Making decisions about knee replacement as an older person with multiple conditions

So this is a very interesting question. I think there's been a lot of change and there is quite a lot of variability across regions as to how this works, but I'll give you a broad outline of the referral pattern.

It still remains that the primary point of contact for a musculoskeletal problem is a general practitioner (GP), who would be able to assess, offer simple advice in managing osteoarthritis, but can also pick up if there's a very severe almost acute problem that needs something very rapidly done to it, the GP can intervene. But the general practitioner, in that first point of contact, will be sharing information, typically giving advice around exercise, weight management and referring to physiotherapy as a first- a sort of port of call to help in the management, because exercise and physiotherapy is a key part of managing this condition.

At that point, a patient may get referred through to what's called an intermediate care pathway. So there are groups of medical practitioners who work with GPs to manage musculoskeletal conditions. So they're assessed, and physiotherapy and non-operative - essentially non operative measures for managing osteoarthritis - can be kind of choreographed and organised by the intermediate care providers.

Essentially I think you could summarise that group of very experienced people who are good at managing these conditions, it's based around physiotherapy and based around assessing your initial response to these sorts of simple measures.

Now osteoarthritis has a habit of presenting with symptoms that come and go, particularly in the early stages of this disease and even in the most severe stages of this disease. So the non-operative approach with good information is really important; the self-management effectively but supported by these services. If over a slightly more prolonged period of time, the symptoms are severe and intrusive then a patient would be referred through to secondary care or a hospital. That's what you might describe that part of the pathway.

That referral in some regions does come directly from the GP, but in other regions will come from intermediate care or what people call musculoskeletal hubs, where you're referred to a hub, they assess you, you have physiotherapy and if you don't settle, you'll be referred through to secondary care. And in a secondary care setting, you'll be seen in a clinic by a hospital consultant. And I think a way to think about that is if you're approaching the stage where surgery may be a good option for you in managing your disease, managing the osteoarthritis, then you'll end up in secondary care.

I think it's important to understand that the vast majority of patients with osteoarthritis still sit in primary or intermediate care, with their symptoms managed non-operatively with good advice and support with exercise and weight loss and physiotherapy. It can also be augmented with injections into the knee and there are some other simple measures that can be done.

About 10% of the population of people who have osteoarthritis might end up having an operation. And that is the-, about 1 in 10, so the vast majority of people are managed non-operatively. But if things progress then you go to secondary care through these different pathways and it's assessment around surgery.

So pathways are really sort of quite well defined now. So if you were referred from primary or GP through intermediate care and you end up in secondary care, it's highly likely that the secondary care consultant that you see will be specialised in treating the osteoarthritis in a specific joint, commonly hip and knee go together. But those consultants are specialists in managing knee and/or hip arthritis.

It's a different problem if you have shoulder or elbow or hand osteoarthritis. So it starts to become quite tailored down to your specific problem. So I'm an example of a knee specialist. So if you came to see me in secondary care, I would be dealing with your knee osteoarthritis. And I think that's the way to look at it, there isn't a general consultant you would see; the system from GP to intermediate care is refining that down. So by the time you come to secondary care, you'll see a specialist in your specific problem.

So, the terminology and what services are offered is highly variable from region to region, which is really confusing for patients and I see regularly patients that are just utterly confused as to what they've been sent for and who to. So, for clarity, I think that we should try and simplify it. Within-, so you have a surgical service operated, run by an orthopaedic surgeon, which is very clear; they are there for patients that need operations. People that don't need operations or aren't sure if they want one or GPs aren't sure whether they need one - these musculoskeletal services are a good option. OK.

Now they are generally manned by advanced practice physiotherapists and orthopaedic physicians. So orthopaedic physicians are usually doctors that have gone through a non-surgical training program to manage musculoskeletal problems that don't need an operation. Physiotherapists go through a very similar period of training. They're both-, they often work in one service. They're there to explore all of the non-surgical treatment options.

So that these are usually physios, sometimes nurses with regards to the knee, who have done extra training to be able to request things like X-rays, MRI scans. Some of them are prescribers, so they can prescribe drugs. So yeah, it's the idea really when it was initially introduced was to see if we could offer a service to patients for whom the pathway their journey was unclear. So maybe somebody with early arthritis - moderate but they're doing OK, they're not sure whether they want to knee replacement, they might need some imaging, they might need a steroid injection.
MSK [musculoskeletal] services are a good place to be.

And I say that because number one, these services are often offered in the community, so they don't have to travel. They are pretty abundant, certainly within conurbations like Birmingham, big cities, you know. And what it also does is it tries to channel patients that are good surgical candidates to surgeons.

Now some GPs will, you know, have an interest or a good understanding of what makes somebody likely to do well with surgery, and they can make those decisions and they can refer to surgeons if they want to. But others are not so sure. Or maybe the patient isn't sure. Or there are factors like X-ray findings that means that the whole situation is less clear. And quick access to these MSK services and that's the attraction, isn't it? It's getting in to see somebody quickly that knows what they're talking about and can offer you some advice.

So yeah, in an ideal world, what we would like to have is an MSK service that's dealing with ambiguity, and surgical clinics that are largely offering a good service to people that are likely to need an operation.

Well I was, I think I was at the docs and I think it was the last doctor that gave me the cortisone injections and, you know, obviously we, I think we chatted again about replacements and then he said, “Well, now,” he said, “I can’t I can’t refer you now like we used to be able to,” he said, “We have to put you on what’s called the knee pathway and then other people do the referring and so on,” you know, so that was I think that was how I had it, I got onto the knee pathway, you know.

Well, you have to go on this knee pathway before you can get to see a consultant or anything. So, I had to go on a knee pathway. So, I went to our local hospital and had them x-rayed and had to see a lady there and she said, “Yeah you’ve got osteoarthritis in both knees.” And I had to fill out this this lengthy form, you know, with all these, tick this box, that box and another box. But I said to her, “Really there’s little I can tick there,” because I said, “All the questions like ‘Can you get up? Can you sit down? Can you do this that and the other?’” I said, “I’m not gonna lie about it, I can do all that,” and for me luckily they don’t, my knees don’t lock, they don’t give out, they just hurt.

And, she said, “Well you have got osteoarthritis in both knees,” so she said, “You-,” so I had to go to see a consultant at [hospital].

And she, oh of course because of Covid and the lockdown, this is going back, this was not long before lockdown actually. In fact, I think it might have been the month before lockdown, something like that. And she said, “I’ll put you on-, yes you’ve definitely got arthritis”. I told her the same, I said, you know, “They just hurt, nothing more than that they just hurt,” and she said, “Well I’ll put you down on the list,” and so I said that I was a bit reluctant at the time to have it done for one reason or another and so she said, “Well I’ll put you down on the list and should you decide to have it done you can get straight in, your GP can contact-,” oh I mustn’t mention names but the main man sort of speak, “And you could be sort of put on the list, shortlisted if you like.” Yeah.

So, I said, “That’s fine,” I said, “I’m very happy with that actually.”

So that was, I said, “Oh that is brilliant, just what I wanted,” because as I said, I really didn’t want it at that moment in time but I didn’t wanna be taking myself out of the picture completely either, you know, just in case, you know.

You know it’s just recently at my surgery that I learnt that we had a physiotherapist. And I thought right, if I go and see him maybe he’ll refer me? Which he’s done.

And I feel as if I’m getting something done now rather than - I mean - I went at the beginning of the Covid carry-on. I was going into town for physiotherapy, but of course that had to stop. You know with the Covid, so I didn’t.

When we could go back out again and mix with people I didn’t go back to the doctors and say I wanted to take it back up, you know, go back to the physiotherapist. I thought I can’t be really bothered with all this carry-on. But as I say it’s now getting worse.

So, I thought I’d go and see the physiotherapist at my surgery and he’s been really good. He got me back for an x-ray and then he’s referred me to this specialist, which I’m gonna see tomorrow.

The physiotherapist at your GP’s surgery, how long ago did you see them? When did they put that referral through for you?

Oh that wasn’t that long ago, I’m trying to think when, it must’ve been January, I saw him, and then he sent us for an x-ray, and then I’ve seen him again while he was, wellI had to go back. He says, “I’ll see you in a fortnight.”

I went back to see him after the fortnight, but he was on holiday, so it would be into the beginning of February, I think.

And then he's seen me again and he’s had my x-ray results, and he said, “Right, I’m gonna pass everything down to the specialist, you’ll probably hear from them.” Which I did.

I went and had an x-ray and then got the referral. So, I had a telephone conversation with [hospital], I think it was about the August 2020. And I got the letter back, it just said “Refer to the knee team,” like an opinion you see and I thought ‘yeah, fine, okay, that’s fine’.

“He’s 78-year-old man and a worsening right knee, despite conservative measures, is now at the point where he feels he would consider surgery. His x-rays are not too severe, but his pain and functional limitations are”. I mean we’re a year on from this.

“We have had a frank discussion regarding the risk versus benefits of knee surgery, and that knee surgery will not solve his spinal issues.” I’m aware of that. “I’ve advised him to continue his own exercise programme and exercise bike, and he can have a look at ESCAPE-pain Online,” which I did, “For further exercise education. He is aware of the long waiting times. I would appreciate your opinion”.

Okay

And that’s it. And then all it is at the top of the letter, it says, “Oxford score 14 over 48”.

So, was that a letter that was produced after you’d had that phone call, or that letter-?

Yes, it was.

Oh, it was, yeah.

From the consultant, yeah. It’s from the Extended Scope Practitioner.

Anyway, I had a couple of instances with my knee since and I went back to the doctors again and I’ve had two or three steroid injections and it hasn’t basically done had, had any effect at all. And then it was still giving out, the knee gives out and, you know, you’re very conscious of going down stairs and steps and what have you that you hang on tight. And he then said to me, the doctor when I went to see him one day, he said, “Oh, well you’re on the list.” I said, “What list?” He said, “You’re on the list for a new knee.” And I said, “Oh, am I?” He said, “Yeah, it’s in the letter.” I said, “Well, it just says ‘refer’.” “Yeah, yeah,” he said. “But you’re referred”. But he said, “At the top it’s a scale.” And he called it the ‘Oxford Scale’ believe it or not. And it was 14-, I think it was 14 over 58 if I remember rightly. I said, “Well, that’s not very high, is it,” you know.” He said, “No, no, it works the other way”.

The lower the score, the more critical you are. He said, “So, you’re on the critical list,” he said, “Between one and 14, it’s critical”. I thought, ‘Oh’ so that’s basically it. And I, you know, I’ve been with that mode ever since.

My doctor referred me and it was quite a long time, and I think I got hold of her and she re-referred me, I went to see her, she re-referred me, and it all got moving then quite quickly.

But yeah - I can’t remember if I phoned the hospital or the hospital phoned me, and just cos I, I just didn’t want to have to go through all those exercises again because I knew, I knew it wasn’t muscular, I knew it was you know my knee.

And so when I spoke to this guy from the triage team he said, “No,” he said, “You won’t need to do physio before you go,” he said, “This is going straight to the surgeon.” So I said, “Oh thank you.”

This, or the surgical team, or something like that so.

The last time I spoke to the physiotherapist and I think that must’ve been in July, June or July. She said, “Right, well we’ll have to refer you this time.”

This was somebody from the [hospital] in that department talked to me, very good in-depth, not just a five minute, you know, thing. They said, “I think something’s got to be done because you’re now caught in this vicious circle. We can’t leave you too long because you’re worried about what your weight and, and movement. You’re becoming so sedentary with this all. We need to see you to, to move forward with something. We can’t go on delaying it any longer because it affects, seriously affecting, you know, how you manage."

Because I said to him, “I live alone. I have to manage. I don’t have, don’t have anybody here, or help, at the moment.”

So, you were quite pleased that they were making that happen then? That they were sending on the referral at that point, after a long wait?

We can’t delay. We can’t delay seeing you any longer. We, we’ve got - the decision has got to be made and try to get you back on your feet. But, but at the time we were talking about that, although my back’s an ongoing thing, it, it was my knee that was limiting for walking and standing for any distance and going anywhere. That was the most worrying part.

I got up in the middle of the night one night and I couldn’t walk - something had gone in the back of the knee. That has since righted itself somewhat, but I mean the surgeon was telling me it was almost bone-on-bone back in 2000 and- well, I suppose, ’15 or ’16 when he finished my check-ups.

And was that the sort of trigger event that happened, and then you saw your GP wanting some more investigations?

Yes. Yeah, because the surgeon had always said to me- when I felt the knee needed doing, because he already has one X-ray on file already, although I will be having another one on Friday. He said, “Just get your GP to contact me directly, you don’t need to jump through so many hoops to get to me,” he said, “you will know.”

And I’m on, you know, I’m on the books, as it were [laughs].

Do you mind me asking a bit more about that appointment you had with the GP? What was that like, what sort of topics did you discuss?

Right, first of all I had a phone appointment—and then she said, “Oh, I think I need to see you.” So, I went down to the surgery and she did quite a thorough physical examination - poking and prodding and stretching, and seeing how far I could bend things.

From what I remember that’s when she prescribed me the ibuprofen gel.

She was - I thought she was good, she was only a young woman and I didn’t know her—but she did take her time, you know? She took time to do it—and I was quite glad to be seen quite honestly.

I asked her to refer me—explaining to her that this is what the prof had told me to say—that he sort of knew about it and knew it would need doing and just told them to refer as soon as I said.

Do you have to go through your GP to get referrals to see them?

No, I go direct.

You go direct.

Now, I’ve got to the stage I just go direct. I know their names and I know where they work. I need to leave a message. I will phone. I mean, I know, I used to do a lot privately because my husband had this included with his job. But, of course, when he retired, the five years afterwards or something it then, it then stops.

It’s much much easier to get an appointment with whom I wish to speak to if I go privately. And actually I’ve, I’ve stopped going privately to this particular consultant because he obviously does both.

But I think I, I have stopped going privately. I… rather hope the insurance might pay and of course, they don’t, ‘cos I’ve had too many, I think. So, we’ve been paying to go privately to see him in his office. And I think this is why I’m going to have to go again. Although, any operation he does will be in the NHS place.

But they do the operations in the big NHS hospitals rather than the private hospitals, especially the operations like this, ‘cos this is a very major operation, having one’s knee totally done. Just in case anything goes wrong they’ve got all the equipment there. Which is why they choose to do it in the big NHS. And I can understand that. It makes a lot of sense.

And I did say to him, “Presumably, even if I go privately, the operation will be done on the NHS well-, will be done in the other, in the big hospital.” And he said, “Yes, it would be.” So, I thought ‘right, I’m going to try and see if I can do a bit of both’.

When I said to my doctor “I think I need to be referred for my right knee” he gave me, well he didn’t really give me a choice - I said “ I wish-, I have a preference for such and such hospital.”

And I have a - it seems sensible to me that because this particular consultant dealt with the left knee it seemed sensible for me to be going on the same team to have the right knee done. So that if I ever have any problems I have, not gonna be referred to two consultants - I can have the same consultant for both knees.

Which seemed sensible to me. And I told my doctor the name of this surgeon who is supposed to be top dog, they say, he‘s the one that does all the children’s joints, and things like that. He’s, so he’s very good, top of the tree I’ve been told by the various nurses and junior doctors that I’ve spoken to.

So obviously I wanted to have the same - to go to the same chap really. So that’s what I was, I know that my doctor did write to this hospital and request that I be put on this chap’s waiting list.

And how did you first start going to that hospital? Or when you had your first operation, was that just the one it was referred to?

No I, because of all - the hospital that I’m going to is, I mean, [laughs] you must already know which hospital I’m talking about - it’s just known for - it’s one of the leading hospitals in orthopaedics as far as I know.

And purely on the reputation of people like my surgeon who dealt with my first knee who, as I said the medical staff, they told me he was top of the shop. And the same with my shoulder - I had the surgeon who was top of his game, you know? And so, if I go in, I only want to go in once.

Yeah so, I said I didn’t want to go to the local hospital which was the first thing the doctor said to me, you know, “I can get you booked into so and so.” And I said, “I’d rather go to the other one”.

Because initially, years ago, I believe you had to go to the hospital you were sent to, whereas I think they changed that in more recent years, where you could elect to go to the hospital you wanted to.

I had a, first off, I had a letter to say that they would like me to have an assessment at a different hospital then, I can’t mention names, a different hospital and anyway I said, “Well-” so I rang them and I said, “Look I don’t really wanna go to a different hospital,” I said, you know, “The hospital is,” I said, “That’s a long way away for a start and my Mrs doesn’t drive and also,” I said, you know, “I’ve got total faith in our-, what I call our local hospital,” still a little way from us, but it’s still our local hospital.

And I said I really didn’t want to go to a different hospital” and they said, “No that’s perfectly alright.”

They said, “But it’ll be quite a while before you’ll hear anything again.” But then surprisingly a few weeks later, I did get this appointment at what I call our hospital,” you know.

The referral was made to that original hospital. And that is a very interesting thing because for quite a long time now, years and years, there’s been all this talk about choice, hasn’t there?

But none of that cropped up.

And really it was only a lot later with conversations with a friend that, you know, the idea of the new hospital came into our decision making.

Alongside possibly paying or going through our insurance where you still had to pay, but all of those things we were, you know, looking at because my knee was just getting worse and worse all the time.

My knee - I was obviously - all last summer I was hoping that I would get a consultation for my knee. At one point, yeah, I’d been offered the chance to have it done at a private hospital at the expense of the National Health, and I was asked if I was prepared to go to a hospital further away.  And I said yes, I would do that - but nothing, nothing materialised.

And then I think it was in the October time - it might have been a bit before then - I was rung by this hospital and [they] said, was I still happy to do that? And I said yes, I would be happy to do that, and they said that someone would ring me the next day.

Well, the next day by coincidence I got a, someone rang me and offered me a consultation, and in fact I assumed that it was the person who’d rung me the day before, at least he referred to the same, was referring to the same hospital as the day before. But in fact it was from the hospital, can I mention the name of the hospital or should I-?

That’s fine yeah.

Yeah. It was from [another hospital] offering me a consultation. Anyhow, so that day I got offered two - one from the private clinic and one from [another hospital]. And as the first one that rang me that day was the hospital, I accepted it there, and therefore I gave up my place on the second one that rang, which was to have it done privately.

So, I got it in writing, the consultation, where it was going to take place, but then it was cancelled, as a lot of things have had to be cancelled, you know? I assume because of Covid or something. But anyhow it was cancelled.

But then I thought - well I’m not going to worry because I’m obviously near the front of the queue if I’m being offered a consultation, with the National Health, so I waited, and a few weeks after I was offered another consultation at the, with the National Health.

It’s taken two years to get my shoulder looked at and 13 months to get my knee looked at.

Because the new system in the North East is that your GP can’t refer you directly into osteo- what do they call it, musculoskeletal?  You go through physios.

So, they send the application to the physio and then they’re supposed to get in touch with people; just nothing happened.

And I rang them and - oh yes, they had it - so I had the referral, but nobody had had time to look at it, and this was one marked - well, for my knee it was marked urgent: ‘Needs urgent knee replacement’.

And it just- well, honestly, it seemed to get lost in the system.

I mean the physio that I spoke to was really nice. She was a consultant and she’s going to look into why it’s taken them so long to sort me out, but it’s been very distressing.

Because as the knee gives way- I mean when my right knee gave way was when I fell backwards down the stairs: I got to the top of the stairs and my right knee hyper-flexed and I just fell backwards down the stairs, and my husband was sitting there watching.

I mean he- the poor soul, he got such a fright and how I didn’t kill myself I don’t know. I must be quite made of sturdy stuff, I think [laughs].

Goodness, gosh. And how long was it once your GP put in that referral to the physio before you followed them up and sort of had to ask them what was going on?

Six weeks.

Six weeks.

Six weeks. I thought I had to be fair and I gave them a reasonable time but then I kept ringing and I think the woman got sick of me ringing in the end [laughs].

So then all of a sudden something happened [laughs].

I mean I had to see the physio before I could even have an X-ray and once I saw the physio, she got me off for an MRI very quickly mind - and it didn’t take that long to get the MRI results. It took a little while, but I think that was six weeks again.

But I mean I was fully aware that my knee needed replacing anyway because it wants to bend backwards, which really shouldn’t happen with a knee - unless you're a bird [laughs].

I’ve seen the GP about that knee quite a few times. But what happened was, I got to the stage of having speaking to a physiotherapist, which is the first step through the procedure leading up to an operation that you have. There’s a tick list  that the GPs have to do.

But you go through the list of and ticking off what stage you’re at. And it was decided before lockdown that the knee did seriously need looking at. And I needed a referral. But I needed to see a physiotherapist.

But before I managed to even do that, I waited for the appointment because there is a delay - Covid started.

So, they didn't want to see me. They said, we’ll do it by telephone.

Didn't see how that was going to do anything. But it did, actually because the phone call went quite well and she understood exactly what was going on, and said that, yes, you do need to be referred, but we can’t do that for you because of Covid.

So, she said, “I, I’m gonna give you my name and number. Phone me back when it’s died down. When it’s over. When it’s passed.” I hoped. Because when I phoned after six months because obviously it was dragging on and I knew there was no point in phoning her until you got sort of towards the following summer when hopefully things were improving.

Of course, they, they weren’t, hadn’t improved enough. So, I had the same phone call with her and she still said, “Well, we need to refer you, but we can’t do that now.”

So, I think it’s two years now.

Gosh.

That I’ve been going on waiting for this referral. But they’ve decided I do need to see at least the consultant and have it looked at, X-rayed again and looked at to decide whether they are prepared to do anything to it - but I’ve waited two years already. I expect [other] people have done the same.

Obviously with all the problems of needing a hip. What happened was that I went to query my knee again after it was operated on when I realised that the first one - the second one - was so much better. I went back and queried the state of this. I think way back, you know?

I saw my own doctor and then I was referred. And each one of them would say that he didn't think that it was my hip; the knee person said he thought it was my hip. The hip person thought it was my back. And I was going round in circles for ages, pillar to post it was.

Until, in the end, you know, one of them said to me, “Well- has your doctor not referred you to a back person?” And I said, “Well, it’s all in the same hospital.” I thought possibly that if you thought it was that bad that you would do it within, in this hospital, that you would refer me to another department.

I had no idea - stupidly, because I don’t have much to do with doctors before that - that I should go back to the doctor to get a referral again. So, but I finally got there and had that done.

I think that’s an important point though because we don’t, as patients, know how the systems work often do we? Or what goes on within them?

Why are they not talking to each other?

Why do they keep sending me in for appointments - hip and knee and hip and knee - and they mention back, and back was really then a major thing?  And it wasn’t until a real collapse of, of this disc [which] then trapped all the nerves down both legs and then that was indescribable. And that went on for quite a few months [clears throat] That pain. So, it was such a, a relief when it was done.

It just seemed odd that you-, but I understand it’s the financial part. You go back to the doctor to be referred because they have to weigh up who has to be seen, who’s more important, you know? Who needs it more importantly than anyone else. You know, they have to put it in, trying to think of the words really. Well on the scale of, of one to ten of those that need it most or those that don’t.

So, it’s the doctor that has the say, or the GP that has the say whether you are referred, and whether you’re put forward for treatment. But once you’re handed over into the hospital’s care for that treatment the doctors really are never involved.

I don’t think I’ve ever involved the doctor after that

Thinking about when you went back to the GP last about your knee, did you know you were having that discussion and the GP was deciding whether to refer you? Did you sort of feel that you were able to get across that it was important for you to be referred?

Yeah. She did, she very much understood that, that this was impeding on me coping with life and that it needed to be referred.

But, you know, I had to go through. Although I’d had physiotherapy, she said, “I’m still gonna have to refer you to the physio ‘cos it’s the route you go through."

I can’t remember the name of the procedure that decides whether you get an operation or not. There’s a tick list that goes down. I know that much by now. And she said, “Well, you’re already at the bottom because you know, we would refer you to a physiotherapist, but you’ve already paid for one of those. So, there doesn't seem a lot of point.”  And especially as, you know, the waiting list for that is abysmal.

Because it would’ve been a wait to see the physio and then a wait again for you?

It would be months. A few months ago. In which case it didn't matter because it’s now been two years anyway.

I think you have to wait two or three weeks for the results, and then I got a phone call from my GP at home saying he’s just been looking at the x-rays and he- I don’t know whether he understood what they said or not, but he asked me was it interfering with my way of life?

And at the time it did, cos I couldn’t move hardly. So, he said, “I’ll put you on the list, the referral list.”

So, they referred me to whoever they refer you to, and I got a form to fill in to say what hospital and when I would like it done. So I filled that up and said I’d have it done, have an investigation at the [hospital] as soon as possible.

I then got an appointment at the [hospital] in about two months I think. Then when I got there the woman was very cagey and said, “Do you mind sitting down?” So I sat down, and then another woman come over and said, “I’m sorry Mister, [name] but your appointment’s been cancelled.”

And I said, “Oh when was it cancelled?” And she said, “Oh today.” So I went, “Well, no-one told me.”

So, and the reason they gave me was that they didn’t do revisions, I think the word they used. They don’t do repairs I suppose. The fact that I’d already had half a knee they wouldn’t look at repairing it, yeah.

So that meant I had to go back to my GP, who said to me. Well the receptionist said, “Oh it’s nothing to do with us, we’ve referred you so that’s all we can do.”

So, I offered to go and buy a pop-up tent and sit outside the doctor’s reception and go on a hunger strike until someone gives me an appointment for me knee.

With that she then I think she rung around and got me eventually - I didn’t get it on the day, but I eventually got this appointment which I think is next Wednesday at the orthopaedic hospital in [city].

And how long was it between? So you basically got to the appointment at the other hospital, - how long had that process taken to get from your-

Well. it was about, it must’ve been at least three months, because it was well - it was during the last summer’s cart racing team and I didn’t get the appointment till just before Christmas.

So, and then, can you imagine, I’d waited all that time and I was, I was crippled really. I was just sitting watching the grass grow, that’s all I could do. And then when I get the appointment I stumbled to the hospital and I’m then told it’s been cancelled.

And no-one told me or they told, they told me they’d told the surgery but the surgery said no-one told them. As it was actually on the day of the appointment, I can understand that, but when I got back to the GP no-one knew what to do once a referral wouldn’t, been cancelled, yeah?

And it was, you know it wasn’t - I can understand if there’s a seven-year waiting list but it’s just that, there’s that, there was, no-one seemed to care about me.

So, I went to that consultation and I was really disappointed because it was explained that there was a very, very long waiting list and that there was a really big backlog of patients needing knee surgeries and other surgeries, hips etcetera, and that there was very, very little chance of me getting it done for at least another two years. Well, I’ve already been waiting two years, so that that was a bit disappointing.

The person, the consultant was very, very kind and very good, and did say well he could explore the possibility of other hospitals to see, but it could be anywhere else, any other hospital might have a shorter waiting list, but I felt I’d been waiting such a long time and my family had been saying, suggesting that I go privately, and I had rather - I had not really wanted to go privately, obviously because of the expense, but at, I suddenly thought, ‘No, it’s, this needs doing. If we’re talking about two years with one hospital, we’ll probably talking a similar time length with another hospital.’

So, I asked if I could go privately.

But even to go privately I was told it would be unlikely to be done, well for at least six weeks or so, perhaps two months. But I made, I’d made up my mind and I thought, ‘No, I’m not, I’m not messing around any longer with this, I’m going to pay for it and I’m going to get it done. And that’ll be fine.’

So I did, I got into the private system, it would be the same, the same person who I’d seen at the, with the National Health, but he has a private clinic as well, and I was very happy with the thought of him doing it because I liked him, I trusted him.

And I thought, ‘Yes, he’s obviously a very capable person.’ But again, he really was extremely willing to explore all the other possibilities of me having it done without having to pay for it to be done. But I just, I just felt it was, I just wanted to get on the private list and get it done.