15 November 2018
With the British Society for Surgery of the Hand (BSSH) marking its 50th anniversary last month, it is a good time to consider the status of Hand surgery in the UK. 20% of visits to Emergency departments in England are currently for hand trauma, and elective hand surgery for common conditions is set to increase by 39% over the next 10 years. Yet questions have been raised recently regarding the value of some Hand surgery procedures. NHS England has proposed cuts to patient access for four common hand conditions: carpal tunnel syndrome; Dupuytren’s contracture; trigger finger and ganglia. Whilst ganglia largely do not need treatment timely treatment for carpal tunnel syndrome, Dupuytren’s contracture and trigger finger relieves symptoms, prevents irreversible loss of function and keep patients in employment. These treatments are relatively low cost and have a high level of success and cost effectiveness. Their exclusion will be damaging to patients and, over the long term, more costly to the UK economy as many people will be unable to work without treatment.
As an example: the symptoms of carpal tunnel syndrome (pressure on a nerve in the wrist that causes tingling, numbness and pain in the hand and fingers) affect up to 5% of the population. Surgery is an effective treatment for patients with persistent symptoms, and provides a complete cure in 80-90% of cases. The cost-effectiveness of these procedures can be highlighted by using NICE’s measure of Quality Adjusted Life Years (QALYs). A carpal tunnel release provides 0.78 QALYs for approximately £1,000; well below the threshold used by NICE to guide NHS commissioning, of £30,000 per QALY.
Hand specialists deliver effective, evidence-based treatment for patients. We can often assess and treat patients very swiftly, minimising the disruption to patients’ daily life, ensuring they can return to work more quickly. The evolution of treatment over the last 50 years means that with early assessment by an expert hand specialist, most conditions do not require surgery but can be managed with non-surgical treatments. Injections or hand therapy are the first lines of treatment and often resolve problems without the need for surgery. In addition, the number of patients operated on as day cases under some form of local anaesthesia has risen significantly.
Twenty-five years ago there were around 20 full-time hand surgeons working in the UK. Now, the British Society for Surgery of the Hand has over 700 members dedicated to treating hand problems to preserve or restore pain free function. Our members combine skills from Orthopaedic and Plastic surgery, as well as Emergency medicine, and work alongside other specialist disciplines of Rheumatology, Neurology, Neurophysiology, Pain medicine and Psychology. There is now a far better appreciation of the value of hand specialists. But more remains to be done.
It is critical that hand specialists become better understood across the healthcare system and by the public, so that they can reap the benefits of earlier diagnosis and treatment, and improved outcomes.
Frank Burke has been a member of The British Society for Surgery of the Hand for 42 years.
 In 2015.16, there were 22.9 million attendances at England’s A&E Departments of which 20%, or 4.58 million attendances, were for hand injuries (NHS England, A&E Attendances and Emergency Admissions), BSSH: Hand Surgery in the UK report 2007 –p.13 under ‘Hand Injuries’, ‘Current Provision’.
 Bebbingon & Furnis 2015
 Rupel VP1, Ogorevc M2. Use of the EQ-5D Instrument and Value Scale in Comparing Health States of Patients in Four Health Care Programs among Health Care Providers. Value Health Reg Issues. 2014 Sep;4:95-99. doi: 10.1016/j.vhri.2014.07.001. Epub 2014 Sep 15.
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