P 38
Ymchwiliad i’r Adolygiad Blaenoriaethau ar gyfer y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon
Inquiry into the Priorities for the Health, Social Care and Sport Committee
Ymateb gan: Coleg Brenhinol Llawfeddygon Caeredin
Response from: Royal College of Surgeons of Edinburgh
The Royal College of Surgeons of Edinburgh is the oldest and largest of the UK surgical Royal Colleges, and one of the largest of all the UK medical Royal Colleges. First incorporated as the Barber Surgeons of Edinburgh in 1505, the College has been at the vanguard of surgical innovation and developments for over 500 years.
Today we are a modern, thriving, global network of medical professionals with a membership of well over 23,000 professionals who live and work in more than 100 countries around the world. 15,000 of these live and work in the UK with 625 in Wales. Our membership includes people at every stage of their career, from medical students through to trainees, consultants and those who have retired from practice.
With our interest in professional standards, the College’s primary role – and the main concern of our Fellows and Members - is to ensure the safety of our patients and provide them with the best possible care. We do this by championing the highest standards of surgical and dental practice; through our provision of courses and educational programmes, training, examinations and Continuous Professional Development; our liaison with external medical bodies; and by influencing healthcare policy across the UK.
Improving the Quality of Services
Given that common conditions account for the majority of the surgical workload, the development of general surgical skills and competencies are vital, especially as surgical care should always be consultant-led and delivered as close to the patient as possible.
However as rarer conditions are best dealt with by specialist surgeons who have the training and expertise to produce the best care, we believe patients needing specialist surgery are often best served when services are concentrated in regional or national centres of excellence.
Pooling expertise in this way allows for economies of scale, better knowledge sharing and a professional environment that helps attract and retain the very best consultants and trainees. All these are a vital prerequisites of better patient outcomes. As recommended in our Standards informing delivery of care in rural surgery[1], it is vital that these configurations are supported by more formal collaborations between urban and rural hospitals, an increase in the number of generally trained consultants and greater multi-disciplinary working.
Similarly as per our Trauma Care report[2], major trauma services continue to be consolidated into a smaller number of specialist centres as they provide the most effective way of reducing mortality and disability for patients with multiple injuries.
In terms of seven day services, many of our members are already providing round the clock emergency surgery when it is needed. However, we do not believe that seven day elective surgery can be delivered without a significant increase in the surgical workforce. Likewise those services related to surgery, such as pharmacy, radiology, physiotherapy and social care, will be need to be expanded and appropriately resourced.
This is just one example of the importance of an adequately funded health service. Whilst there are efficiencies that can be found, any sustainable model will depend on new sources of income. However, we believe that patients receive the best value service when funded through taxation and this principle should be the bedrock of any future model.
Therefore we feel it is important that:
· Every service meets the standards established in the Academy of Royal Medical College’s Report Guidance for Taking Responsibility[3].
· There is a guarantee that all patients will not suffer negative consequences as a result of longer distances to specialist centres. This can be realised by underpinning services with the ability to move all patients safely without depleting local services.
· Provision for general surgical trainees in Wales to have the opportunity to spend four months in a Rural General Hospital are made.
Improving Surgical Training
Good training leads to better patient care, but we are concerned that the perennial high dissatisfaction amongst trainees and trainers with the quality of surgical training remain stubbornly unresolved.
RCSEd therefore supports the Shape of Training review, particularly its emphasis on developing more generalist surgical skills, a more competency based approach and an enhanced training for members of the wider surgical team. The recommendations of this review should be support by a greater use of credentialing in order to support surgeons in developing specialist skills later in their careers.
We also believe that workforce planning needs to be focussed on producing more consultants. Not only do we believe that all services should be consultant led, but are concerned that staff shortages have created an undue reliance on trainees delivering services that have little educational value.
Therefore both trainees and trainers need to have guaranteed time for training enshrined in their job plans. Further, surgical training should only be delivered by trainers using the Faculty of Surgical Trainers’ Standards for Surgical Trainers and where possible, effective surgical trainers are formally identified and appropriately rewarded.
Surveys conducted by the College and the GMC consistently report that bullying, undermining and harassment is a frequent occurrence within the surgical profession. Not only is this harmful for the individuals affected, but these types of behaviours adversely affect patient outcomes. As such, non - technical skills training, such as around team working, leadership and patient safety should also be made mandatory.
Therefore we feel it is important that:
· Each surgical speciality is supported to determine their own training pathway to complement the implementation of the Shape of Training review in Wales.
· The focus on building competency rather than just experience in the early stages of the surgical career is increased.
· All contracts guarantee sufficient time for training but also allow flexibility within work plans.
· The Faculty of Surgical Trainers’ Standards for Surgical Trainers across Wales and encourage membership of the Faculty.
· Non-technical skills training is made mandatory for the entire surgical workforce.
· The use of credentialing is encouraged to increase the flexibility within the surgical workforce.
· A single body for workforce planning, development and commissioning of education and training is established.
Improving Patient Outcomes
The sole aim of the RCSEd is to improve patient outcomes. As such, we support moves including the publication of surgical outcomes data, revalidation, and Fitness to Practice reviews as important ways of improving patient care, strengthening continuous professional development and identifying those doctors who encounter difficulties.
More can always be done to improve patient safety, so in addition to calling for an overall increase in the number of NHS consultants, RCSEd advocates greater emphasis being placed on patient safety in the revalidation process. We also believe that a statutory Duty of Candour and a common framework for reporting and learning from adverse events should be adopted.
It is also vital that we address the shortfall between the supply of donated organs and the demand. Transplantation is the best option for many patients with end-stage organ failure, improving survival and quality of life. Whilst we welcome the debate about a potential opt-out system, any legislative changes must be supported by significant investment in the necessary infrastructure.
Therefore we feel it is important that:
· A requirement for all Health Boards to publish unit level surgical outcomes data in partnership with the Royal Colleges and Surgical Specialty Associations is introduced.
· All revalidations processes are centred on patient safety.
· NHS management to strike a balance between the sometimes conflicting needs of meeting Government targets and addressing staff concerns about quality.
· RCSEd will be formally represented on all relevant consultant appointment panels, and provide a more clearly defined role for faculties, specialty organisations and Royal Colleges within the overall advisory and quality assurance structure.
· More Specialist Nurses in Organ Donation (SN-ODs) and Clinical Leads in Organ Donation (CLODs) are introduced to support families through the tough decisions they are faced with.
Improving Workplace Culture
Surveys of NHS staff regularly describe a workforce that is committed to working together and supporting one another to deliver high quality care. However the same surveys also point to a number of recurring issues that are adversely affecting staff morale. Good staff morale is a vital pre-requisite of good patient care and we believe more can be done to improve team working, transparency and openness.
Firstly more can be done to encourage all staff - regardless of their seniority or specialism - to report all unsafe care to help create a ‘just culture’ in the NHS. For instance where staff feel unable to raise concerns internally, then independent third party bodies need to be created for staff to pass complaints on to.
Similarly we need to have a zero tolerance attitude to bullying, undermining and intimidation wherever it occurs in the workplace. The College actively seeks to eradicate such behaviours through our education and training activities but believe staff need to be able to identify and voice their concerns without fear of personal and professional repercussions.
Secondly efforts need to be made to reduce unnecessarily long hours. Whilst circumstances may dictate that the 48 hour working week as set out by the European Working Time Directive is not always feasible, RCSEd unequivocally supports its retention and believe that accurate reporting of hours is vital to help guard against burn out and a resulting drop in standards. We also want to see more opportunities for those wishing to work or train on a less than full time basis so that personal circumstances do not deter individuals pursuing surgery as a career.
Finally, it is vitally important that that all staff feel happy and supported in their workplace. Awkwardly placed viewing screens and break rooms stocked exclusively with junk food are just two examples of how the work environment can jeopardise a surgeon’s ability to perform to the best of their ability. Likewise, inadequate and ineffective IT systems can waste valuable time and energy.
Therefore we feel it is important that:
· A zero tolerance approach to bullying is enforced.
· The Welsh NHS work with the Royal Colleges to create a transparent system for raising concerns, overseen by an Independent National Whistleblowing Officer.
· Health Boards ensure working hours data is accurate and provide funding to increase rota numbers where the 48 target is being missed on a regular basis.
· There are no barriers to less than full time training and working.
· All NHS IT systems meet standards established by the Academy of Medical Royal Colleges.
· A review of the surgical working environment is undertaken in order to reduce unnecessary ergonomic problems
Public Health
As healthier lifestyles significantly improve the chances of surviving major surgery, the College supports all health interventions that clearly improve patient outcomes. This includes, but is not limited, to exercise, diet, alcohol and drugs and smoking. [4]
It is also vitally important that patients are discharged from hospital as soon as is appropriate. Patients with low cardiorespiratory health are five times more likely to die during or just after a surgical procedure than their fitter counterparts, and on average an unfit person costs the NHS an extra £6,000 when they undergo an operation, due to longer recovery times in hospital. In addition, patients who smoke, take drugs, or consume dangerous amounts of alcohol are more likely to develop complications, be admitted to an intensive care unit and be re-admitted after discharge.
Even when these factors are not an issue, there can be a number of reasons for delays which put the patient’s wellbeing at risk. Confronting these blockages means investing in support services such as diagnostics but also in social care so patients can be supported to finish their recovery at home.
Therefore we feel it is important that:
· Spending in social care and public health is increased in order to help reduce demand on NHS resources, manage bed blocking and improve the patient pathway.
· The development of ‘Perioperative Care Teams’ who can undertake necessary interventions but also coordinate a patient’s care along the pathway is supported.
· That every patient has the opportunity, working with their surgeon or GP, to develop an exercise plan that suits their condition and the type of operation they will undergo.
· Children and young people are protected from commercial interests which profit from recruiting new smokers or promoting unhealthy food and drink.
[1]https://www.rcsed.ac.uk/media/414891/rural%20surgery-web.pdf
[2]https://www.rcsed.ac.uk/media/167859/web_trauma%20care%20report%202012.pdf
[3] http://www.aomrc.org.uk/images/dmdocuments/aomrc_papers_takingresponsibility_final.pdf
[4]PRCSEd co-signed letter on 12 March 2016 http://www.bbc.co.uk/news/health-35785848