Shortages in the workforce, training gaps and operational difficulties have all contributed to wide variation in outcomes and quality in emergency general surgery (EGS). And as the Nuffield Trust’s new report – commissioned by the Royal College of Surgeons – explores, addressing this variation is no simple task.
First and foremost, it appears that there are not enough surgeons willing or able to undertake EGS work. This is, in part, explained by an increasing trend in general surgeons specialising in specific conditions related to one part of the body – or even just a small range of complex operations. This sub-specialisation – while improving outcomes in some cases – has also led to a shortage in surgeons that are available for the management of patients requiring EGS, resulting in difficulties in staffing 24/7 emergency rotas and delivery of training.
Second, there can sometimes be more conflict than collaboration between surgeons and their medical and primary care colleagues. Poor relationships can lead to inappropriate patient triaging, with patients being admitted to medical teams instead of surgical ones, or being referred to directly to A&E departments.
Third, high levels of bed occupancy, lack of attention devoted to patient flow, lack of on-site support from other specialities and tariff structures that poorly compensate emergency work all contribute to inefficient and suboptimal delivery of care.
Would centralising services make a difference?
Within this context, it is easy to jump quickly to the conclusion that services need to shift across sites, and that concentrating work at those sites with more capacity for EGS will lead to improved outcomes. Indeed, there is a case to be made for reconfiguring some services, or at least strengthening network arrangements between smaller hospitals, in order to ensure adequate levels of staff and support services are available wherever EGS is carried out. However, it is a common mistake to conflate this workforce argument with one that says that quality of care will be improved automatically at higher-volume centres.
The volume–outcome relationship is complex, especially at a hospital level, and high volumes do not necessarily lead to better care. Outcomes for EGS can be heavily influenced by a number of different factors. The types of patients being seen, the initial resuscitation and the individual surgeon performing the operation can all influence outcomes – not simply the volume of patients treated in that hospital.
Ultimately, shifting hospital services to different sites can be highly disruptive and expensive, and without clear arrangements for how care will be transferred and where it will be delivered, networks can potentially fragment and damage care. Indeed, asking how to effectively design and implement networks raises more questions than answers.
Introducing protocols and pathways
From a quality of care perspective, it is likely that what is done is as important, if not more important, than where it is done. For example, a study showed that almost half of patients who were assessed as having peritonitis – a serious infection inside the abdominal cavity – and requiring surgery within six hours had yet to receive their first dose of antibiotics 3.5 hours after admission. If straightforward components of care were delivered more consistently, the quality improvements could be substantial. This is where the implementation of standardised protocols and pathways can be effective.
For example, the Emergency Laparotomy Project Quality Improvement Care Bundle (ELPQuic) – a set of five standardised interventions – was associated with an almost doubling of the number of lives saved per 100 patients when piloted in four acute NHS trusts. This is currently being expanded as the Emergency Laparotomy Collaborative, and provides an important example of how similar protocols and pathways can encourage best practice.
Addressing workforce challenges in EGS
Boosting the availability of surgeons capable of doing EGS work in existing centres must be part of the solution. While many support the development of 'emergency general surgeons', an unpublished 2014 survey by the Association of Surgeons of Great Britain and Ireland suggests that the majority of trainees would take on roles including EGS only if they were badged with a subspecialisation. Training may therefore need to be examined across the board to ensure all surgeons retain generalist skills and are better equipped to serve the population’s needs.
The delivery of EGS, particularly in smaller, remote hospitals, faces major challenges. However, ‘smaller centre’ does not automatically equal ‘worse outcomes’, and a number of small hospitals deliver excellent EGS services. The judicious use of protocols and care pathways, such as ELPQuiC, to ensure good practice could go some way to reducing national variation. Nevertheless, these kinds of local interventions must be complemented by national solutions to ensure adequate staffing of rotas. While networks may merit serious consideration, making sure that we value, train and develop more generalists is arguably of more importance.
Robert Watson is a junior doctor and was on academic placement at the Nuffield Trust until February 2016.
A version of this blog also appeared in the British Medical Journal.