Waiting for a hip or knee operation is traumatic for older people and demand is increasing. But some waiting lists are edging down. Éibhir Mulqueen reports
Lame and in pain about sums it up for people on waiting lists for hip replacement operations. Those waiting have, in the past, run into many thousands. But with improved assessment, information technology and improved operating facilities, some hospitals are, for the first time, showing significant reductions in case loads.
And it couldn't have come sooner. With people living longer and older people projected to make up a greater proportion of the population, it is an operation that is increasingly going to be needed.
Since 1996, when the Health Amendment Act made health boards more accountable for their budgets, there has been growing pressure to reduce waiting list times using existing resources for an operation renowned for bringing immediate relief.
Last year, the North Eastern Health Board area, covering Cavan, Monaghan, Meath and Louth, began a re-organisation of its orthopaedic services, designating Our Lady of Lourdes Hospital, Drogheda, as the regional centre for trauma cases and children's elective (planned) cases, while Our Lady's Hospital, Navan, became the centre for adult elective surgery.
"We carried out a major rationalisation and reorganisation of services," explains orthopaedic consultant Mr Owen Barry. "Both were doing their own thing and that resulted in duplication of equipment and duplication of lists.
"It involved a major re-think for people in the region and a very extensive consultation process because it also had effects for Dundalk, Cavan and Monaghan. We re-organised the clinics in those centres also."
The results are that the number of joint replacements has increased by 20 per cent, to 446-335 hip operations and 111 knee operations. "The total number of operative procedures in Drogheda and Navan has gone up from 3,600 to 3,961. That is a 10 per cent increase right across the board," says Barry.
For fracture cases, 70 per cent of the region's population has access to a clinic within 24 hours of the injury. Weekend and bank holiday cases make up the remaining 30 per cent.
The effect on the waiting list for hip replacements has been to reduce the number of adults waiting more than a year for an operation from 287 to 44. For all forms of orthopaedic surgery, the number is down from 905 in 2002 to 627 in 2003.
In Castlebar, Co Mayo, a €40 million development programme being completed at the 317-bed Mayo General Hospital includes a new orthopaedic unit - the programme includes new maternity, acute psychiatric and accident & emergency units, a general surgical ward, and a 33-bed orthopaedic ward and a clean air theatre due to open in late summer, which general manager Tony Canavan calls "a really, really big step for Mayo General".
He describes the use of the new resource as critical for minimising waiting lists for hip and knee operations, in co-operation with the regional orthopaedic centre in Merlin Park Regional Hospital, Galway.
"What really matters is how long the person on the waiting list has to wait. It does not matter for the patient if there are 3,000 people on a waiting list," he says.
The new unit will also deal with about 2,500 trauma cases annually, a legacy of the county's poor road infrastructure and high car dependency, giving Mayo a serious traffic injury rate which is a third above the national average.
"The safest road you can travel on is a motorway. You will rarely hit a car coming in the opposite direction," orthopaedic consultant Mr Derek Bennett notes.
The county, which has a population of 117,000, has about 16,000 elderly people, a higher proportion than any other county in the State, and about 40 per cent more than the national average because of its high migration levels.
In the past, orthopaedics was a problematic area, which quickly led to long waiting lists for planned hip operations as emergency 'trauma' cases took precedence.
Canavan and Bennett are aiming to combine the greenfield site status with an analysis of demographic trends and GP surveys to produce the most efficient service possible. Mr Bennett describes beginning a service from scratch as "a unique advantage".
"The difficulty in the health service over the past few years is that the ability to respond to the unforeseen has been mopped up by the day-to-day stuff.
"The absolute beauty of the system here is we can evaluate service demand and tailor our resources to exactly match it."
While capable of dealing with a major disaster, when extra capacity is not being used for trauma cases, it will be diverted into elective procedures such as hip and knee operations. "With information technology, you can fine tune systems as effectively as possible," Bennett says.
As joints wear out due to osteoporosis and with older people's susceptibility to hip and knee arthritis, it is possible to forecast how many elective procedures and how many repeat procedures will be needed.
"As our population gets older, more and more people are living long enough to get hip or knee arthritis," Bennett says.
Repeat procedures also need to be factored in as artificial joints wear out. "Several years down the line we are going to create a need for secondary and indeed tertiary joint replacement.
"This is a service for which there will be a rapidly expanding demand," he adds.
In the Western Health Board area, covering Galway, Roscommon and Mayo, the waiting list period for in-patient treatment, as of December 31st, was approximately 31 weeks for adults and 20 weeks for children. There are 456 patients on the in-patient waiting list. The board states it is working in conjunction with the National Treatment Purchase Fund to reduce waiting lists, in line with the National Health Strategy (NHS) targets, specifically targeting those people who have been the longest on the waiting lists.
One of the main goals of the NHS is that no adult would have to wait more than 12 months, or no child more than six months, on a waiting list, although this target, which should have been reached at the end of 2002, has not yet been attained.