The differences between British and post-Soviet healthcare systems are a topic Russian-speaking residents of Britain are ready to discuss endlessly. The approach to women’s health here is completely different, and women who have become accustomed to regular check-ups with a doctor back home often fall into despair because they are not receiving the medical services they are used to. To guide and reassure these patients, we talked to the gynaecological surgeon Denis Tsepov, a member of the Royal College of Obstetricians and Gynaecologists and a specialist in the field of robotic surgery.
You have worked in two countries: Britain and Russia. Was it difficult to re-qualify as a doctor here? What are the advantages of free-at-the-point-of-need British gynaecological provision? Is there anything about the local system that can be irritating?
In 1997, I graduated from the First Leningrad Medical Institute (now it’s called the First Saint-Petersburg Pavlov State Medical University). While doing a gynaecology and obstetrics internship and residency, I decided to emigrate to Britain. In all, it took me a year and a half to receive a licence for British medical practice. I wouldn’t say that it was difficult, but it took some effort. What was a bit tricky was understanding the system, the processes of diagnosis and treatment and how healthcare is organised overall. Of course, the principles of gynaecology and obstetrics remained the same, but the specifics were different. I began work as the Resident Gynaecologist at the Royal Hospital of Devonshire and Exeter. I remember this time of my life with special warmth. While there, I realised that, even if you are a foreigner and you speak English with a terrible Smolensk accent, your more senior colleagues will still support you and cover for you. I also realised that if you want to achieve something in British medicine, the only limits are your own laziness.
However, since the end of the 1990s, the National Health Service (NHS) has undergone significant changes, which have, unfortunately, largely been for the worse. It has not been able to adapt to the dramatic increase in demand for medical help as the population has increased, nor to rising costs. In the past, it was fantastic and effective, but for the last ten years, this system that provides free healthcare has been constantly fighting fires. It’s got stuck in a mire of bureaucracy and debt and is suffering from a chronic shortage of doctors, nurses and other healthcare workers, while they have an excess of managers. Emergency healthcare, just as much as obstetrics, urgent treatment, oncology, cardiology and intensive therapy are all struggling to support the necessary quality of care. Areas such as planned surgery are at the limits of their capacity. My area of expertise, which is the surgery of benign gynaecological conditions, predominantly endometriosis, uterine fibroids, ovarian cysts, etc, is no exception. Due to the inefficiencies in the NHS, I took the decision to go into private medicine, where such phenomena as six-month waiting lists for consultations and two-year waits for scheduled endometriosis operations do not occur. My main aim is to help patients, and since the system was not giving me the support I needed to do so, I had to make a change.
Back in their home countries, our female readers have become accustomed to regular check-ups from a gynaecologist. How should women look after their health in Britain? In what situations should they return to their homeland for treatment?
Every woman, even if they consider themselves entirely healthy, should undergo a prophylactic check-up by a gynaecologist at least once a year. I recommend all my friends and patients sign up their families for private health insurance. It’s not very burdensome on the budget if you have a steady job. But this insurance allows you to choose any specialist, for any medical problem, and in a few minutes, arrange a consultation to see them in a day or two. If it’s not possible to arrange medical insurance, you need to sign up for a cervical smear test, which is done every three years. Then you need to act according to your circumstances; if it’s impossible to arrange a prophylactic check-up through your family doctor, or GP, then fly home and go to the doctor there, this is what many of my compatriots do. For the time being, the NHS is in SOS mode, so, unfortunately, they’re too busy for check-ups.
Do you have any information about what gynaecological problems British women suffer from most often and which diseases are more common among women in Russia?
Without World Health Organisation statistics, it’s quite hard to give an exact answer. From my personal observation, the ailments tend to be the same everywhere; endometriosis, myoma and other gynaecological disorders. For example, the frequency of endometriosis is the same in both countries, affecting 10% of women of reproductive age. An important factor in determining the most widespread diagnoses is a national screening programme, if there is one, of course. For example, in Britain, they have successfully launched a cervical cancer screening programme using the smear test. It is likely impossible to completely defeat this disease, but this programme safeguards 70-80% of women in the United Kingdom. In Post Soviet countries, as far as I am aware, there are no such compulsory screening programmes which is reflected in the number of women presenting with new cases of cervical cancer and consequentially, in the mortality rate.
The greatest problem, both in Russia and in the West, is obesity. This causes diabetes, which, in its turn, can directly lead to cervical cancer or other gynaecological disorders. Additionally, the number of caesarean sections is increasing, although in Russia there are fewer of them than in the EU. Conversely, in Post Soviet countries pregnancies are aborted more often than in Britain. This may be because any woman here can go to a Family Planning Clinic to freely receive a choice of contraceptives and advice on how to take them. Not everyone knows that the NHS provides this service (nhs.uk/service-search/other-services/Family-planning).
Many Russian-speaking women who live in Britain complain that they don’t do anything to save pregnancies here, as women aren’t put on special measures to stop them from losing babies. Is this right?
Not quite. We need to be very careful about defining what we mean by saving a pregnancy. Unfortunately, currently, no medicines or procedures exist which would allow the natural process of the termination of a pregnancy to be halted. Once again, we need to draw a distinction between early pregnancy (the first 12 weeks), the first trimester and pregnancies in the second and third trimesteкs. When considering the threat of the termination of pregnancy early in its term, there are no effective treatments. Approximately 35% of pregnancies end in early miscarriages, and it is thought that these early terminations are predominantly associated with problems at the level of the chromosomes and that they arise when the sperm fertilises the egg. Naturally, these pregnancies are, on balance, unviable, and saving them is impossible. Proven prophylactic techniques exist for women who have had so-called ordinary terminations (spontaneous terminations, or miscarriages), and currently, quite large-scale research is being conducted into low-dose administrations of aspirin and progesterone during early pregnancy. The results are promising. But the problem is unlikely to be completely resolved. In my view, the hospitalisation of women at risk of termination during early pregnancy is unjustified, unless there is profuse bleeding, as generally outcomes are unchanged. This excludes cases where emergency medical assistance is required.
What is your advice; to pay for a relatively inexpensive birth in one of the best clinics in Russia, or to have free treatment on the NHS?
In my view, the choice of the venue for birth should be made according to a range of factors, the most important of which is the safety of the mother and child during and after labour. When choosing a hospital, it’s vital to know whether it can provide surgery and intensive therapy round the clock, both for adults and neonatal patients, and whether it has a ward for high-risk patients, equipped with an anesthesiology service and with a consultant obstetrician on duty.
It’s also necessary to clarify whether the medical facility offers foetal monitoring during labour and to check their statistics for mortality and serious complications amongst neonates, infants and mothers. Beyond that, women should follow their personal preferences; whether she’d like to have a birthing pool in the delivery room, whether she needs the Give Birth Like at Home service, or any other additional assistance. The process of ensuring safety in British obstetrics departments is extremely strict. If I had to give birth, I would choose the delivery room of an NHS hospital, but only after having carefully analysed its record. And also, something to bear in mind is that in Britain, neonatal mortality stood at 2.8 per thousand births in 2019 (Gov.uk), while in Russia the figure was higher, at 4,9 (statista.com).
What are the latest technologies for the treatment of women’s ailments to have appeared in Britain? Is it true that soon robots will soon be treating us and performing surgery?
Robotics is a dominant new branch of surgery. Currently, there are 70 hospitals which offer robotic surgery on the NHS. The main applications are in urology, colorectal surgery and gynaecology. In 2019, more than 10,000 of these operations were carried out in the UK.
Personally, I have almost completely gone over to robotic operations using DaVinci consols, and I regret not having done so much earlier. My special area of expertise is severe infiltrative endometriosis, which is the most difficult area of gynaecological surgery. Robots simplify life for surgeons, as they allow them to easily access awkward anatomical areas and conduct extremely delicate excisions on endometrioses. They also reduce the risk of damaging the nerves that control the bladder, intestines and sexual functions, as well as blood vessels and other important structures of the female pelvis.
The robot provides high-definition 3D visualisation and ensures high accuracy when making incisions. The feeling during the operation is as if you have been directly transported into the space you need to work on. You control what you can see and you manipulate your tools with your fingertips, which are in direct contact with the robotic sensors. At first, it felt slightly surreal; everything looked strangely enlarged, with more depth and clarity.
After robotic operations, patients get better more quickly. What’s more, the operations also take less time than traditional laparoscopies, even more so when compared to open surgery. Of course, this technology is no guarantee against surgical complications. You have to understand that robotic surgery is merely a tool in the hands of the human operator. The human surgeon performs the operation and remains responsible for the patient both during and after surgery. It is just that this tool provides a new standard and new capabilities. Surgical robots are not autonomous, but they are able to point out potential dangers to the human surgeon.
My operations can take from four to seven hours, and when I finish a conventional laparoscopic operation, I usually feel dead tired and I’m suffering from back pain, but after an operation using robotic surgery, I have an unusual feeling of lightness and pleasure from having finished a complicated procedure. Going back to conventional methods would be as difficult as for the pilot of a Su-57 to abandon his fighter plane for a crop sprayer.
