The Crisis in the Provision of General Paediatric Surgery

1
The Crisis in the Provision of General Paediatric
Surgery
The Effect of Modernising Medical Careers
2
General Paediatric Surgery (GPS)What procedures?

• Elective
• Herniotomy for congenital hernia or hydrocoele
• Orchidopexy for palpable undescended testis
• Circumcision
• Removal of minor soft tissue abnormalities
• Repair of umbilical hernia
• Emergency
• Appendicectomy
• Operation for torsion of testis
• Operation for incarcerated inguinal hernia
• Minor trauma

3
The aim of Paediatric Surgery is to set a
standard, not to seek a monopoly.

• -Sir Denis Browne
• 1953

4
The Past

• All DGH General Surgeons Treated Children often
  without Specific Training

5
NCEPOD Reports 1989, 1992 and 1993

• Highlighted increased risk created by occasional
  practice in DGHs
• Trainees should not operate on or anaesthetise
  children without appropriate Consultant
  Supervision

6
Guidance for Purchasers on Paediatric Anaesthesia
The Royal College of Anaesthetists 1994

• Only appropriately trained Doctors should
  Anaesthetise Children
• Paediatric Anaesthetic Service should be led by a
  Consultant with adequate ongoing experience (1
  list /wk)
• Children lt5 years must be anaesthetised under the
  supervision of an appropriate Consultant

7
A Guide for Purchasers and Providers of
Paediatric Surgical Services The British
Association of Paediatric Surgeons 1995

• Designated General Surgeon and Anaesthetist for
  Paediatric Surgery in DGH
• General Surgeon should have at least 6 mths
  training in Specialist unit at Year 4 or higher
• At least 1 operating list per week for children
• Continuous cover by Paediatrician

8
Report of an ad hoc multi-disciplinary Childrens
Surgical Liaison Group The Royal College of
Paediatrics and Child Health. Childrens Surgical
Services 1996.

• Dedicated Operating lists for Children
• Surgeon should have at least one Childrens
  Operating list per week to maintain skills
• In-patient care of Children should only occur in
  a fully staffed paediatric department

9
The Provision of General Surgical Services for
Children The Senate of Surgery of Great Britain
Ireland 1998

• Recognised the continuing role of General
  Surgeons in treating the majority of children
  requiring operations
• One dedicated operating list per 2 weeks
  essential to maintain skills of Surgeon
• Surgeons appointed after 1999 must have SAC
  recognised training in Paediatric Surgery

10
Childrens Surgery A First Class ServiceReport
of the Paediatric Forum of the Royal College of
Surgeons England 2000

• DGHs that meet National Standards should
  continue to provide surgical services for
  children
• Hub and spoke arrangements with Specialist
  Paediatric Surgical Centre

11
Summary of Important Recommendations

• Occasional Practice is Dangerous
• Children should be treated by Trained and
  Experienced Doctors and Nurses
• Children should be Treated in a Child Friendly
  Environment

12
What has happened since these recommendations
were published?
13
Current Position

• Most DGHs have an appropriate Paediatric
  environment
• Most DGHs have appropriately trained and
  Experienced Anaesthetists
• Sufficient Training Positions have been created
  for General Surgical Trainees in Paediatric
  Surgery to meet demand in Great Britain

14
Current Position
However

• Less than 10 of these potential Training
  Positions are occupied
• Less than 2 of General Surgeons currently have a
  declared interest in Paediatric Surgery (ASGBI
  survey 2004)

15
Why?
16
Failure to Recruit General Paediatric Surgical
Trainees
Related to

• Compressed training programme caused by Calman
• Competition with other subspecialty interests eg
  Vascular Surgery
• Little or no Private Practice
• Life Style Issues

17
Risks Within 5 years

• Reduced Numbers of DGH General Surgeons capable
  of safely undertaking General Paediatric Surgery
  caused by Retirement of Grandfather Surgeons
• Declining capability of DGHs to provide both
  Emergency and Elective General Paediatric Surgery
• Unplanned Shift of Children with Surgical
  problems towards Specialist Paediatric Surgical
  Units

18
Modernising Medical Careers
19
MMC

• Government Sponsored
• Will be implemented from 2005
• To Provide Seamless Structured Training
• ?Shortened Training to CCT
• To Increase Numbers of Emergency Safe
  Specialists
• Anticipated Ratio 15 Trainee to Specialist
• Specialist Delivered Service

20
Specialist Training
After MMC
Prior to MMC
Post Reg. Houseman
Foundation Year 1 (F1)
At least 3 yrs and Up to 6 yrs as SHO
Foundation Year 2 (F2)
Six yrs Specialist Training
?Six yrs Specialist Training (ST1- ?)
45,000 hrs Total
16,000 hrs Total
21
The Effects of MMC on DGHs

• Reduction in the Opportunities for Trainees to
  get Exposure to Paediatric Surgery
• Likely to Reduce further the uptake of Training
  in General Paediatric Surgery

22
In any case.
23
Current System of Training General Surgeons does
not Provide a Comprehensive Safe Surgical Service
for Children in DGHs
24
While Most DGHs will have sufficient work load
to justify one Paediatric Dedicated Elective List
every 2 weeks.
25
Most DGHs will not have sufficient numbers of
Trained General Paediatric Surgeons to provide
24/7 Emergency cover
26
Risks for the Future

• Unless there are Changes to the Training
  Programme for General Surgeons..

27
Provision of General Paediatric Surgical Services
in a DGH will be by fewer General Surgeons thus
increasing the risks of occasional practice for
those who do not treat children
28
Possible Outcome for DGHs (1)

• General Paediatric Surgical Training will
  continue to be offered in Tertiary Centres to a
  level which is compatible with treating Emergency
  and Elective GPS in the DGH down to about 1 year
  of age providing there is appropriate ongoing
  experience
• Otherwise Emergency GPS can only be justified
  down to about 5 years of age
• The uptake in this option is likely to continue
  to be low

29
Possible Outcome for DGHs (2)

• GPS Training for all General Surgical Trainees
  during or after ST1, to a level which is
  compatible with treating Emergency GPS in the DGH
  down to about 5 years of age
• For these Surgeons, Elective GPS in this age
  group can only be undertaken if there is
  appropriate ongoing experience

30
Possible Outcome for DGHs (3)

• Those General Surgeons who have no training or
  experience in GPS (but because of Generic
  Surgical Skills) could safely treat selected
  emergencies in children over the age of 8 years
• Initially there will be an increasing number of
  these DGH General Surgeons as the grandfather
  Surgeons retire

31
The Effects of MMC on Tertiary Centres

• Will increase numbers of Paediatric Surgeons by
  at Least 150
• This will deskill the Work Force unless
  sub-specialisation occurs
• Create 2 type of Paediatric Surgeon
• Generalist
• Specialist

32
Possible Outcome for Tertiary Centres (1)

• General Paediatric Surgeons working in the
  Tertiary Centres could provide regular hub and
  spoke Outpatient and Day Case Operating Lists to
  DGHs
• This could provide Educational Opportunities and
  ongoing experience for DGH General Surgeons and
  Anaesthetists

33
Possible Outcome for Tertiary Centres (2)

• The Demographic Shift of Work to the Specialist
  Centres is likely to be significant but difficult
  to estimate.
• GPS Emergencies could compromise treatment of
  Specialist problems such as Oncology in Tertiary
  Centres.

34
What is being done to prevent the potential
crisis?
35
Professional Action

• BAPS has opted to safeguard DGH GPS by providing
  hub and spoke services where necessary from the
  Tertiary Centres.
• The Senate of the Surgical Colleges is
  implementing a compulsory GPS component for ALL
  General Surgical Trainees at ST1 or higher.

36
DoH Action
Urgent

• Modelling of shift of Paediatric Surgical
  Emergencies to Tertiary Centres from DGHs for
  different age groups
• Resource Re-allocation from DGHs to Tertiary
  Centres to take account of this shift

37
To do nothing would be to seriously compromise
Children with Surgical Problems in Great Britain.