General Surgery of Childhood Problems and Solutions? FD Munro Consultant Paediatric Surgeon RHSC, Edinburgh

General Surgery of Childhood Surgery of chidren “traditionally” provided by general surgeons in DGH Specialist paediatric surgeons for “local” catchment of children’s hospitals Elective - predominantly D/C –UDT, inguinal hernia, circumcision, hydrocele, umbilical hernia etc Emergency –Abdo pain, appendicectomy, acute scrotal pathology, I&D simple abscesses, suture of lacerations, early management of trauma

The Problem Annual fall in DGH activity of 15% across UK Declining rapidly in some areas In others, perceived threat due to imminent retirements of “grandfather surgeons” Failure to train replacements Impact of change in “paediatric” age range to include up to 16 years Risk of inadequate capacity in both current and planned children’s hospitals Well recognised and subject of several recent reports but no action!

Operations 0-12 years

Who is to blame? Anaesthetists? Surgeons? Managers? Royal Colleges? SEHD?

What’s wrong with centralisation? Erosion of caseload for paediatric anaesthesia (especially emergencies) Inability to manage even non-operative cases Increased travel and disruption for families Risk that other surgical services follow and ultimately even medical paeds Overload capacity of Children’s Hospitals

What might we gain by maintaining local services? Greater convenience for families and children Maintain “critical mass” of paediatric surgical and anaesthetic activity Maintain expertise in paediatric emergency anaesthesia and resuscitation in local hospitals Improved links between local hospitals and regional children’s hospitals

Specialist Children’s Services Review General Surgery

Solutions 1 No lack of anaesthetic expertise or willingness to deal with children Safe care requires surgical, anaesthetic and medical paediatric input and co-operation Local anaesthetists, paediatricians, theatre and ward staff all involved Surgery and in-patient paediatrics must be co-located for emergency care Separation of elective and emergency services on different sites unlikely to be viable “Elective first”

Solutions 2 Emergency service requires the commitment of all general surgeons and anaesthetists Elective service could be provided by a local general surgeon with a declared interest and appropriate training, a visiting specialist surgeon or both Local clinical lead essential Hospitals require a multidisciplinary forum to discuss, plan and review children’s surgery.

Elective v Emergency For Forth Valley and Tayside 892 ops in 2005 Elective 70% Emergency 30% Ages Elective48%35%18% Emergency12%25%63% C/O/I/U/H59%32%9% Appendix2%38%60%

Elective v Emergency Common elective operations are different in children to those for the analogous conditions in adults –Inguinal herniotomy v herniorraphy –Ligation PPV v Lord’s or Jaboulet Common emergency operations are the same as in adults –Appendicectomy –Testicular torsion

Models of service General Surgeon with an interest in children’s surgery Specialist Paediatric Surgeon –Regional appointment –Inreach –Outreach “General Paediatric Surgeon”

Tayside Model Specialist paediatric surgeon appointed with sessions both in Tayside and Lothian Local general surgeons with an interest in children’s surgery Enabled the continuation of all children’s general surgery in Tayside Selected specialist surgical cases OP clinics for both general and specialist cases Local specialist consultation for in-patients Link with the specialist department in RHSC both for general surgeons and paediatricians Greater use of telemedicine links

Tayside Model 2 Maximises use of diagnostic facilities locally Allows earlier repatriation of complex cases Education –General surgeons –Paediatric surgeons –Paediatricians/Neonatologists –Obstetricians –Anaesthetists

Next steps Solutions need to be in place very soon Uncertainty as to availability of appropriately trained general surgeons in near future Predicted “glut” of trained paediatric surgeons in next 1-2 years Regional solution involving specialist paediatric surgeons favoured as a short term fix Improved training for all general surgeons in children’s surgery and encouragement of some to subspecialise Service delivery by a combination of “visiting”specialist and local general surgeon with interest

Questions?