Sometimes referred to as a rupture, a hernia is a pouch which protrudes through the abdominal wall. It contains fatty tissue and loops of bowel which emerge through a weakness in the abdominal muscles.
The commonest form of hernia is in the groin region and is called an inguinal hernia. Pain and swelling are the main symptoms. Hernias in adults are caused by heavy lifting or by excessive straining of the abdominal muscles.
While a pad called a truss can be used to press back the hernia, the definitive treatment is by surgical repair. This usually involves an in-patient stay in hospital and a general anaesthetic.
The contents of the pouch are returned to the abdomen, the pouch is removed and the muscles are strengthened. Inguinal hernias affect 3 to 4 per cent of the male population; they are much less common in women.
In Northern Ireland
Chris is a 42-year-old married man with an active job which involves a lot of lifting. He lives and works in west Belfast.
Two months before visiting his GP he noticed a painful area in his left groin. A lump then developed which spread into his scrotum. The pain increased to the point where it interfered with his sleep.
His GP made a diagnosis of inguinal hernia and, because of the level of pain, made an urgent referral to a general surgeon in the Mater Hospital, Belfast. Referred on August 30th, 2000, he was assessed in the outpatients' department on September 8th. He had an inguinal hernia repair performed on September 18th. He was able to return to work on November 10th.
Chris benefited from the fact that his GP is a fund-holder, which means the practice purchases services from local hospitals. His surgery cost in the region of £850 sterling.
There is an incentive for the hospital to offer a good, efficient service. If it does not, fund-holding practices will not refer cases, and the hospital's income falls. The practice referred four other patients for repair in 2000. All were operated on within two months of referral.
In the RepublicJim is a 23-year-old production operative in a large multinational company. He is single and lives in Co Kildare.
One year after developing a lump in his groin he went to see his GP, who diagnosed an inguinal hernia. Because he was having difficulty lifting, he was urgently referred to the local general hospital. Despite an attempt to continue working, Jim was forced to leave work because of his condition.
Referred initially on June 15th, 2000, he eventually had surgery on November 30th.
This, however, was the third time he had been called into hospital to have the operation. On the first occasion, he was sent home because there were no beds available. In October, six weeks before he eventually had the operation, he was admitted to hospital.
He had been fasting, and was shaved and prepared for surgery. But just before getting his pre-medication he was told the operation was cancelled. The reason given was a shortage of anaesthetic staff.
Although his surgery eventually went well and he has made a good recovery, Jim is understandably angry at the two false starts. He returned to work only this month, having been on sick leave since July. Jim's GP says delays, cancellations and long waiting lists are a feature of the local hospital service.
The Department of Health was unable to supply a costing for inguinal hernia repair in the public sector. However, a similar operation, involving a two-night stay in a private hospital in the Republic, would cost in the region of £1,300.
Comparisons:
Clearly, Jim's experience of the public health service in the Republic leaves a lot to be desired. Two false starts at surgery reflect a system that is struggling to cope. In terms of time off work and lost productivity, Chris in the North was back at work in about 10 weeks, while Jim was absent for six months.
The Belfast practice can shop around for hernia surgery, basing its decision to use a particular hospital on waiting-time, price and quality of service.
If Jim's GP could purchase surgical services, would the performance of local hospitals improve? The evidence from the North is that it would.