This site is intended for health professionals only

It’s an obstacle course

Wondering why there’s been a reduction in hip and knee replacement surgery? Here’s a clue. It’s not because patients are getting less demanding or less obese. Nor is it because of the vast range of pharmaceutical options currently available to us, which start with topical NSAIDs and end with, er, topical NSAIDs.

No. The explanation is this. To achieve a TKR, say, the following must happen.

1. My referral must fulfil the increasingly draconian criteria of the service restriction policy, ie the patient must be slim, fit, motivated, compliant, toned by physiotherapy and suicidally pain-addled.

2. My letter must be detailed and compelling enough to satisfy the referral review panel, ie the patient has knackered her hips/knees running marathons for charities which aim to ban the clubbing of baby seals, and wishes to be pain-free and mobile enough to be able to visit her leukaemic grandson in Australia before it’s too late.

3. The patient must successfully negotiate the inevitable diversion to a physiotherapy limb practitioner who will simply repeat all the assessments and therapies she’s already had and who will then say: ‘See you GP for a referral to the orthopaedic surgeon’, which is what I’d asked for in the first place.

4. If the patient somehow escapes from the Kafka-esque loop of 1-4 above, she must not be put off actually agreeing to the operation by a surgeon who seems to equate ‘gaining consent’ with ‘scaring the bejesus out of’.

5. My patient must avoid dying during any of the above.

In short, to get anywhere near a knife and a prosthetic joint, they have to get through a gruelling obstacle course. And who could do that with those knees?

Dr Tony Copperfield is a GP in Essex. You can email him at and follow him on Twitter @DocCopperfield.