Poor team-working among surgeons must be challenged no matter how uncommon, says RCS

Today the Royal College of Surgeons (RCS) is calling on surgical teams and leaders in UK NHS and private hospitals to ensure they embed strong team-working across all of their services. This follows findings that, where rare problems occur in surgical practice, poor team working between surgeons is often a major factor.  Analysis of one hundred surgical reviews over 10 years conducted by the RCS, published in a new report today¹, identifies poor teamwork as an issue leading to problems in surgical practice in over three quarters (76%) of the reviews. In more than two thirds (68%) of the RCS reviews, timely recognition and resolution of concerns was an issue. 

The RCS says that in many areas of surgery, patient outcomes are of a consistently high standard and surgeons are leading the way in delivering major improvements to the quality of people’s lives. Various clinical audits published by the Royal College of Surgeons and NHS England show the UK has surgical outcomes among the best in the world.  The most recent Care Quality Commission Annual State of Care report² demonstrated that the vast majority of surgery in hospitals is either good or outstanding. However, in a small number of surgical departments, more needs to be done to improve the quality, and to reduce the variability, of surgical outcomes and the standards of patient care provided by the NHS.

The Royal College of Surgeons’ Invited Review Mechanism (IRM) provides hospitals with an independent, external and professional review of an individual surgeon or surgical service. This typically involves surgeons and lay people being invited into a hospital to talk to staff on a confidential basis and examine information to determine whether there is cause for concern and make recommendations for improvement. In some cases no problems are identified. The RCS has now analysed a sequential sample of 100 of its reviews - 58 service reviews, 25 individual surgeon reviews, and 17 clinical record reviews - out of a total of 240 conducted between 2008 and the end of 2017, to identify lessons about how problems occur and where improvements need to be made.  

Professor Timothy Rockall, Chair of the RCS Invited Review Mechanism, said:

“Through our Invited Review Mechanism we have identified some of the common themes that lead to poor practice, which create risks to patient safety.  In all but a handful of reviews, team working was an issue. This was an issue because, for example, consultants were not meeting regularly to reflect on practice, or where tensions between group members form after mergers with other teams or organisational restructuring. 

“In well over half of the reviews we analysed, problems were not recognised and dealt with quickly enough. As difficult as it can be to question the practice of colleagues, it’s vital that surgical teams improve the quality and frequency of discussions about surgical performance, so that problems can be resolved before they affect the safety of patients.

“It is also worth emphasising that problems with team-working are not unique to surgery and hospitals should be considering how improvements in team-working can be made across all services.”

Analysis of the RCS reviews shows that often individuals were not meeting regularly or effectively as a consultant surgical team.  Without regular contact between a consultant surgical team, problems can occur and patient safety can be affected. Teams have little practical experience in using consultant surgical team meetings to develop, improve and assure the quality of surgical practice. 

Surgical care delivery issues were a significant factor in four out of five reviews (82%), however these were multidimensional and unique to each review. Among the problems identified were: the training undertaken by a surgeon before embarking on independent practice or adopting a new technique, the preoperative assessment offered to patients, and the quality of immediate postoperative care. 

RCS analysis revealed that in over half of the reviews (51%) an aspect of the facilities and resources available needed further attention. This included: a lack of availability of surgical ward beds and/or the ability to ring fence beds for elective procedures; managing emergency admissions; access to sufficiently well-staffed, specialist, high-dependency and intensive care units; access to appropriate and functioning hospital computer systems; and the number and skill-mix of nursing staff, among other things. 

In over half of the reviews analysed, there was a need for improvement in:

• the timely recognition and resolution of concerns (68%)
• multidisciplinary team working (57%)
• individual surgical behaviours (54%)
• leadership and management (54%)
• outcomes data (53 %)
• facilities and resources (51%)

In over a quarter of analysed, there was a need for improvement in: 

• audit (48%)
• relationships with surgeons in training (45%)
• morbidity and mortality meetings (43%)
• activity data (38%)
• managing change (35%)
• appraisal (35%)
• learning from patient experience (31%)
• patient consent and candour (30%)

Alongside the report, the RCS has developed an interactive web resource to help hospital teams improve the quality of discussions about surgical practice and the action that takes place in response to it. 

Notes to editors

1. A full copy of the report, ‘Learning from Invited Reviews’, is available here: https://invitedreviews.rcseng.ac.uk/ 

2. Care Quality Commission State of Care Report: https://www.cqc.org.uk/publications/major-report/state-care 

3. The Royal College of Surgeons of England is a professional membership organisation and registered charity, which exists to advance surgical standards and improve patient care. www.rcseng.ac.uk 

4. For more information, please contact the RCS Press Office: telephone: 020 7869 6047/6041; e-mail: pressoffice@rcseng.ac.uk; for out of hours media enquiries: 07966 486832.