Waiting List for foot surgery

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Just had a patient who was told by their GP that they will have to wait until Aug 2011 for a orthopaedic surgeons assessment (through the public sector) for her painful hallux valgus deformity. The patient was very upset.

Once again, this highlights the overwhelming need for specialised podiatric surgeons to work and train in Australian public hospitals.

MERRY CHRISTMAS TO ALL!:santa:

 

With cancellation, changes in rosters etc... that wait will not be as long as it is originally stated.

It may be 6 months or so.

Tell her to book, get her name on the list and make decisions as she goes relating to her management and her need.

Keeping in mind it is considered "cosmetic" surgery and I am sure there are many lists ahead of your patient with potentially life threatening disease/disorders.

We must keep things in perspective. Even if Podiatric Surgeons were allowed into Public Health I would argue that they would make little or no impact on waiting list times for the general public, mainly because:

a) There are too few of them - the waiting list for one of them would be as long as an orthopod!
b) Most would still keep private lists and do what most surgeons in public health do - share a private and public list at a hospital theater.

Keeping in perspective Spur, she does have the option to see a Pod Surgeon privately with yur referral. The out of pocket expense (regardless of private health) in NSW anyhow would be similar to that of an orthopod, with no waiting list. Considering general visits to a Podiatrist, orthoses and anything else might rack up the bills over that two year period, it might be an option for your patient?

Other option is to become close to your local orthopods. I know several in my area quite well and they will generally get them onto a public list if the problem is "urgent" enough after a friendly phone call.

 

There's another way of looking at this.

Perhaps it's the system that's the problem.

If we get a National Health Care system here (USA) (for everyone) we will have the same situation! The only ones waiting here are Medicare patients (i.e., Federal health care plan).

Why rush to perform a surgery on Patient "A" (with Medicare) for $500 when you can perform the same surgery on patient "B" (with private insurance) for $1000?

Steve

 

Steve

The situation is almost exactly the same, in fact.

Here in Australia, Patient 'A' can wait for 1-2 years to have elective, non-urgent surgery (eg bunions) for free. Or they can elect to use Medicare, see a private orthopaedic surgeon (with or without using private health insurance to cover the difference between the Medicare rebate and the surgeons' fee + hospital costs) - potentially a very cheap exercise, but not totally free. The only waiting time is how busy the surgeon is.

Finally, they can see a private podiatric surgeon, pay a fee that is generally not covered (we are just humble toenail cutters after all) by Medicare or private health insurance - and get it done tomorrow.

The problem is not so much the system - I think it is very fair and cost effective - and if you are at the bottom of the socioeconomic ladder - then there is a very decent high quality safety net. You just will need to wait a while if your problem is not considered particularly urgent. Certainly - a bunion is rarely that.

It would just be nicer if podiatric services were given parity with medical services. But that's really our fault.

I think Americans should get over this irrational and paranoid fear of having a government run option for the most vunerable in society. The rest of the western world has been doing this for a long time and we haven't turned into communist dicatatorships. And Steve - you can still earn a sh*tload of money if you are practicing surgery!

LL

 

Hi LL

"I think Americans should get over this irrational and paranoid fear of having a government run option for the most vunerable in society. "

I know the rest of the world has this conception of our system where there are all these poor citizens with no coverage and no helath care.

Nothing could be further from the truth. The problem is that these Government run programs pay so damned little that it actually COSTS the providers money just to treat them, so there is certainly no rush to get them on the schedule.

Did you see the hundreds of Millions being sent from the last TARP payment for Federally Run Health Clinics? Millions and Millions for upgrading facilities and computer data handling soft ware and hardware. These clinics turn NO ONE away.

LL: Many Americans have very strong beliefs in free enterprise (which means NON GOVERNMENT). We are anti socialism. It's in our blood and in our history. Our Government run NOTHING WELL. To think they would be more involved in something as precious as our health care is very very scary to many of us.

Steve

 

All my work here in the UK is for our National Health Service (free at the point of use and available to all).
Here in the UK we work to the NHS 18 week pathway.
We are required to provide the patients with their definitive treatment within 18 weeks of their being referred.
We must therefore effectively see them - confirm the diagnosis - do any tests x-rays - ensure that they are fully aware if the risks as well as the benefits of surgery (if that is the best thing for them) and provide the surgery all within 18 weeks of the date of the letter of referral.

Our system is not perfect and has its faults - but long delays for operations are no longer one of them

 

Podsurg55:

18 weeks!
Well, I'm sorry, but 4 1/2 months does not sound exactly quick!
I guess it's relative.

When I get booked-up 6-7 weeks out for surgery we usually start losing patients. If a patient is in pain, I don't care how "good" you are, patients are not going to wait 18 weeks to have their surgery. Not here anyway.


Steve

 

I bet they would if it were free like it is in the NHS!

If they are dissatisfied with waiting for free surgery - they can just go private and use insurance cover if they have it - and it would probably be done in a couple of weeks.

Steve - I don't understand why you seem to unable to accept that public health services co-exist in quite good harmony with private services in most parts of the world.

There is always a CHOICE. Free vs. pay from your own pocket. If you want it for free, you will have to wait a little while if it is elective surgery (like a bunion or a hammertoe). If it is a rampant diabetic foot infection, you will get an urgent free MRI (if deemed necessary) and be in the OR for an I&D within hours.

It works well - you guys should give it a go!

Over 90% of my friends and family pay for private services - but we are fortunately comfortably middle class. However, it is reassuring to know that there is a public system available to us if the worst of circumstances were to befall one of us.

LL

 

Hi LL:
Well, unless you're living in Bizarro world, NOTHING is FREE. Someone is paying (i.e. higher taxes - fees - etc...most likely those with private insurance are paying for themselves AND those on the Government program)

My problem with COEXISTING (as you put it) is that in a free enterprise system (which I favor, of course) you cannot compete against an entity who plays by different rules.

If the Government has a public health Care system that does not need to show a profit, can acquire added funds through legislation, and does not have to show performance in order to please stock holders, then, well, it's NO COMPETITION!
Why do other countries insist that a Government can do ANYTHING better than the public sector?
How many times does this have to be proven?

If the Government had remained "out of the way" of free economy our present economic "mess" would not have happened.

My 2 cents

Steve

 

Dear DrSArbes
You are of course quite correct - NOTHING is FREE - Someone is paying (i.e. higher taxes - fees - etc...most likely those with private insurance are paying for themselves AND those on the Government program).

I would not disagree with you in the slightest. I pay the taxes and get the healthcare.

I do not begrudge those who cannot afford to pay as much as I can getting the same high quality care that I do, because perhaps the poor child whose parents could not afford his/her cancer care (if they had to go privately) might be the person who survives to come up with a cure for some illness I might get in the future (or be the next leading light in our profession).
You then say that the "problem with COEXISTING (as you put it) is that in a free enterprise system (which I favor, of course) you cannot compete against an entity who plays by different rules.
If the Government has a public health Care system that does not need to show a profit, can acquire added funds through legislation, and does not have to show performance in order to please stock holders, then, well, it's NO COMPETITION!
Why do other countries insist that a Government can do ANYTHING better than the public sector?
How many times does this have to be proven?
If the Government had remained "out of the way" of free economy our present economic "mess" would not have happened."
You also say "18 weeks!.... 4 1/2 months does not sound exactly quick!...........
When I get booked-up 6-7 weeks out for surgery we usually start losing patients. If a patient is in pain, I don't care how "good" you are, patients are not going to wait 18 weeks to have their surgery. Not here anyway."
Well on these statements - I cannot agree with you quite so much.
If we think back to the start of this discussion: I think we would all agree that a waiting list that means a patient being told by their GP that they will have to wait until Aug 2011 for an initial consultation and assessment (through the public sector) for painful hallux valgus deformity is a substandard service. No doubt after the initial assessment and the patient then needed surgery - if they were kept waiting so long to be seen in the first place, the patient would likely go on a long wait to have their surgery.
I hope we could all agree that in a country like Australia where there is a publicly funded healthcare system- if orthopaedics keep people waiting and there are podiatric surgeons who could see patients - it does highlight the overwhelming need for specialised podiatric surgeons to work and train in Australian public hospitals.
I do not understand how free enterprise and the market place is much of an issue, because rest assured the patient in Australia is entitled to pay to be seen privately to be seen sooner. If they are in work and pay the taxes and can afford to pay above and beyond that - good luck to them.
If she cannot afford to pay for private healthcare then we are back to the fact that an initial consultation and assessment (through the public sector) for painful hallux valgus deformity is a substandard service.
Now in respect of my comment that we work within and 18 week pathway.
I think I did say that the 18 weeks was a maximum, and that the time started from the date of the referral and that the time was from the date of referral to the date of the operation.
If we consider the mechanics of that in our system where the patient sees their GP (family doctor) before being referred to any specialist (whether privately or on our NHS).
day one the patient sees their GP with foot pain and he notes hallux valgus and refers the patient to me.
He gets onto our National choose and book computer referral system and books a convenient time and date for the patient on one of my new patient clinics. He then does an e-referral letter with the relevant information.
The next day I look at the referrals on the system and prioritise them based on clinical urgency - using the GP referral information from the GP.
Within a few weeks (based on the patient's preference), I see the patient in clinc.
If this was the ideal perfectly targeted referral would mean we can go straight to considering surgery because all the non-surgical treatment has been tried and failed (if appropriate) and all necessary pre-op test and checks and x-rays etc have been performed and reviewed by me beforehand and the patient has been well informed about the surgical and pros and cons and turns up well informed enough to make an informed decision and give consent for the surgery. This is ideal and not common (but it does happen due to close working relationship and clinical guidelines).
In the absence of the above ideal situation best practice on informed consent and best clinical implies that just as we should not keep patients waiting unnecessarily for surgery - we should not rush to operate either.
Some things do flare up and then settle and every bunion does not need to be removed and every Hallux Valgus does not need to be realigned.
Also some patients may turns up poorly informed or misinformed and need good information to go away and think about it.
So – in the absence of the perfectly ideal situation of no inappropriate referrals coming to us, and all tests and advice and conservative management being undertaken before our first consultation - and the need for additional pre-op consultations as necessary to ensure that the patient has understood the plan and we have explained any test results –x-rays etc and the pros and cons of the specific surgery so that the patient is well informed about the surgical and pros and cons to make an informed decision and give consent for the surgery the 18 week wait limit is not excessive.
Don't get me wrong - we get great results, but if it was me - I would not rush headlong to surgery for my own hallux valgus (if I had one) but would wait until the problem I had with it outweighed the risks of surgery. Now of course here I would be taking into account the level of pain level of deformity speed of deterioration of pain and increase of deformity level joint damage and likely future joint damage and the risks of the specific procedure likely needed to achieve the optimal results; my own medical status and how lucky I felt (weighed against the previous results of the podiatric surgeon and his/her complication rate and experience in respect of the proposed surgery).
Funnily enough I gave up seeing private patients only a year ago, not because I have any hang-up against it but because I just could not offer a patient who asked about private treatment anything different (either better or faster ) than I could offer them through our NHS service.
In addition - although there are lots of horror stories about avaricious USA podiatrists - I have worked with dozens and observed many more and only seen one instance of dubious practice (and I am sure there are just as many bad apples in any group in any country).
So I hope I do not come across as evangelical for our NHS (as I am certainly not), I just would like to try and demonstrate that it is not the public nature of the healthcare system that is the cause of many of the problems, it is as was said at the start of this thread," the dog in the manger" attitude of the orthopaedic lobby keeping podiatric surgeons from providing a service that they obviously fail to provide effectively themselves (either through lack of numbers or interest in foot pathology) and this is exactly the situation that pertained in the UK until we managed to get ourselves able to provide NHS podiatric Surgery).
So while I agree with you that "COMPETITION" is vital - I think that it is not whether it is private or publically funded that is the issue - it is whether there is a level playing field for podiatric surgery and orthopaedics which allows the patient choice of profession expertise and clinician whichever type of system pertains nationally.

 

Podsurg55:

Hi

Wow..I've read books shorter than your post.
I haven't gotten through ALL of it.....I will.

As far as waits - I was talking about from the time I see a patient to when their surgery is performed. I see some of your post has to do with criteria for surgery, etc... beside the point.
You were discussing definitive treatment (i.e. surgery) and this is what I was eluding to.

From the visit when I give a surgical consultation to the time of their surgical date - it can't be 4 1/2 months. They will not wait. This is the time frame I was referring to.

Thanks

Steve

 

Well you can't say I was less than thorough!

Happy Christmas

(from a UK gridlocked by a few inches of snow - but that is another debate re the cost effectiveness of investment versus risk and cost of the resources needed to prevent the problem)