Bupa curb on knife-happy surgeons

BUPA, BRITAIN'S biggest private health insurer, has moved to curb knife-happy surgeons amid fears that they are performing unnecessary hysterectomies for profit.

The private healthcare organisation is demanding that consultant gynaecologists who propose to remove a woman's womb get prior authorisation from Bupa before they go ahead. It is alarmed by surveys that suggest up to 25 per cent of the 80,000 hysterectomies done in Britain each year may be unnecessary.

The move angered the British Medical Association, which accused Bupa of unwarranted interference in clinical decisions. The BMA says Bupa is trying to cut costs, not improve quality, and is urging its members to charge for the extra work.

Bupa paid for 3,600 hysterectomies at an average cost of pounds 3,890, last year. Of that sum, the consultant gynaecologists performing the operations received an average of pounds 760. In some cases, a consultant might carry out several operations in a morning.

The move has been partly prompted by the case of Rodney Ledward, the Kent gynaecologist struck off the medical register last year, who operated at the Bupa-run St Saviour's Hospital in Hythe, Kent. Mr Ledward styled himself the "fastest gynaecologist in the South-east" after once completing seven hysterectomies between 8am and noon. He is now the subject of a public inquiry after allegations that he maimed hundreds of women.

Andrew Vallance-Owen, Bupa's medical director, said: "I personally felt very affected by the Ledward case. He was working out of one of our hospitals and I have been involved in working through the implications. When you have seen the consequences of inappropriate hysterectomies on women and then they have got complications it makes you think."

One woman in five has a hysterectomy before she is 60, according to the Royal College of Obstetricians and Gynaecologists, and in at least half the cases menorrhagia [heavy periods] is the main problem. In half of those cases the removed uterus turns out to be normal. Other evidence suggests that the most effective drugs for menorrhagia, which could avoid the need for hysterectomy, are often not prescribed.

Dr Vallance-Owen said Bupa had drawn up indications for hysterectomy, based on Royal College guidelines, which had been agreed by 50 leading gynaecologists. Requests for a hysterectomy that met the indications would be automatically granted within 48 hours, or immediately for patients with cancer. "There is a real choice here for patients. We thought we would try to ensure they have the most appropriate intervention," he said.

The move is being seen as a step towards the adoption of American-style principles of managed care, where funding organisations - health authorities or insurance companies - dictate what care is provided. Bupa is looking at other operations whose value is controversial, such as tonsillectomies and the insertion of grommets (to drain fluid from the middle ear), which may in future also require prior authorisation.

The BMA said that Bupa was causing delays for patients and extra paperwork for doctors. "There is no way we condone poor practice or unnecessary surgery," said Derek Machin, chairman of the BMA's private practice committee. "The argument is not over the guidelines. What we are saying is that it is not up to an insurance company to police them in that fashion."