President's Newsletter

Questionnaires: the bane of our lives

Professor Norman Williams, President

Ann R Coll Surg Engl (Suppl) 2012; 94: 190–91

One of my particular bugbears, and I suspect I am not alone, is receiving a request via email to fill out a questionnaire. The number of such requests has increased exponentially as email has become the key means of communication. These requests are always accompanied by a message to say that this particular questionnaire will take no more than five minutes to complete – usually an underestimate in my experience. My natural inclination is to delete the request unless I really think it is an important topic and that my participation might change thinking. I would like to therefore thank all those individuals who completed the College’s questionnaire regarding concerns related to the Health and Social Care Act. The results of the questionnaire can be found at www.rcseng.ac.uk/policy/publicaffairs and you will see that the principle concern of respondents is the impact of the changes on education and training.

The results of this survey and those of previous consultations will form the basis of my discussions with ministers as we move forward with the implementation of the act. I have already met Paul Burstow, Minister of State for Care Services, and impressed on him the need to improve the organisation and delivery of emergency surgery. I stressed that this was not just about the availability of consultant staff, which has been prominent recently in the media, but related to operating theatre access, scanning availability, access to interventional radiology and the provision of sufficient high-dependency unit and intensive care unit beds. The discussion also touched on the need to train and commission appropriately for such a service.

Commissioning is the key for all services, both emergency and elective, and it must be done with appropriate advice from both primary and secondary care practitioners. This, in theory, is enabled by the act and it is up to government, the National Commissioning Board and clinical commissioning groups (CCGs) at a local level to listen to us and ensure that we are intimately involved in the process. Paying lip service to us in this key area could prove disastrous. I now have meetings with other key ministers and will drive home this message and our other priorities. It will also be important to solicit support for our position from other colleges and medical institutions and I can assure you that the team at the College is working hard in this endeavour. If ever there were a moment for the profession to speak with one voice it is now.

The results of another survey have also had an impact on our thinking in recent weeks. A report by the Patients Association revealed that waiting times for seven common forms of elective surgery, including hip and knee replacements, cataract removals and hernia repairs, increased between 2010 and 2011, as they did between 2009 and 2010. This survey also showed that, based on information supplied by 93 of England’s 170 hospital trusts, we now know that the number of patients receiving these operations is falling. These data may not come as a surprise. We are aware of lists of procedures that are categorised by some primary care trusts and CCGs as being of ‘limited clinical value’ as they try to deal with the swingeing cuts required by the Nicholson challenge. The Department of Health counters that the Patient Association has produced a report based on partial data and that overall numbers for waiting times are generally within the required limits.

I expect this argument will run and run in the coming months and will be conflated with the adverse effects of the new act. It is our duty, however, to point out that any reductions in the number of operations are short-term measures and will not only leave patients in misery but will not be cost effective in the long run, as patients who could have been treated electively present later as emergencies and/or develop more post-operative complications resulting from the intra-operative complexities that accrue as a consequence of delay. One appreciates that budgets are tight but cost savings can be achieved in other ways and trusts and commissioners must be prepared to be more imaginative in delivering their services and yes, this will involve centralisation and reconfiguration of services. With regard to the latter this College will support reconfiguration of services provided it is clinically beneficial and not solely cost-driven.

I turn now to another questionnaire, the World Health Organization checklist. This was introduced in 2007 and was met with a fair degree of scepticism. Nevertheless, many of us have over time realised its importance. Sadly, not everyone is so sure and it is often treated as merely a box-ticking exercise. When trusts were recently surveyed about the implementation of the checklist, over 90% stated that their staff fully complied. However, a soon-to-be-released study from Imperial College demonstrates that compliance is patchy and often incomplete. This study involved independent observers going in to operating theatres in a variety of trusts. They found that very often the checklist was carried out while the surgeon was either scrubbing up or was even absent all together. Frequently, not all of the items on the list were checked and importantly debriefs were rarely carried out.

This study has been completed at a time when ‘never events’ are continuing to rise. Never events include wrong-site surgery and retained foreign bodies (both swabs and instruments), not to mention the use of the wrong implant. Such events are of course a disaster for patients but surgeons should reflect on the catastrophic effect they may have on their professional lives. Medical directors are under increasing pressure to consider disciplinary action, including referral of surgeons to the General Medical Council if something does go wrong in theatre and the checklist has not been completed, so I implore fellows and members to do all they can to ensure that this relatively simple procedure is followed for all invasive procedures.

Finally, thanks to everyone who voted in the last Council election. I am delighted to congratulate Mike Horrocks and David Ward, who were re-elected, and Sue Hill, Peter Kay and Paul O’Flynn who were elected. In addition, Mike Horrocks was elected at the April Council meeting to be our next Vice-President and joins John Getty, who continues in this role. I would also like to take this opportunity to thank John Stanley, demitting Senior Vice-President, for his superb contribution to Council over the years. Our thanks also go to Bob Greatorex and David Neal for their significant contributions. Despite these departures we have a very strong, capable and extremely active Council and I am very grateful for the tremendous support I receive from all members in my role as President.

4 May 2012