The case for reconfiguration in emergency surgery

A couple of months ago, my father required complex, emergency surgery on his bowel. According to a report published by the Royal College of Surgeons (RCS) last week he was one of the lucky ones. He was not one of the 100,000 patients in the UK each year who develop significant complications or one of the 25,000 (15 per cent) who die after this type of surgery.

The RCS report provides a valuable, forensic examination of the potential causes of these unacceptably poor outcomes. These include: lack of involvement of senior medical staff in early decision-making and in surgery itself; lack of access to protected theatre time and to critical care; and no systematic risk assessment of patients and a lack of supporting protocols that ensure that appropriately skilled staff deliver optimum care.

In my father's case, he was rapidly assessed by a consultant surgeon. The same surgeon then undertook the surgery and followed up with him on the ward. I saw that surgeon on the ward late at night and at the weekend. The nursing care on the specialist surgical ward was also excellent, including regular observations, attentive care and early mobilisation. My father was discharged a matter of days after complex surgery that had taken out over a foot of his bowel.

A recent report for NHS London covered by the Health Service Journal revealed that only four of the 31 acute trusts in London could reliably ensure a consultant-level review within 12 hours of admission. So why aren't all hospitals able to offer the quality of care my father received?

The RCS report suggests that trusts could do much more to develop systematic approaches to patient care and to organise elective and emergency care so that they prevent competing demands on the same resource. However, I was disappointed that it failed to mention how reconfiguring services could address many of the issues raised. Reconfiguration could help guarantee senior input and create a critical mass to support dedicated emergency theatre facilities and other specialist support.

One of the strongest arguments for reconfiguration of emergency surgery concerns workforce. A quick calculation makes the point: according to the latest Centre for Workforce Intelligence figures, there are about 1,800 consultant general surgeons in England. Not all of these surgeons are suitable for an emergency surgical rota (for example they may have moved to specialise in breast surgery). This suggests there may be only around 1,500 surgeons able to provide emergency cover.

Royal College guidance recommends that a minimum of ten junior doctors are needed to provide 24/7 cover for their specialty and comply with European working time regulations. For a rota involving consultants, for whom this would be a career long commitment, 15 is likely to be a more reasonable number. This suggests that, at a rough approximation, there are only enough surgeons to provide 24/7 cover for about 100 hospital sites. This does not necessarily mean that all other hospitals would stop emergency surgery, instead they could restrict the hours in which they accept admissions.

Lord Darzi (himself a gastric surgeon) argued for a model similar to this in the Healthcare for London strategy he led for NHS London. Under this strategy only the proposed 'major acute' sites (less than half the current sites) would undertake emergency surgery out of hours. These sites would work as part of a clinical network with the remaining hospitals to ensure the safe management of surgical patients.

I am thankful that my father was lucky, but what about the many who will not be so fortunate next year? The RCS report and the audit work recently undertaken by NHS London make a compelling case for change and we all need to recognise the consequences to patient safety if these messages are not heeded. Reconfiguration of emergency surgery should be part of the solution.

For more, read Candace's briefing on reconfiguring hospital services

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