An independent provider in the City of Nottingham area

3. Mrs H complains about aspects of care the Provider gave her between August and December 2024. Specifically, she says:

• the Provider did not see her face to face and diagnosed her with haemorrhoids and an external perianal skin tag via a telephone consultation • she had to undergo two procedures for haemorrhoid banding, instead of having all banding completed in one procedure and the Provider did not tell her she would need a second procedure • the Provider told her perianal skin tag surgery was not available on the NHS and says she should have been told this sooner than she was.

4. Mrs H says she is experiencing ongoing symptoms, and the lack of care she received from the Provider delayed her getting the treatment she needed by over six months. She says she paid for a private consultation and X-ray but has since been referred back to the NHS for treatment given the costs she would have to incur for private treatment. She says she will need to wait longer than she should, had her concerns been treated appropriately and in a timely manner.

5. She says the lack of communication she received was frustrating to be then told when asked that a skin tag procedure was cosmetic and not available on the NHS.

6. Mrs H is seeking service improvements and a financial remedy as an outcome to the complaint.

7. Mrs H’s GP made a referral to the Provider on 27 July 2024 due to symptoms of itching and an external flap that was identified following an examination.

8. The Provider spoke with Mrs H on the telephone on 15 August and arranged a flexible sigmoidoscopy. This is a procedure to examine the inside of the lower large intestine with a long, flexible tube attached to a camera.

9. On 29 August, Mrs H had a flexible sigmoidoscopy. The Provider diagnosed first degree (internal) haemorrhoids, diverticulosis (pouches in the intestine wall) and perianal skin tags (benign skin growths around the anus).

10. On 25 September, at a follow up appointment the Provider noted ongoing symptoms of persistent itching. A repeat flexible sigmoidoscopy was to be arranged if symptoms did not improve.

11. The Provider had a telephone consultation with Mrs H on 28 October. It noted symptoms of persistent itching and arranged a repeat flexible sigmoidoscopy.

12. The Provider carried out a second flexible sigmoidoscopy on 14 November. It banded three haemorrhoids during the procedure.

13. The Provider held a telephone consultation with Mrs H on 18 December. It noted symptoms of intense itching. It advised Mrs H that treatment for perianal skin tags is not available on the NHS.

16. Mrs H say the Provider did not see her face to face and diagnosed her with haemorrhoids and an external perianal skin tag via a telephone consultation.

17. The Provider said that as Mrs H’s GP had already diagnosed haemorrhoids and perianal skin tags with itching, it was appropriate to proceed with a telephone consultation initially.

18. A diagnosis of haemorrhoids is usually made via a face-to-face clinic and physical examination. Mrs H’s GP did a clinical examination and this is recorded in the referral letter.

19. NHSE guidance on outpatient services gives guidance on post-COVID-19 operations. It says providers should:

• ‘increase your use of remote consultation and telehealth to help increase your clinic throughput.

• explore the use of straight to test pathways.’

20. During the COVID-19 pandemic, it was not possible or safe to see patients face-to-face and compromises were made in clinical practice to triage and clinical care via telephone and video consultations.

21. Post COVID-19, some services within hospitals continued with a percentage of patients having telephone consultations, or hybrid care with a face-to-face consultation and telephone appointments as appropriate.

22. Mrs H’s initial consultation was a triage telephone consultation with the option to test straight away in line with guidance from NHSE. Some patients need to be seen face-to-face if they need a clinical examination or communication over the telephone is not adequate enough to have a satisfactory consultation. Other patients can be referred on for an appropriate test based on a presumed working diagnosis.

23. The Provider correctly assumed that the working diagnosis was probably going to be related to haemorrhoids.

24. Our adviser said a flexible sigmoidoscopy was an appropriate next step which allows a clinical examination and some treatment to be completed at the same time, including the banding of haemorrhoids if required. A working diagnosis can then be confirmed or changed.

25. The Provider’s decision to first triage Mrs H on the telephone, make a working diagnosis, and then see her face to face was in line with NHSE guidance.

26. Mrs H says she had to undergo two procedures for haemorrhoid banding, instead of having all banding completed in one procedure and the Provider did not tell her she would need a second procedure.

27. The Provider says it decided to perform a follow up sigmoidoscopy to address ongoing symptoms. It says symptoms can persist after initial intervention, and further care or procedures are sometimes needed for comprehensive care. This was done to reduce the severity of Mrs H’s symptoms. With regards to the banding of haemorrhoids in two procedures rather than one, the Provider said the equipment used during a sigmoidoscopy allows for up to four bands at one time. A second procedure was necessary to complete banding of the remaining haemorrhoids to optimise symptom relief.

28. NICE guidance on rubber band litigation says:

• ‘a band is applied to the base of the haemorrhoid. The strangulated haemorrhoid becomes necrotic and sloughs off. The underlying tissue undergoes fixation by fibrotic wound healing. Up to three haemorrhoids can be banded at one visit.

• this is currently the best available outpatient treatment of haemorrhoids. About 2 in 10 people will require a second banding within 6 months for symptom control’.

29. It was appropriate for the Provider to perform two procedures for banding of haemorrhoids. Banding of haemorrhoids is a minimally invasive technique to try and treat haemorrhoids. Rubber bands are placed on the root of a haemorrhoid to strangulate the tissue which sometimes causes the haemorrhoid to shrink.

30. In some cases, it is not fully effective. Some patients need more than one banding treatment and in other patients it just does not work at all.

31. There is a limit to the number of bands that can be placed at any one time. The Provider suggested four, and the NICE guidance suggests three. Our adviser explained that when a band is placed it can obstruct the view to safely place another band. After the placement of three or four bands, it can be difficult or impossible to safely place any more.

32. The bands can also cause some discomfort with the number of bands placed and there is a small risk of a patient fainting due to pain or developing severe pain that may stop the patient from being safely discharged from the hospital the same day.

33. The need for a second procedure depends on the clinical impression of the doctor when Mrs H was reassessed. It was reasonable for the Provider to reassess with a flexible sigmoidoscopy. Mrs H developed more symptoms which warranted a repeat flexible sigmoidoscopy and at that time, it was decided that placing more bands would likely improve her symptoms. This was in line with NICE guidance.

34. Mrs H says the Provider told her perianal skin tag surgery was not available on the NHS and says she should have been told this sooner than she was.

35. The Provider said the focus was to treat haemorrhoids as this was the primary cause of the symptoms Mrs H was experiencing so a discussion about skin tags did not occur.

36. Our adviser says perianal skin tag removal surgery is not ordinarily funded on the NHS. It is considered a benign condition that is not routinely commissioned.

37. The Nottinghamshire commissioning guidance says the NHS in Mrs H’s area does not fund ‘surgical or laser treatment for a range of benign skin lesions [including] skin tags. It goes on to confirm that surgical removal of anal/rectal skin tags is not funded.

38. In some cases, skin tags are closely associated with the haemorrhoids and as part of a haemorrhoidectomy operation which is NHS funded, skin tags are removed.

39. There is no guidance on when a discussion about skin tag removal should take place. This happens at a consultation, when a patient is examined and a diagnosis is made. It was not appropriate to discuss this on the first telephone consultation. Many patients have asymptomatic perianal skin tags. Our adviser said it was reasonable to assume the symptoms of itching and soreness were from haemorrhoids and to treat these first.

40. It was reasonable for the Provider to treat the haemorrhoids as blocked blood vessels in a haemorrhoid cause the majority of perianal symptoms rather than a skin tag.

41. We recognise the frustration Mrs H experienced in the clinical care and treatment she received during her journey for colorectal treatment. We have seen no indication the Provider managed her treatment inappropriately. We are grateful to Mrs H for bringing her concerns to our attention.

1. We have carefully considered Mrs H’s complaint about an independent provider in the Nottingham area (the Provider). We understand the events that caused Mrs H to complain are important to her. We recognise how upsetting it was for her to feel like she did not receive the correct care and are sorry to hear about her ongoing symptoms.

2. We acknowledge Mrs O’s concerns that the Provider did not treat her appropriately following a diagnosis of haemorrhoids. We have seen no indication the clinical care Mrs O received was incorrect.