The pre-op assessment is a really important part of the process. It’s an opportunity where we get to impart a lot of information to patients about what will happen in their journey through hospital and after that in follow-up.

Perhaps the easiest way to think of it is that were going to do an assessment of the patient to make sure that were making that process as safe for them as possible. There are some medical checks, blood tests, heart tracing and general assessment of ability of people to be able to mobilise and to be safe at home when we let them out after hospital.

I think central to that process is the transfer of a lot of information to patients about what they can expect. And wed also expect to answer a lot of your questions about the precise detail that may be very specific to you about having a joint replacement.

You have a letter that comes through and it does tell you, warns you, that you’re going to be there for three/four hours and take a book or, you know, take something with you. I think most people would do that anyway but a friend drove me there so I didn’t have to go on public transport. And almost immediately the receptionist was really good, lovely. She said that obviously there were times when you’d be sitting still but just let me know if you want to go away and have something to eat or drink and so I am aware that you’ve gone.
And there was almostI was given a sample bottle to go andto the loo. Take a plastic cup from the water dispenser with you; it’s much easier ladies [laughs]. And then sort of handed it back and then almost immediately I had the nurse who was going tointroduced herself and said that, you know, I’m your main person today and went through for blood pressure, blood tests and then told me and went through sort of the other things I was seeing. Came back to the waiting area and somebody else was already asking for me. So everything was going really well. I saw a physio who talked about afterwards [after surgery]; gave me some more information – it was one after the other. Then I think we went off to have some lunch, came back and that’s when I saw the consultants and yeahoh I forgot the nurse did the MRSA check as well. But everything sort of flowed really well.

Did you have an ECG as well?

Yes, somebody gave me, yes somewhere along the line. I don’t think it was that first nurse; it must have been another one, yeah putting all the leads on. So there was very, you do, you are seeing different, lots of different, seems to be lots of different people but it’s all very efficient.

Went up for the pre-op, and a good system going. Went to see all the different people in turn, and one of the last bits was blood pressure test. And that was when it was found that I had high blood pressure, which was a bit of a bombshell really. But, you know, being self-employed and pressures of work etc., I suppose it, and my lifestyle, I don’t eat a lot of green stuff. So then it was just a case of getting the blood pressure under control, which my GP done quite well. Had a bit of a murmur on the heart, but that turned out to be, I think they said it was just hardening of the arteries, age as well. But they didn’t seem to worry too much about that.

In terms of all the doctors, nurses, physios, anaesthetists?

They couldn’t have been better; they were excellent, really excellent. They were so attentive and that, you know, if you rang the bell for them they were there straight away and they couldn’t do enough for you. It was really good; it’s an excellent hospital, excellent.

Was there anything that could have been done better in that respect, healthcare wise?

No, I don’t think so, I can’t imagine, no.

The doctors, I didn’t see a lot of them. I guess it might have been nice to have spent a little more time with the doctors. But I recognise that, you know, the pressures on them. The physio was fine. I thought she was very helpful. Obviously one saw quite a wide range of nurses and there were some who I was a bit disappointed with.

Some were really good and helpful and so on. But there were some who, you know, you’d ask them, Could you do something to help me, do so and so? And they’d say, oh, they’d come back. And they didn’t come back. And that happened two or three times.

And I mean once, for example, you know, the ward was quite close to a road and at night, you know, one wanted the blinds down. And I asked a nurse to do that and she said, Yes. Walked off and never came back. And so I had to get out of bed on my crutches and go across and do it. Which seemed unfortunate. So I was a bit surprised, and particularly given the ward wasn’t that busy, that that happened. But, you know, some of the other nurses were great. And, it was mixed.

When you say the nurses, some of the nurses were great, how were they different to the ones who weren’t so good?

Well, I think they were, they seemed to know about ones personal situation and were just sort of, I felt, better at connecting with you, me as an individual. And in terms of paying, you know, you felt they were paying attention to you as a person rather than maybe just going through the motions.

I had something like a week and a half between my, or two and a half weeks, I don’t remember, between my holiday and the surgery date, and I got a cold. And you have to phone the hospital up the day before you have your surgery and I phoned them up, and I said, Well I’m okay for it, but I’ve got a cold. And she said, Oh well I can’t make a decision about that, I’ll put you through to the ward. So she put me through and I got a nurse who said, Well take two paracetamol.

And I thought, that’s a funny bit of advice, ‘cos I’m actually telling you, not for advice about what to do with a cold but does it matter whether I’ve got a cold? ‘Cos they hadn’t said anything about if you’re not well, nothing at all, but I thought perhaps being unwell is significant if you’re having surgery. I don’t know.

So I went in the next morning, you have to be there at 7 o’clock having starved yourself, and my daughter came and so we both got up at the crack of dawn. And I saw a nurse and I said, I’ve got a cold. And she said, Oh right. Well tell the doctor. So I saw the pharmacist and I said, I’ve got a cold. She said, Right well tell the doctor. So I saw the doctor and I said, I’ve got a cold. And he said, Oh right. Well I think it’s important that we do the surgery today because you don’t want to put it off, but you must tell the anaesthetist. And I finally, the anaesthetist was the last person I saw, I said, I’ve got a cold. And he said, Well you’ve got to go home then.

And then he said, Well did you tell anybody? And I told everybody, and I thought, you know, if he was going to say that before, I mean they’d known he was going to say that, then why did I have to go in? But I don’t know whether it was just him that was going to say, No, you’re not having the surgery. Or whether it was all anaesthetists, you know, or whether a different one would have said something different. So it was a bit silly ‘cos I’d even got arrows drawn on my leg by that time and I was in a gown. I was first on the list. I was all ready. And I had to go home again. So I was out again by 8 o’clock. So I had to go back to work as well having said goodbye to everybody.

I called my GP and I said, They cancelled it for the 10th. And then they put me in for the 31st of July. And then it was cancelled as well.

Any reason?

Well, I haven’t seen any reason in a letter. These are the letters and they didn’t say any, give any reason. So I called my, I went to see my, I called the GP and I said, you know, It’s been cancelled again. And that’s the third time. And I don’t get any good reason why. I mean the first time, when they said they couldn’t get the letter from the, they didn’t have the letter from the [hospital name], then I could see with that. But the next two times after that, I can’t see why they cancelled it. And I was supposed to be emergency.

Did your GP call them afterwards?

Yes, my GP, well, she didn’t call them in front of me, but she said she will call them and she will talk to them. And she talked to the consultant at the Nuffield, secretary, speak to them and things like that. And every time when she called and they make an appointment, then they cancel it.

So next time that I went back and I said, I’m getting fed up of this thing. I’ve got to make a complaint, I shall complain. And I said, I’ve been cancelled three times. The first one was because I didn’t get any letter from the [hospital name]. And I saw them cancelling as a lack of communication between my GP, the [hospital name] and the Nuffield. So I get, I get a bit cheesed off with it all. I wrote to PAL and

You wrote to PAL, PAL? Patient Assistance? [Patient Advice and Liaison]

Yes, yes. Patient Advice Liaison, yes. And I wrote to them and I explained to them about being cancelled so many times and with one reason that they gave me. And they contacted the Nuffield, this is the letter I’ve got from them, and they contacted the Nuffield and the Nuffield put it from the 31st of July and brought it forward to the 24th of July because PAL got in touch with them.

One of the things I was surprised about was that I wasn’t initially offered any physiotherapy after the surgery. Which seems to me when you’re, you know, having expensive surgery, not to have physio arranged when exercise really is so important to ensuring maximum benefit from recovery. At least that’s my understanding. However I did, after sort of putting some pressure on, I was given an appointment at a local clinic, NHS clinic. I went once. And then the next appointment was a month later and I decided that was too long for me. So I went and got private physiotherapy and was able to see someone on a regular basis. And that was, I found, extremely helpful.

I would say that physio, you know, fairly regular physio appointments should be part of the process. And I’ve been someone who’s done sports and been used to exercising. So for me it was sort of natural. For people who haven’t, you know, and maybe people who are very overweight and find it difficult, they really would need a lot of help with this I think. And I think it’s wasteful of NHS resources in terms of expensive surgery if people haven’t got that back-up. Which, you know, okay, it costs quite a bit, but not that much. A tiny percentage of what the surgery would cost to ensure that they can make, get most benefits from the surgery. So I would say that would be a major recommendation.

Did you feel you were given as much information as you needed?

Yeah, I think beforehand absolutely fabulous. You know, you’ve got all this information. You’ve got people that are actually talking to you that are interested and presumably. And then you have this really big fall, black hole, afterwards.

Were you told anything about what happens afterwards because you’re told a bit about recovery aren’t you in that video?

Yes, yeah.

But what were youwere you expecting to have more appointments and then it’s a bit of a shock when you don’t?

I think it’s because yeah, theres I asked the physio who came round on a Saturday morning and got me out of bed and, no didn’t get me out of bed, l leapt out of bed. I was so pleased that I could get up and she went through the exercises that you have to do and I’d seen they’d got a hydrotherapy pool and I said, “Is there any follow-up?” and was a smack in the face when she said no and not even locally, which happened before when I’d had the meniscectomy [surgery to remove all or part of a torn meniscus. A meniscus tear is a common knee joint injury], I’d had local follow-up on, you know, at physio.
So yeah I didn’t realise that there was this full-stop that you came to. And friends and family would ring me or, you know, visit and say, “How are you doing?” “As far as I’m aware I’m doing OK, I don’t know. I don’t know whether I’m supposed to be doing any more than I am.”

You said that there was a big hole in terms of follow-up. So you came back home and did you go back after six weeks I suppose?

Yes.

But were you expecting at that point that maybe you might see a physio after a couple of weeks or something like that?

I think yeah, I thought that I know when I sort of had problems with the knee that I was seeing a physio for three or four months you know, once a month. So I assumed that maybe that would happen afterwards because the physio you see, I saw wasbasically it was just an examination to how, you know the sort of your angle of your knee bend and asking you questions about pain and are you doing the exercises.

That’s in the six week appointment?

That’s, yeah, the outpatients which I found out was the discharge clinic and that’s it.

Could you tell me what would be the ideal situation, what would happen if you leave the hospital, you come back home to recover; you mentioned district nurses coming if you’re living on your own for the first couple of weeks because it is difficult. And what else would be good during that, you know, coming home phase?

I think actually to have like within the first month, the end of the first month, a physio appointment just so they can check on your progress and say, “OK you’ve mastered these ones; I would like you to do these ones as well, as much as you can.” Obviously, you know, people have different sort of levels of pain and whether they can master the, master it.

What’s really important after joint replacement is regaining a good range of movement. And a physiotherapy [exercise] programme is critically important in doing this.

Anything which allows you to try to get your leg moving in a full arc of movement is to be encouraged. And this strengthens the muscles around your knee and in the end improves the functional recovery that you get.

In a small number of cases, patients struggle with their range of movement. And what wed like to do is to intervene early in that situation. And that’s one of the important checks at 6 weeks is to make sure your movement is coming back. And that’s a key part for us.

Sometimes when people were doing their exercises in the early stages of recovery, they wondered if they could damage the knee. Is there any way that they could damage it or is that highly unlikely?

If you follow the guidelines for recovery following joint replacement and specifically partial knee replacement, there are very low risks of damaging a knee replacement.

The thing that wed wish to avoid are falls. And falls can lead to damage or sometimes fracture around a knee replacement. But that’s very, very unusual. And most people recover very steadily and avoid those sorts of issues if they stay within the realms of the recovery programme we lay out.

If someone did accidentally fall, who should they see first?

Well, I think once you’ve had a fall, if you’re able to get up and everything seems fine, then I think you can monitor that yourself.

If you have a fall and you feel new pain or theres swelling in the knee and it’s clear that something more serious has happened, then I think initially the person to contact is your GP. And your GP tends to assess that situation and will refer you through the appropriate channels.

You came home, you did your exercises?

Yeah.

Did you feel you were doing them OK or how…

Yeah, yeah.

But it would have been nice to

To have some feedback really, to have someone else to tell you that you’re doing OK. You know you think you’re doing good, you can get around but you don’t know what anybody else has experienced so, with no feedback, you don’t know if you’re doing good or you just sort of messed it up really until you go to a physio and they say, “Well your leg’s doing well,” and they bend it right over.

What would have been the ideal situation in that time, so if, you know, if the hospital or the GP or the physios could, you know, provide a service and they were listening to your feedback, what would you suggest?

It would be good after, let’s say for the first eight weeks really you can just do the standing on the stairs and whatever you do and the exercises they gave you. But after that and you’re going back to work, I think it would be good to have half a day physio just doing knee bends or building your muscles up.

Half a day physio?

Well a couple of hours, not a whole half day, but yeah.

Just once or?

Just once a month maybe so once you get the idea of what you need to do you can carry on that for yourself, which isn’t so bad. But you’re frightened to do anything for yourself because you know what damage you’re going to do.

And there was no one available to give feedback. Did you ever feel like going to the GP or you felt?

No, I was fine. I was happy to have no pain and go back to work.

But there was no physio at all?

No, no.

The physio is my sort of mainwell not complaint really, it’s just a theory from my point of view. You know, I think that it would have benefitted me just all the way through from the first time I met the physio guy to going back to work.

Even if that’s just someone here local rather than having to go back?

Yeah, most surgeries or cottage hospitals have a physio department and you only need to spend an hour. I mean if you have to contribute towards that it wouldn’t be the worst thing in the world would it? You know, if you say you’re going to see a physio it’s ten pounds a session, I don’t think many people would complain about paying that for every week or every fortnight. And I think to make that decision on your own is, you don’t know if you’re doing the right thing so that would be my only thing physio all the time. And the physios I’ve had at the hospital and everywhere else have been really good; can’t sort of complain about it, it’s just not got the time to do it with everyone.

The only thing I think is a shame is that once you’re discharged you don’t get any physio. And I know it’s difficult because they’re busy. But I almost feel it would be easier for me because I know I’m a bit perhaps younger than people that might have it done if they’re older. But if you could go once a week even just to see a physio, it makes you feel more that you must do your exercises. Because you’re left to your own devices really. And that makes you a little bit more, I must get on and do that or else they’ll know I’m not doing it. But that would be my only thing as a follow-up thing. I would have liked to have seen someone rather than just be left for six weeks before you go back and see the doctor and presumably be discharged at that point.

You mentioned it would have been nice to go for physiotherapy once a week.

Yes, yes, yes. It’s like anything, isn’t it really? If you go to a fitness class and you’ve got a specific time when you’ve got, you, you go, you do make time for it. When you’re left to your own devices, you think you’ll do it, do it later. And later comes and you don’t do it. So a video would perhaps help. Or I think they did say you could go in for drop-in, you could drop in at the physio at the hospital. But I think you had to ring first. It wasn’t something you could just go and do. So I do understand though that they’re pushed up there and they can’t see everybody that has, you know, joint surgery on a weekly or daily basis at all. But actually I wondered whether it would be possible, if they could do group classes.

The physios?

Yes. So like if every day there was a group class and they could see however many people they’ve got room for that have all had knee surgery. And you can all go along at the same time.

Going from sort of what my family have said and friends, you have the strength of character to do all the things that they’ve told you to do. It always worries me that there are people that aren’t going to do that. I’m on my own. I live on my own and, if I was older and living on my own, I would be far more afraid than I had been. Because one of the things I have is an over the bath shower. It was frightening, it is frightening getting into that bath and showering when you’re on your own.

And I don’t know, I think it would have been good if they had had a ten minute/fifteen minute visit from district nurses if nothing else, nothing else yeah in the first few weeks. As I say, I’ve got a good family and friends that were constantly in touch. I always make sure I was wearing clothes, or whatever clothes I had had pockets in so I could carry my mobile phone around with me and strategically place it when I was getting into the shower and things so that I could reach it if I fell.

It was little things like that and it would have just been nice if it’s just encouraging as well; encouragement you are doing well, you are doing OK but I think you really now need to push yourself a little bit further in this direction.

The physio was very good. He had a, we had a lengthy discussion. And I mean I have complicated personal circumstances. My wifes disabled with a progressive neurological condition. And because we have carers, there was a whole discussion around how the surgery could be organised such that we could make arrangements for carers. You know, so that, because obviously we would need people in much of the time initially while I was recovering. So there was a very good discussion about that and I think that was very helpful.

And then when I saw the surgeon in January, we had again quite a lengthy discussion about the pros and cons of the surgery. Which again was I think very helpful. And we both sort of ended up I think agreeing now was the time in terms of quality of life, that my situation had got, you know, much worse. And given my personal circumstances, with my wifes disability, that I, you know, I was going to find it increasingly difficult to help her, because she needs to be moved from chairs to wheelchairs and so on, with a dysfunctional knee.

So, so you had those discussions. And then a date for surgery soon after?

It took a little while to get the date. Which was worrying because one wanted to make the arrangements for carers. And there was a bit of toing and froing with the surgeon’s secretary, saying, Look, can you give us a date? We need, you know, I need it to be able to start making all the arrangements. But then I guess I had about three weeks’ notice of the surgery.

Three weeks’ notice?

[Mhm]

And was that enough time to organise in terms of carers?

It was, yes, yeah [mhm].

Well, the follow-up appointment is a really important moment. When you’re discharged from hospital we might not see you until the 6 week point where you attend for follow-up. And that’s an opportunity for the majority of patients to have some feedback from our perspective about how the operation has gone, to assess the wound and check that you’re progressing in the right direction.

It’s also a point where patients, if they are having problems, can raise that with a health care professional. And in the small number of instances where there are real problems, we can address them. And we can bring you back into hospital to make sure that you’re back on track.

I think patients are really reassured by that follow-up appointment because it’s an opportunity for you also to ask questions that may have arisen in your rehabilitation, reinforcing the amount of activity you can do, what you can expect going forward from that 6 week point. So I think it’s a really useful meeting, the follow-up appointment.

Is it usually the physiotherapist who they’ll see at the follow-up appointment?

There are two real streams. A lot of our patients are routinely followed up by our physiotherapist practitioners, who are highly experienced in seeing patients after joint replacement. And I think patients enjoy that contact with them.

A smaller number of patients are seen by the doctors involved in looking after the patients. And there may be reasons why you are brought back to a physiotherapy clinic or to see a doctor, which are specific to each individual. But overall everybody is seen at 6 weeks, and it’s a great check to make sure everybody is moving in the right direction.

Some people were wondering if they’d be having x-rays at the follow-up appointment. So what usually happens when they get there?

The follow-up appointment usually doesn’t involve an x-ray. X-rays are taken whilst you are in hospital, before you leave hospital. And then at the 6 week point you’ll have a meeting, an interview with a physiotherapist or a doctor, where we will check the wound, make sure the knee is moving well. And that improvement in movement is a key marker for us of how the patient is progressing.

Well check that, well ask you a lot of questions about how you’re doing. And we might take a score to see, so we can try to measure your progress.

The pre-op assessment I thought was fantastic. There was no, there was a bit of waiting but not very much. I thought it was going to last much, much longer. Everybody was helpful, lots of information. I came away sort of really happy and pleased about that and went in. I had the op; was determined to come out the next day and the physio said, “Yep, OK.” They were very busy. I felt sorry for the nurses. There seemed to be not enough of them. I didn’t suffer because of that but, you know, I just didn’t want to be in hospital and came out the next day, which was great and family rallied round, sort of helped with everything. I was so pleased I could walk without the pain. I knew there was dull ache from, an ache from the operation, but it was great.

But the one thing I don’t understand was no follow-up – you’re left on your own. If you don’t have the backbone, the courage, the strength, to do the exercises and get doing it yourself there was nothing, absolutely nothing and I was so surprised that this is what it was like. I just couldn’t get over it; I really couldn’t get over that. You know sort ofI had a new dressing to put on and I thought, ‘I’m going to go and ask for the surgery to do it so at least somebody professional is looking at this,’ and which is what I did. They were very good, very nice and so it looked OK and I thought, ‘Well thank goodness for that, somebody’s told me something, it looks OK. And then I had to go back to the surgery with I’d be given the clip removers at the hospital to go to the GP’s. But then you’re on your own, completely lost.