SECOND OPINION : HEALTH

SHOULD patients with breast cancer be treated by doctors who spend their whole time treating that condition? Should someone who needs a replacement hip joint be treated by a surgeon who does that operation at least twice a week? These questions have not yet been resolved in the NHS, and patients and patients' groups who ask them risk being treated as nuisances.

Yet the evidence is accumulating that surgeons who follow the old traditions of treating any disease from the neck to the knees are out of touch. The latest survey of surgeons' expertise appeared before Christmas in the Annals of the Royal College Of Surgeons of England. A questionnaire was sent to 668 orthopaedic surgeons who between them carried out around 44,000 operations a year to insert artificial hip joints.

The main concern of the questions was the cement used to fix the two parts of the new joint into the bones. This cement is designed to provide permanent fixation, but in a small proportion of cases the joint becomes loose. The risk increases with time; research studies have shown that after 10 years at least 10 per cent of joints will have worked loose to some extent. Over the years surgeons have improved their cementing techniques, and with the newer modern cementing methods the risk of failure has been reduced, probably to as little as three per cent.

What the survey showed, however, was that only a minority - around 25 per cent - of the surgeons used the latest cementing techniques. Furthermore, those who performed fewer than 20 hip-replacement operations a year were the ones most likely to be using the older techniques. The ones who did the most operations were the most up-to-date. This is not surprising. In virtually every published study specialist surgeons come out best.

Yet the structure of the NHS is still based on the local district hospital which provides a full range of medical and surgical services for its own population - between 250,000 and 800,000 people. The management of some conditions, such as cancers in childhood and transplants, is concentrated in fewer regional centres, but for the most part every hospital still does everything - and within a typical hospital several surgeons will still each carry out a wide range of operations, maintaining competence but not specialised skills in all.

A reasonable analogy is with the old-style garage whose mechanics would tackle repairs on any vehicle. Few still offer such a service. The owner of an Alfa Romeo or Ford knows that he or she will get the best service at one of the makers' service stations. The same is now true of surgeons and physicians, who need to work hard to maintain their skills in dealing with a small group of related disorders.

The first question a patient should ask on being referred to a surgeon is, "How many of these operations do you do each year?" An answer of 100 or more does not guarantee competence or up-to-dateness, but it does make them much more likely.