattern between choice A and B.

Some time later, a wonderful NJR colleague asked me how I had gone on with my second opinion.  I outlined the bare bones of the meeting and the dilemma I felt I faced.  She insisted I should seek a third opinion immediately and set about making this happen.  I am immensely grateful to her.

Third Time Is The Charm

As a direct result of my NJR colleague’s intervention, I sought an appointment with Surgeon C.  By this stage, I had had a fall and was feeling concerned about the way my hip function was deteriorating.

In light of past experience, I concluded that I should not attend any further appointments on my own.  Mike, my husband, agreed to rearrange his schedule to come with me.

As an aside, I would say, no matter how confident and prepared you feel as the patient, it really is important to have someone else there to take in the information you are being given and to remind you if you forget to raise something.

There is a world of difference between acting as an advocate for someone else and receiving information yourself, as the patient.  I have concluded that it is very difficult to process information dispassionately and accurately when it’s your body being discussed.  I recognised that I had a tendency to get stuck on a detail mid-conversation, and I certainly did not want a repeat of my experience with Surgeon B.

So with some trepidation, we arrived for a meeting with the very experienced Surgeon C.  I need not have worried.

Instantly, we were put at ease and filled with confidence.  Surgeon C reviewed my notes and x-rays and asked me questions about my pain and movement.  He explained my situation clearly in terms that were easy to understand and gave me his advice – that I should not hesitate in having my hip replaced.

He inspired total confidence in every way.  I did not need my list of questions and concentrated on listening to his advice which was comprehensive, clear and reassuring.

When he said, “I’m thinking because of your age, activity and height, option A device should be….and that I should have option B as a back up just in case, but I would be interested to hear your view,” I wanted to shout “hallelujah!”   Not because I had a strong view on device A or B, but because this was confirmation for me that Surgeon C was applying his knowledge and experience to work out what would be best for me given my specific situation.  That was all I really needed to know.

That he was so delightfully nice and kind and such a great communicator provided the icing on the cake.

I wish his approach could be bottled and shared with other surgeons.  I hope he has lots of students who are learning from his technical skill as well as his humanity and communication skills.

Because of Surgeon C, I am now facing my date with destiny in two days with much more confidence than I imagined possible.

I am sorry for the self-indulgent length of this posting.  I hope that describing my experiences may help other patients feel confident in choosing a surgeon.

To recap the excellent advice I received from others:

  1. Do not be reluctant to request another opinion
  2. It is important that you feel confident in your choice of surgeon
  3. Do review the surgeon-level data available at: This is a developing area, and the data available now indicates whether your surgeon is providing data to the NJR and how many similar operations he or she performed.
  4. Do prepare questions (the Ask 3 Questions are spot on)
  5. If possible, always bring someone else to any consultations.
  6. Do seek advice and support.  Arthritis Care provides a great online forum and a free helpline.  Patients are also very welcome to join the NJR Patient Network.
Posted in Hip replacement, Joint replacement, NHS, Orthopaedic surgery, Patient, Uncategorized | Tagged , , , , , , , , | 11 Comments

Daunting Decisions – What Hospital?

Immediately after receiving my diagnosis, I was asked to choose a hospital for my treatment.  I was not particularly knowledgeable about the options and asked for advice from the physio who diagnosed my condition.  She said most people are referred to their local hospital and suggested that might be the most convenient option for me.

I confided in her that my son had had a particularly bad experience at our local hospital, and I felt reluctant to go there for my treatment.  I explained that a few years previously, Harry broke two bones in his forearm playing football at school.  Following surgery to pin the two bones, he acquired MRSA which went undiagnosed for several weeks.  He went on to develop acute osteomyelitis, a serious infection of his ulna bone which put him at risk of losing his arm and his life.

Poor Harry had a pretty gruesome time of it requiring eleven surgeries, many weeks in hospital, intravenous antibiotics and a long spell attached to a wound vacuum.

Happily, he made a full recovery, and, as a measure of his positive outlook on life, he credits the whole dreadful chapter as “a good thing”, enabling him to find his vocation to become a doctor.

He bears some permanent reminders of his experiences in the form of two long, deep scars on his left arm.  When anyone asks about them, he typically says with a smile, “You should see the other guy.”  He is a very wonderful, sorted fellow.

I, on the other hand, am cut from far less forgiving cloth.  Without question, watching my son in pain tops my “life’s worst moments” list, and I felt uncomfortable planning my surgery at the hospital where his woes originated.

My physio said she understood my feelings and mentioned that both she (carpal tunnel) and her father (knee replacement) had recently had successful surgery at another hospital known as an orthopaedic centre of excellence.  She thought I might be best going there, despite its distance from home.  I agreed, and that was that.  First decision, choice of hospital, made.

Choosing the right hospital is very important from the patient’s point of view.  Given the opportunity, many people choose to research their options and compare the performance of different hospitals.  There is an increasing amount of information in the public domain available to assist.  The NJR Annual Report and Public and Patient Guide are good places to start.

Many patients also look at the NHS Choices website which includes information on infection rates, number of similar procedures performed and details of patients’ experiences.  This last section is a bit like a “Trip Advisor” with patients providing ratings on a scale of 1-5 and comments about their stay.  As with all similar systems, the comments range from glowing endorsements to very detailed complaints.  I made the mistake of looking at my hospital’s ratings recently and am now worried that I might be sent to the fearsome-sounding Ward 5!

Posted in Hip replacement, Joint replacement, NHS, Orthopaedic surgery, Patient, Uncategorized | Tagged , , , , , , , , , , | Leave a comment

Diagnosis – A Long and Surprising Road

Like a lot of osteo-arthritis sufferers, I found my diagnosis came as something of a surprise.  For years, I had been a keen runner, swimmer and Pilates devotee, and I dismissed the nagging pain in my hip as muscular discomfort resulting from over-doing it a bit.

After a year or so, when the pain in my hip began to travel down to my knee after a run, I finally mentioned it to my GP.  She gave me a referral to a physiotherapy clinic where I was advised to stop running, to rest and to complete a number of exercises and stretches at home.  I did all of the above diligently and returned every four weeks or so to have my progress assessed.

At every session, I was also offered “massage treatment” to release my “trigger points”.  “Oooh lovely, yes, please,” I recall saying the first time round, thinking how nice it would be to have a relaxing massage.  Ha! I soon discovered that “massage” in this context meant something a world away from the pleasant spa experience of my imagination which, of course, involved aromatic candles, fluffy towels, warm, fragrant oils, soothing sounds of the sea interspersed with the odd whale call.

In fairness, I should have guessed something painful was to come when my physio reminded me to tell her if the treatment became too intense to bear by raising a hand if I found myself unable to speak.  A “safe word” for a massage?  Really?  What kind of a wimp did she think I was? And then, the treatment started…

My physio understandably believed that my pain was muscular and linked to an inflexible ITB (or iliotibial band which is the fascia that extends from knee to hip along the outside of the thigh).  The massage initially involved pressing hard on trigger points otherwise known as clumps of knotted muscle fibres in my thigh.  That wasn’t too bad and actually provided some relief.  The ITB release, however, involved dragging an elbow with strong pressure slowly along the outside of my thigh.  Oh boy, that hurts.  And I’ve had two children.  At the end, I was congratulated on not crying.

As the months ticked by, I was getting worse instead of better.  Although I had stopped running and was doing all the recommended exercises and stretches, I was finding my range of movement was reducing and my pain was increasing.  My sleep began to be disturbed, and, to my astonishment, I found myself waking up in tears on occasion.

After nearly a year, my physio decided to refer me to her boss as she confessed to being flummoxed by my continuing symptoms.  And so, a few weeks later, I met the senior manager of the team.  She asked me some questions about my medical history and any past injuries to my hip (none).  She asked me to stand up and demonstrate how close to the floor I could comfortably reach with straight legs to assess my hamstring length.  Then she asked me to lie on the bed with my leg in the air with a bent knee.  She gently moved my leg around to assess the range of flexion and rotation my hip could accommodate.  Within seconds, she said she was 99.9% sure I had severe osteo-arthritis and was in need of a hip replacement.  She said she would refer me for an xray at the local hospital to confirm her diagnosis and would phone me when the results arrived.

This was not at all what I expected.  I remember saying that I was too young to have arthritis or a hip replacement.  With gentle good humour, she explained my condition wasn’t like voting and that, although I was atypically young for such severe symptoms unrelated to an injury, arthritis does not have a minimum qualifying age.

Within a few weeks, I was called in for the x-ray and then received confirmation that the predicted diagnosis was indeed correct.

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Pre-Op Assessment – Again

I am very grateful to be treated on the NHS.  When dealing with the anxiety of facing surgery, it is comforting not to be facing financial ruin at the same time.  Nonetheless, my inner control freak/process nerd is protesting at the confusion accompanying the pre-op assessment process.

As I mentioned in an earlier post, for some reason, my pre-op assessment was scheduled nine weeks and six days before my surgery date.  Having previously experienced the need to repeat my MRSA screening test three times before having a cortisone injection last year, I was well aware that the shelf-life of these tests is finite and fixed at a maximum of six weeks.

Hence, I asked the question at my original pre-op assessment.  I was told that “probably” some of the tests would have to be repeated.

As the calendar advanced to mid-November, and my tests approached their seven-week birthday, I heard nothing.  Determined that my operation should not be cancelled because of an expired MRSA screening test, I asked the question several more times.

I asked the person who answered the pre-op assessment team phone number I had been given.  She said I would probably be all right, but just to be sure she would put my call through to someone else.  She transferred me to the admissions department so I asked again.  I was told I would probably be all right, but then again, I might not be.  I tried really hard to understand what I was being told.  It didn’t work.  Even when I asked, “so what exactly should I do now?” I listened attentively, but could not decipher a clear instruction.

Then, last week, three letters came in the post on the same day from the hospital.  Two chunky letters, which were exact duplicates, confirmed that I was ‘passed fit’ for surgery and should appear at 7am on my scheduled date.  The third letter instructed me to attend the pre-op assessment clinic to have all my pre-op tests repeated.

I found this a little confusing.  So I rang the pre-op assessment team again.  They assured me I was passed fit for surgery and did not need to repeat any of the tests.  I would like to say I’m a trusting soul, but the nagging voice inside made me ring the number on the other letter just to be sure.  From the other department, I was told that they weren’t really sure, but it would be best if I came in to repeat the tests.

So, on Tuesday, after an interesting Board seminar on risk management at the NHS Community Trust where I am a Non-Executive Director, I raced up the M6 to make my appointment on time.

As I’m in process nerd mode, I will digress to comment on the car parking at the hospital.  Every time I go, there is a cluster of irate patients gathered at the pay and display machine railing at the inadequate facilities, the miniscule spaces adequate only for rickshaws or Smart Cars (both notoriously absent), the charges, the scheduling of appointments which seems to create fierce competition for spaces at peak times, and the distance and terrain from car park to hospital entrance.

When I say “railing” I mean this in the British sense, of course.  There is low-decibel, almost inaudible, grumbling, there is faint tooth sucking, there is head shaking, there is the shared look that passes between fellow sufferers indicating, “I could really do without this just now.”

Despite patients’ seemingly endless capacity to endure inconvenience, this really is poor.  I hate myself for getting into this subject, but I have started now.  Can there be any excuse for a hospital that prides itself on being a specialist centre of excellence for orthopaedics offering such abysmal parking facilities to patients – almost all of whom struggle with mobility?

Anyway, my parking karma was working for me on the day, and I managed to find a space after just three vulture-like sweeps of the car park (hurrah) but then despaired that I had the wrong change.   The machine does not accept 10p coins.  My frantic search of the car, my handbag and my coat pockets was fruitless.  I joined the clucking group by the machine and was offered a bountiful supply of 20p coins in exchange for my useless 10p coins by experienced veterans who came prepared.

As I was limping down the hill toward the hospital, I saw one of my 20p providers remonstrating with the parking warden.  She was cross that a driver, who was unable to fit a normal sized-car into the tiny space allotted, had opted to park horizontally across three spaces. She also added a cutting observation about confused priorities in that the hospital has chosen to invest in a warden to police car parking charges rather than provide adequate facilities in the first place.  She was right.

When I got to Ward 4, it seemed I was indeed expected, and my chunky file was there on the trolley by reception.  The nurse I met was delightful – kind and reassuring – and equally confused as to why I was originally called in so far in advance of my surgery date.  She reported the good news that only some of my tests had to be repeated.  It seems that EKGs, height and weight tests last longer than MRSA, urine and blood tests.  There you go.

I repeat my previous observation that this type of experience – potentially multiplied by hundreds of patients at just one hospital – seems so unnecessarily wasteful of resources when the NHS is under financial pressure.  I am not a logistics expert, but I suspect sorting out these processes would be pretty straight-forward and would bring some welcome clarity for patients and staff.

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