Current Newsletter

Mr John Black, President

Busy times ahead

Ann R Coll Surg Engl (Suppl) 2010; 92:114-115

My last newsletter in support of the concept of the consultant’s personal medical secretary produced a lot of very supportive correspondence and it is clear that Bulletin readership is high among surgeons’ secretaries or at least those who are still in a job! It is clear that the national position is not all bad and some surgeons have managed to retain their personal secretaries, very much to the advantage of the efficiency of their departments and the welfare of their patients. It can be done if you are determined. May I repeat the advice I gave you in January: ‘What can you do about it? Please stand up for your secretaries, turn up for the management meetings when their future is discussed and point out how essential they are to safe, efficient surgical care with a human face.’

A very interesting and I think groundbreaking consensus conference was held at the College on 21 January. The subject was bariatric surgery and its governance, following the approval of its use by the National Institute for Health and Clinical Excellence (NICE) (www.nice.org.uk/guidance/CG43) and the realisation of the very large numbers of operations needed should NICE guidelines be followed. Concerns have been expressed about the lack of surgeons trained in the various techniques, evidence gaps about the appropriate procedure for each individual patient and the lack of universal collection of follow-up data, without which the evidence gaps will not be filled. There is also a wide plurality of provision, with about half the operations currently being performed in the NHS and the rest in the private sector and abroad.

The conference had all the key players present. These included the three surgical societies involved: the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, the Association of Laparoscopic Surgeons and the British Obesity and Metabolic Surgery Society. There were representatives from NHS commissioners and private sector providers of care, NICE (Sir Michael Rawlins himself), the National Confidential Enquiry into Patient Outcome and Death and of course patients. There was unanimity on the following three principles.

• Developing a bariatric surgery service
  Patients should be referred only to units with a multidisciplinary team able to offer the full range of operations as well as preoperative assessment, long-term follow-up and, where needed, revision surgery. All cases must be discussed in multidisciplinary team meetings.
• Building an evidence base to improve outcomes
  No bariatric operation should be carried out either in the NHS or private sectors unless the case is entered into the National Bariatric Surgery Registry, with particular emphasis on recording long-term follow-up data.
• Workforce for the future
  There should be a national training programme based on mentoring similar to that for laparoscopic colorectal surgery to address the shortage of appropriately trained surgeons required to implement the 2006 NICE guidelines.

I find this exciting and a very good template for the establishment of new surgical techniques in the future. Think how much better and safer the introduction of laparoscopic surgery would have been if these rules had been followed.

The next step is implementation of the principles. I am sure they will be received with enthusiasm and introduced rapidly in the private sector. The NHS may be a tougher nut to crack but with support from NICE I hope the College will succeed. Meanwhile clear College advice to all individual surgeons carrying out bariatric procedures is that you must enter every patient you operate on into the register. In any event you will soon need to collect these data as part of your revalidation process.

This leads me to a progress report on revalidation and the forthcoming pilots. I am pleased to say that we are about to reach agreement with the other surgical colleges that there will be a single online surgical portfolio and logbook for all surgeons working in the UK, regardless of college affiliation, provided as a benefit of membership. It will be an intercollegiate project, based on the portfolio developed in this College and the logbook developed in Edinburgh, using the best features of each. The logbook will also be incorporated into the Intercollegiate Surgical Curriculum Programme for all specialties, so that there will be the same logbook for surgeons throughout their careers. This is a logical and sensible development that I am very pleased to see and it will be ready for the ‘light-touch’ pilots starting in June of this year.

Venous thromboembolism (VTE) is a problem very well recognised by surgeons and is largely preventable. It is frustrating, indeed scandalous, that only a proportion of patients receive proper assessment of risk and treatment, leading to many thousands of unnecessary deaths each year, 30 years after the research questions as to the efficacy of prophylaxis were answered. The College, collaborating with other colleges through the Academy of Medical Royal Colleges, has been working with the Department of Health (DH) and the strategic health authority medical directors to try to address this.

DH, through its commissioning processes, has introduced financial penalties for trusts that do not assess the risk of VTE, audit the percentage of patients receiving the prophylactic measures appropriate for them and carry out a root-cause analysis in every confirmed case of deep vein thrombosis or pulmonary embolism. I urge you to make prevention of VTE a clinical priority, by making sure that systems are in place in your hospital to ensure that all patients are assessed for risk, that the decision made and therapy chosen is documented and that the process is properly audited. Whether VTE prophylaxis has been given is one of the items on the World Health Organization checklist, which I hope will be another useful mechanism. It could be argued that the NHS has set a new target. The College has no problem with our much-loved but highly centralised NHS setting targets, provided they are clinical and relevant, and not political.

More than half of junior doctors are still working more than 56 hours a week and one in three is working in excess of 65 hours a week. These are data from a survey of all specialties carried out by the BMA junior doctors committee, reported in BMA News. More than 40% of rotas have gaps and the number is increasing. In the surgical specialties the figures are probably even more stark. According to the doctors in the survey, junior doctors’ training, NHS service delivery and patient safety have suffered, thanks to the European Working Time Directive (EWTD). Somehow, DH maintains that there has been full implementation of the 48-hour working week. Can you imagine how much worse things would be if everybody was downing tools on time and actually working the magic 48 hours? The NHS would truly collapse.

At the same time the Royal College of Paediatrics and Child Health (RCPCH) has warned that paediatric units will have to close because of the EWTD. Sick children will have to travel further because of a European regulation designed for lorry drivers, which is either ignored or sidestepped in the rest of Europe.

As more and more evidence emerges that attempts to introduce 48-hour working for junior doctors have been a disaster for patient care and training, what I do not hear from anyone other than surgeons is a solution. The College and the surgical trainee organisations embarked on our campaign for an opt-out for surgeons because we predicted that 48-hour working could not be delivered in the NHS and that attempts to comply would damage service and training. When is the penny going to drop that the EWTD is incompatible with the safe delivery of acute patient care in the British NHS and that the solution, the only solution, is to admit it and to get on with finding ways round the European law?

Criminal Records Bureau (CRB) checks for doctors working with children are of course essential but there has been enormous irritation in the way each NHS employer has been insisting on repeating the checks on doctors coming into the organisation, regardless of the fact that they have been cleared elsewhere. The problem is acute in the children’s surgical specialties, where there is a very wide range of conditions and a relatively small number of surgeons. Rather than send a child across the country to the expert in a particular condition, the expert has been travelling to the child, to the advantage of everybody. However, if the receiving trust insists on a CRB check on the travelling surgeon, who has already been checked by his or her main employer, considerable delays are introduced. This can be disruptive to a lot of children and their families if for example a specialised surgeon becomes ill.

I have taken this up repeatedly with DH and was reassured on three separate occasions in a three-month period that the problem would be solved within a week, but to no avail.We therefore took the problem to the media with a letter to The Times (jointly with the RCPCH and the British Association of Paediatric Surgeons) and a widely covered press release and we were able to have an early day motion tabled in the House of Commons. This has produced a response at last. From July of this year all new NHS employees requiring checks will be vetted once and entered on a single electronic database. This will be extended to existing staff from April 2011.

Meanwhile there is no reason why one CRB check should not be accepted throughout the NHS. DH has provided the College with a personal contact at a senior level, who has undertaken to facilitate this. If you come across any unreasonable delay in the next year, please telephone the President’s Office at the College or email me on president@rcseng.ac.uk.

5 March 2010