Trends in admissions for hip fracture in England and Wales, 1968-85.

should be provided in all cases. The high incidence of patients seeking advice from the general practitioner or district nurse after their return home was worrying and is not a problem of which we are aware in our normal practice. Complications perceived by patients may not necessarily be regarded as complications by a surgeon but, nevertheless, we were unhappy to discover potential infection rates of around 15% after inguinal hernia and varicose vein surgery. Patients having this type of surgery remain in hospital for only a day or so. Inflammatory and infective sequelae are likely to have resolved and may be forgotten by the patient by the time of the surgical outpatient review at two or three months. We intend to survey our patients treated locallv to see if the trend can be confirmed. Transient testicular swelling in three patients after inguinal hernia repair was attributable to one surgeon whose practice was probably to overtighten the internal inguinal ring. Personal technique has been modified. An unexpected finding highlighting the cost of waiting lists was that 13 patients (11 5%) awaiting routine elective surgery claimed that they were unable to work. Though patients rated the scheme highly, the scheme was not without difficulties. Nevertheless, the apparent success of the scheme challenges the traditional approach of initial assessment, operation, and follow up being performed by the same surgical team. Problems might be expected in matters of contentious management and certainly some patients had slightly different operations from those recommended by the referring surgeon. The preoperative ward round must therefore be conducted with the importance and the duration of the outpatient consultation. When complications occur they are best dealt with by the operating surgeon and may not be appreciated when review is carried out elsewhere. Patients were generally allocated for transfer to Wroughton by availability and geographical clustering rather than by the nature of the operation and expected duration of the procedure. Problems were therefore encountered with the content and duration of some operating lists. It is crucial for the efficient use of theatre time and the appropriate allocation of surgical staff that case selection should be made by the operating consultant surgeon and not by administrative personnel. Selection of patients with regard to their fitness for an anaesthetic before transfer is important to spare patients disappointment and a wasted journey. Four patients in our series were returned home without an operation despite prior assessment at the review clinic. An ideal scheme should include advice from the anaesthetic department of the receiving hospital of local criteria and thresholds for deferring operation in the presence of conditions such as hypertension or glycosuria. With regard to overall surgical performance it is not possible to get something for nothing. The rate limiting step in surgical performance in this military hospital is operating time rather than bed space, and as a result of operating on 112 patients from another region the same number of local NHS patients in Wiltshire were deferred. From the operating team's point of view there was no training benefit. The type of routine, repetitive surgery transferred was that which will inevitably be found at low priority on all surgical waiting lists and which we see regularly from day to day. The hospital gained because the Crewe Health Authority contributed £36 per patient per day based on recovery of minimal costs. This amount might seem to undersell the services offered but compared favourably with the existing arrangements of non-sponsorship of local NHS patients. If similar financial arrangements were to be negotiated with health authorities in the local area then there would be no reason to receive elective surgical patients from far away.