If emergency general surgery requires 24/7 consultant cover why do we still spread acute services across NI?

A fascinating letter emerged today from a small group of senior consultants working in the Northern Irish health service that puts its finger the key downside of our habit of electing populist political parties that have little ambition to get things done.

Although its subject is health, the same analysis could be applied to almost any other area of public policy including education, infrastructure, agriculture and even climate change (a thing some DUP politicians seem to think only happens elsewhere).

Post Compton, post Begoa who both put their fingers on the problem no political consensus has emerged around how to fix the health service’s infrastructural problem (in GB these were mostly addressed in the 00s, when Stormont was mostly down).

Health reform remember (as this edition of the Sunday Politics shows clearly) is something every major party in Stormont is officially in favour of, and yet, this is what the letter has to say on an issue we covered as long ago as 2011...

“The stark options facing the HSC system are either to resist change and see services deteriorate to the point of collapse over time, or to embrace transformation and work to create a modern, sustainable service that is properly equipped to help people stay as healthy as possible and to provide them with the right type of care when they need it. This report presents an opportunity that must be seized and acted upon”.

These words, taken directly from the Bengoa report of 2016, sadly have come true in 2022. The difficulties seen in the South West Acute Hospital general surgical services have been escalating for a number of years and the failure to grasp the opportunities within the Bengoa report have resulted, as predicted, in the loss of consultant general surgeons and unplanned collapse of the service.

Changes within hospital services are never easy and it is understandable that such decisions bring anxiety, anger and pessimism. The proposed suspension of emergency general surgery at SWAH by the Western Trust is no exception. This
decision had to be made due to the loss of the last three surgeons from the ‘on call’ rota in December.

As the clinicians who led the review of general surgery in NI, we would like to contribute to the debate on the way forward. Notably this type of change was recommended for Western trust and others by the General surgery review however, it has come about in a suboptimal fashion via a service collapse due to a lack of staff.

It’s an unavoidable fact that smaller hospitals are finding it increasingly difficult to recruit and retain consultant general surgeons. That’s a reality right across these islands. In fact, many parts of the UK changed the delivery of general surgery well
over a decade ago, with emergency general surgery being centralised in bigger hospitals whilst elective activity took place in the smaller hospitals. One of the principal reasons was failure to recruit general surgeons to the smaller rural hospitals. It’s no reflection on the hospitals or the local areas. It’s down to the way modern medicine and in particular general surgery has developed.

Larger hospitals serving larger catchment areas provide greater patient throughput and greater mix of cases for clinicians. That helps them develop and maintain their skills and enables them to specialise further within their chosen field of medicine. This kind of sub specialisation has become increasingly important in general surgery, with different surgeons developing expertise in specific areas such as colorectal surgery (large bowel) and upper gastrointestinal surgery (stomach, gallbladder, pancreas).

Patient care has obviously benefitted greatly from such developments with all the required diagnostics, theatres, staff and support services 24 hours per day seven days per week. Emergency general surgery requires 24/7 consultant cover. When you have smaller teams, rotas are more punishing as they are shared out among fewer colleagues.

Staff teams can be easily destabilised by routine occurrences like a colleague falling ill or moving to a job elsewhere.  The service invariably ends up being reliant on temporary locum doctors to plug gaps that cannot be filled permanently.  Whilst locums can provide excellent care, their constant use often brings inconsistencies and causes difficulties in continuity of care to patients. It also means that the small number of substantive (long-term) surgeons have increased work loads picking up issues from the temporary cover of locums.

In short, the service become less resilient, more fragile and less attractive as a workplace. So, when you hear that SWAH has struggled for years to attract and retain consultant general surgeons, this is why.  Much of it is down to numbers – the limited number of patients coming through the doors, the relatively small size of its catchment area, the small number of emergency operative procedures, the consultant’s feeling of isolation with limited interventional radiology, gastroenterology and other members of the full multidisciplinary team.

It’s easy to accuse Trusts of not doing enough on the recruitment front. Or to keep
demanding that they try harder.  “Trying harder” will not alter the basic realities of population size and modern emergency surgical practice. We fully understand the support in the local community for their local hospital; and the desire to have services close at hand.  In an ideal world, everyone would live near to a major hospital that can provide every single medical specialty. That’s not the world we are living in. Patients needing emergency care already bypass SWAH for specialist treatment.

Heart attack patients requiring stents already go to Altnagelvin or Belfast. Stroke patients suitable for thrombectomies (clot removal) will go to Belfast. So too will major trauma patients and those who have suffered serious life -threatening burns. A local hospital is not always the best or the safest place to be treated. It’s important to explain what this unplanned change means. For example, if you develop severe abdominal pain and need to go to hospital, you should attend the ED department at the SWAH. Here the doctors will start the necessary investigations you need to determine your diagnosis and if they decide you need to be admitted for observations or an operation, you will be transferred to another hospital.

Similarly, in direct discussion with the emergency on call team in either Altnagelvin or Craigavon it may be decided that treatment can be started in SWAH and an urgent ambulatory/outpatient arranged for you (e.g., episode of biliary colic due to
gallstones). Emergency general surgery covers abdominal conditions such as appendicitis, blocked bowel or inflamed gallbladders. It is important to note that this change does not impact the delivery of obstetric services (such as an emergency
caesarian section).

Although emergency general surgery needs to be done relatively quickly, we are not talking about the race against time seen in other types of medical emergencies. The people of Fermanagh are not being asked to decide where to attend if they fall sick. They should attend the SWAH ED as they would normally have done. If you phone for an ambulance then the paramedics will transfer you to the most appropriate hospital, which may still be SWAH, however, it may be direct to Altnagelvin or Craigavon.

The Department of Health have announced the SWAH becoming an overnight stay elective surgical centre. This will not just be for General Surgery but many other surgical specialties. The creation of such centres will allow us to radically address the horrendous waiting lists we have in Northern Ireland. It will also ensure a greater surgical presence on the SWAH site than ever before. Planned general surgery will remain at SWAH – involving on-site surgeons below consultant level and visiting consultants coming to perform surgery and its aftercare.

This new centre should increase patient numbers at SWAH and help secure a brighter, more stable future for the hospital. Need for transformation of our health service has never been greater and sadly we will hear of more examples of unplanned service change going forward unless we make the difficult decisions in a planned, co-produced manner with the ultimate goal that no matter where you live in Northern Ireland you will receive the same, high-quality care whether it be elective or emergency surgery. There is an onus on politicians, clinicians, civil servants to come together to drive the necessary changes forward otherwise we will continue to see services fail.

Anand Gidwani Consultant Surgeon
Andrew Kennedy Consultant Surgeon
Ian McAllister Consultant Surgeon
Barry McAree Consultant Surgeon
Michael Mullan Consultant Surgeon
Gary Spence Consultant Surgeon
Mark A Taylor Consultant Surgeon
Colin Weir Consultant Surgeon
Susan Yoong Consultant Surgeon

Members of the Review of General Surgery Network Board

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