1. Introduction to the RCSEd Rural Surgery Report
Gordon McFarlane
Chairman,
Short Life Working Group
Sustainable Surgery in Rural Wales
Aberystwyth
Oct 2016

2. Training a rural surgeon Maintaining Skills and Providing Support
Current situation
Within Scotland
Within UK surgical practice
Standards of care
Relevant guidance
Volume/outcome issues
Training a rural surgeon
Maintaining Skills and Providing Support
Recruitment & retention

3. Rural General Hospitals, North of Scotland
Lerwick
Kirkwall
Wick
Stornoway
INVERNESS
ABERDEEN
Rural General Hospitals now confined to these 6 hospitals in UK.
Fort William .
Oban
EDINBURGH
GLASGOW

4. Rural General Hospital
“A hospital sited in an area distant from urban conurbations which because of compromised patient travel times provides a locally based consultant led service to meet the healthcare needs of a population not large enough to require a district general hospital.” *
Population 20-30,000;
>65 miles or 1.5hours transfer time
*Kerr Report 2005 Scottish Government

5. Catchment Populations
Hospital
Catchment
Area
Lorn & Isles General Hospital (Oban)
43,553
Caithness General Hospital (Wick)
26,435
Western Isles Hospital (Stornoway)
26,370
Gilbert Bain Hospital (Shetland)
22,000
Balfour Hospital (Orkney)
19,590
Belford Hospital (Ft William)
18,915
Caithness states 39,000 on recent job advert; Ft William rises to 40,000 due to tourism. (page 48) Total 150,000
Remote & Rural Steering group 2007

6. UK Surgical Practice Increasing Specialisation
Urology
Vascular
Increasing Subspecialisation
Breast
Upper GI/HpB
Lower GI
Endocrine
Subspecialisation within other specialties
Expanding range of skills
Endoscopy
Keyhole Surgery
Interventional radiology

7. UK Surgical Practice Training Issues Reduced hours, shift work
Loss of apprentice model
Working in specialist units
No A & E requirement
No experience in Orthopaedics, Urology, Neurosurgery, Plastic surgery
Limited access to paediatric surgery

8. UK Surgical Practice Drivers within the profession
Guidance on professional Practice
Volume & Outcome Issues
Building a specialised service in DGH/teaching hospital

9. Report Recommendations: Standard of Care
Where possible, services should be provided locally
Surgical services in smaller hospitals must meet the same high standards of care provided in larger units
Scottish Government & Key Recommendation 1
Key Recommendation 2

10. Standard of Care Morbidity and mortality meetings National guidelines
Videolink to regional cancer multidisciplinary meetings (MDTs)
Quality performance indicators (QPIs)
Participation in national safety programmes
Relevant publications/guidance from professional bodies

11. All services are consultant-led.
Best practice: Services are consultant-delivered.
As a minimum, a specialty trainee (ST3 or above) or a trust doctor with equivalent ability (ie MRCS with ATLS® provider status), is available to see/ treat acutely unwell patients at all times within 30 minutes and is able to escalate concerns to a consultant.
The designated consultant is able to attend his/her base site within 30 minutes at all times.
Adequate emergency theatre time is provided throughout the day to minimise delays and avoid emergency surgery being undertaken out of hours when the hospital may have reduced staffing to care for complex postoperative patients.
Emergency surgery Standards for Unscheduled care RCSEng 2011
Best practice: A dedicated, separate team is established for the emergency theatre(s) 24/7.

12. Standard of Care
Some surgical procedures will require subspecialty skills only available in higher volume units but commoner operations may be safely carried out in smaller units with appropriate skills, proper case selection, and support from the relevant specialty or subspecialty.
Volume/outcome issues
Key recommendation 2f
Appendix A

13. British Journal of Surgery 2016. 103:136-43

14. Scottish Medical Journal 2011. 56: 26-9

15. Surgical Volume and Outcomes
Retrospective study of colorectal cancer cases in the
Belford Hospital, Fort William
98 patients with colorectal cancer
average age 67
22 rectal cancers
Small can be beautiful; 10 years managing colorectal cancer in a Rural General Hospital
AJ Grant, DM Sedgwick. Scottish Medical Journal 2011; 56: 26-29

16. Surgical Volume and Outcomes
Retrospective study of colorectal cancer cases in the
Belford Hospital, Fort William
Belford (%)
Published Range (%)
Anastomotic leak
2.3
0-25
Local recurrence
4.6
0-21
Post Operative Morality 2
0-20
10 year survival
45.8
20-63
Small can be beautiful; 10 years managing colorectal cancer in a Rural General Hospital
AJ Grant, DM Sedgwick. Scottish Medical Journal 2011; 56: 26-29

17. Patients treated in hospitals with low caseloads (<33 cases per year) had a slightly better survival at 2 years than those treated in hospitals with a higher caseload
N Ireland Colorectal cancer register, (5 years), 3217 cases of colorectal cancer - Robert Shields
BMJ :

18. Commentary: How experienced should a colorectal surgeon be?
Robert Shields, emeritus professor
No information is given on how many of the surgeons had received specialist training.... The experience of the surgeons was measured by the number of years on the medical register  
comparatively small numbers in the various groups and high variability, it becomes statistically impossible to show that surgeons with small caseloads are better or worse than those with higher caseloads.....
Defining surgical expertise in terms of volume of activity may be a misdirected and imprecise yardstick for the quality of cancer care; other aspects of the organisation of services may be far more important
BMJ :

19. British Journal of Surgery 2004. 91:610-7
Specialisation rather than volume important – training but also Anaesthetics, pre-op staging, neoajuvant treatment, - MDT
British Journal of Surgery :610-7

20. Training CCT in general surgery
Post CCT fellowship in remote and rural surgery
Further limited specialty interest
trauma and orthopaedics or urology,
Exposure to
emergency otolaryngology, ophthalmology and neurosurgery.
ATLS training
Credentialing procedures

21. Training - appendices Urology Orthopaedics and Trauma
Obstetrics & Gynaecology
Neurosurgery
ENT
Ophthalmology
Maxillofacial surgery
A & E

22. Working group members:
4 Rural Surgeons
Simon Paterson-Brown Consultant General and Upper GI Surgeon (Edinburgh Royal Infirmary)
John Anderson Consultant Surgeon (Glasgow Royal Infirmary & Chairman, West of Scotland Specialty Training Committee)
Kenneth Walker Consultant Colorectal Surgeon, Associate Postgraduate Dean and Honorary Professor of Surgical Training
Bill McKerrow Consultant Otolaryngologist and Associate Postgraduate Dean, Northern Deanery
Steve Bramwell & David Douglas Consultant Urologists (Raigmore Hospital, Inverness)
David Finlayson Consultant Orthopaedic Surgeon

23. Contributors Clare McKenzie Consultant Obstetrician,
Vice President, Education Committee (Royal College of Obstetricians and Gynaecologists)
Fiona Spencer Consultant Ophthalmic Surgeon
Chair of Curriculum Sub-committee, Royal College of Ophthalmologists
Mahmoud Kamel Consultant Neurosurgeon
(Aberdeen)
Richard Ibbetson Dean, Faculty of Dental Surgery
(Royal College of Surgeons of Edinburgh)

24. Maintaining Skills & ProvidingSupport
Close interaction with local consultant colleagues
Study leave - adequately funded!
Range of procedures
Local skills of the whole team
Appropriate support from referral unit
Development of new skills/procedures with appropriate support from the referral unit
Safe movement of seriously ill patients
Adequate local support services

25. Recruitment and Retention
Encourage medical schools to recruit more students from rural areas
Promote Rural Surgery as an attractive and viable career choice
Maximise the number of junior surgical trainees in Scotland rotating through rural surgical units.

26. Trainees in RGH’s, North of Scotland
Lerwick
Kirkwall
Wick
Stornoway
INVERNESS
ABERDEEN
2 RGHs at present – increase to 6 = 18 trainees per year (4 month rotations) 36 Scottish trainees .
Fort William
Oban
EDINBURGH
GLASGOW

27. Before attending medical school 28% (n=37) had lived in a rural location
During medical school 29% (n=38) had undertaken a placement in a rural location
Following medical school 27% (n=36) had worked as a doctor in a rural location
Ella Teasdale & Stuart Fergusson
Survey of all Scottish surgical trainees responded

28. “Should training placements be offered in remote and rural hospitals?”
Yes 84% (n=110)
No 16% (n=21)

29. “How likely are you to work in R&R long-term?”
Very likely
1.6% (n=2)
Likely
8.8% (n=11)
Unsure
20% (n-25)
Unlikely
36% (n=45)
Very unlikely
34% (n=42)

30. Recruitment and Retention
Enhance the Rural Surgical Fellowship
Offer proleptic appointments
Review the remuneration offered
Promote and adequately fund study leave & time spent at referral units

31. Recruitment & Retention
Keeping the surgeon happy
Lots of operating
Reasonable on call rota
Trainees & Students
Equitable pay, recognition by peers
Support services, referral pathways
Education for children, transport links to urban centres
How to maintain Financial considerations second!

34. 1 month ago – ENT list cancelled – assistance at fracture clinic, tonsillectomy, Emergency caesarean section. Two weeks ago teaching trigger finger x3 then sigmoid colectomy. This week Wednesday TURP, TUR-BT hernia. Thursday colonoscopy list interrupted with Manual Evacuation retained placenta.

38. Emerging Patterns Maximised visiting services General Surgery plus
Wick
General Surgery plus
Ft William
Increased Local Specialist Provision
Stornoway
Traditional R & R Surgery
Shetland, Orkney
From maximum outside contribution to minimum

39. Maximise visiting services: Wick
One local surgeon
Visiting general surgeons from Referral hospital
Night cover includes GPwsi in Emergency Medicine
On site Consultant led Obstetric cover
A & E, ENT & Eye Emergencies covered
Fracture clinic by GPwsi
Wick

40. General Surgery plus Ft. William
Maintain 3-4 local General Surgeons
A & E trauma – stabilise & Transfer
Fracture clinics
Endoscopy service
Surgeons elective practice
within their subspecialty
Surgeons travel regularly to referral units to maintain subspecialty skills
Breast, Orthopaedic Trauma, Urology, – visiting service or patient travels elsewhere
Ft William

41. Increased Local Specialist Provision Stornoway
2-3 General Surgeons practice within their specialty
Visiting Urology service
Local Orthopaedic service (2 consultants)
Local Obstetrics & Gynaecology service (2 consultants)
Local Paediatric service
Stornoway

42. Traditional R & R General Surgery Shetland, Orkney
3 local General Surgeons providing
General surgery,
Breast, vascular (limited)
Urology (limited),
Orthopaedic
Limited Trauma & Limited Cold Orthopaedic
Surgical Obstetrics
GP Led unit
Emergency Gynaecology
Occasional visiting specialist

43. Traditional R & R Surgery
Keeping the surgeon happy
Lots of operating
Reasonable on call rota
Trainees & Students
Equitable pay, recognition by peers
Support services, referral pathways
Education for children, transport links to urban centres
How to maintain Financial considerations second!

44. Summary Island boards must keep service provision as local as possible
Transferring all major specialist emergencies is not financially sustainable
Surgery in Shetland can best be sustained by local surgeons operating on a wide case mix.
Endoscopy provision cannot be shared with gastroenterologists

45. 2016 “Improving Surgical Training”
SAC, ASGBI, ASIT
RCSEng
Shape of Training Steering Group

46. Improving Surgical Training SAC, ASGBI & ASIT
CCT in General Surgery
Able to receive an unselected emergency take
National selection to higher training
Modular curriculum
Entrustable Professional Activities
Further selection informed by local workforce projections
Remote and rural surgery selected modules
Requires new curriculum and revision of FRCS

48. Improving Surgical Training RCSEng
Run through
Non-medical workforce
Post-CCT fellowships
GI pilot

49. CR-POSSUM was the better prediction model than POSSUM
“Coloproctologists delivered a significantly lower overall mortality”
The Surgeon :3-7

50. The statement in the results secion
The statement in the results secion ...”there was a the figures given in Table 3 where coloproctologists do not achieve a significantly better results....
Thus the statement within the abstract that “coloproctologists deliver a significantly lower overall mortality “ completely ignores the case mix and purpose of POSSUM scores: to compare like with like