Thousands of groin hernia patients left in pain and at risk of complications by NHS, warn surgeons

Thousands of predominately-male patients are being made to suffer in pain and, in rare cases, are at risk of death due to the NHS restricting access to groin (inguinal) hernia operations. In a a report published today^1* , the Royal College of Surgeons and the British Hernia Society have found that 57% of clinical commissioning groups (CCGs) are denying patients quick access to the procedure. This is despite the fact that the only curative treatment for patients with a groin hernia is surgery.

Following freedom of information requests the surgeons found:

• 52% (95 CCGs) require patients to suffer from pain or discomfort sufficient to impede everyday activities or working life before surgery is allowed (often referred to as ‘watchful waiting’);

• 5% (8 CCGs) require patients to demonstrate a history of incarceration² and/or their hernia increasing in size from month to month;

• Only 24% (44 CCGs) had policies in line with clinical guidelines from the British Hernia Society and the Royal College of Surgeons;

• Other CCGs did not have any form of restriction in place.

In 2014 a similar report by the Royal College of Surgeons found 29% were restricting access to groin hernia repair.³

A groin hernia usually occurs when a weakness in the abdominal wall allows fatty tissue or a part of the bowel to protrude into the inguinal canal. It can cause pain and lead to severe complications if untreated; surgery is the only form of curative treatment. Elective hernia surgery is recognised by surgeons to be one of the most cost effective measures to reduce avertable morbidity and mortality, and is broadly comparable to the effectiveness of providing insecticide-treated bed nets for malaria.⁴

However, if a patient is treated as an emergency the mortality rate is seven times higher.⁵

In 2016/17, around 78,733 groin hernia procedures were carried out in hospitals in England. 3,700 of these patients had to be operated on in emergency because their symptoms were so serious.⁶

Eight CCGs, all based in Kent and Medway, require patients to demonstrate a history of incarceration and/or their hernia increasing in size from month-to-month before being able to access surgery. These commissioning groups are: NHS Ashford CCG; NHS Canterbury and Coastal CCG; NHS West Kent CCG; NHS South Kent Coast CCG; NHS Thanet CCG; NHS Swale CCG; NHS Medway CCG; and NHS Dartford, Gravesham and Swanley CCG.  

David Sanders of the British Hernia Society said:

“The decision to operate should always be taken in consideration of the risks and benefits after full discussion with the patient.  It is simply not acceptable to justify restrictive criteria as best practice. This denies patients access to a procedure that potentially limits pain and improves quality of life.

 “Hernias do not increase in size in a smooth fashion, with some months seeing significant growth and others seeing limited or no growth. This makes it difficult to assess, using a blunt CCG policy, exactly when a patient may require surgery. Additionally, a patient may not have a history of incarceration but could still suffer from debilitating pain that can have an impact on his or her quality of life.

“The NHS has to be very clear about what it offers. Does it want a value for money service with quality and safety as a priority, or a rationed service that will inevitably put some patients at risk?"

Miss Susan Hill, Senior Vice President of the Royal College of Surgeons said:

“It is an absolute disgrace that some patients have to demonstrate what could be a life-threatening complication of a hernia, which is one of the most straightforward surgical conditions to treat.  

“Instead of asking patients to prove their pain, Ministers and NHS England should immediately intervene to allow patients to talk to their surgeon about whether they need an operation. Allowing commissioning groups, not patients with their surgeon, to make a decision to operate is putting patients at unnecessary risk of serious complications.”

Notes to editors

*A small amendment was made to the report in August 2019. The sentence “a cohort study published in 2014 revealed that patients undergoing a ‘watchful waiting’ approach compared with elective repair ” on page 5 was clarified to read “a study assessing the impact of a watchful waiting policy in a single CCG reported on the proportion of emergency presentations before and after the policy change”.

1. The report ‘A Dangerous Waiting Game?’ is available here. 

2. Incarceration - A hernia is a defect (hole) in the abdominal muscles through which the abdominal contents (usually fat but sometimes intestines or other abdominal structures) can protrude. When you lie down the protruding bit usually drops back through the hole and there is often nothing to see or feel – unless the hernia is stuck in the hole in the muscles. If the hernia does not go back when you lie down this is called irreducible, (or sometimes incarcerated). See symptoms of a groin hernia on the British Hernia Society’s website. 

3. The Royal College of Surgeons’ 2014 report ‘Is Access to Surgery a Postcode Lottery?’ is available here.

4. Higashi H, Barendregt JJ, Kasselbaum NJ  et al, Surgically avertable burden of obstetric conditions in low- and middle-income regions: a modelled analysis. BJOG 2015; 122: 228–236.

5. Hwang, MJ et al. ‘Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias’, Annals of the Royal College of Surgeons of England, 2014.

6. NHS Digital Hospital Episode Statistics Data 2016/17.

7. The Royal College of Surgeons of England is a professional membership organisation and registered charity, which exists to advance surgical standards and improve patient care.

8. For more information, please contact the Press Office: Telephone: 020 7869 6047/6052; Email: pressoffice@rcseng.ac.uk; Out-of-hours media enquiries: 07966 486832.