Emergency general surgery (EGS) in England is facing a number of challenges, including workforce, training, and operational issues. Together these have led to wide national variation in outcomes. For example, mortality for emergency laparotomy can range from 3.6 to 41.7 per cent depending on location of treatment; [1] but establishing effective ways to address such variation is not straightforward. In a recent report commissioned by the Royal College of Surgeons of England, the Nuffield Trust discusses the underlying challenges and the most promising opportunities to address them. [2]
First and foremost, it appears that there are not enough surgeons willing or able to undertake EGS work, in part due to a drive towards subspecialisation. This is now a well-recognised problem, discussed by the Shape of Training Review and acknowledged by the Royal College of Surgeons and surgical associations. [3] The resulting shortfall of general surgeons results in downstream issues, including difficulties in staffing 24/7 emergency rotas and delivery of training. Secondly, there is often conflict, rather than collaboration, between surgeons and their medical and primary care colleagues. Thirdly, high levels of bed occupancy; inattention 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.
Within this context, it is easy to jump quickly to the conclusion that services need to be reconfigured and that concentrating work at higher volume sites 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, a common mistake is 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. Our recent report discusses the nuances of this relationship. [2] Outcomes for emergency surgery can be heavily influenced by patient demographics [4] and organisation of care [5] and volume thresholds designed to ensure sufficient numbers of procedures are being performed to maintain skills are likely to be more relevant at the level of individual surgeons than organisations. [6] Service reconfiguration can be highly disruptive and expensive, and without clear arrangements for transfer, escalation, and site of care delivery, networks can potentially fragment and damage care. How to effectively design and implement networks raises more questions than answers.
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. The National Emergency Laparotomy Audit (2015) found that almost half of patients who were assessed as having peritonitis and requiring surgery within six hours had yet to receive the first dose of antibiotics 3.5 hours after admission. [7] If straightforward components of care were delivered more consistently, the quality improvements could be substantial. Our report highlights the fact that the Emergency Laparotomy Project Quality Improvement care bundle (ELPQuic) was associated with an almost doubling of the number of lives saved per 100 patients, [8] when piloted in four acute NHS trusts. This is currently being expanded as the Emergency Laparotomy Collaborative and we welcome trusts taking urgent steps to implement similar protocols and pathways that can encourage adherence to best practice.
How else can we address some of the more complex and pressing workforce challenges facing EGS? Boosting the availability of surgeons who are capable of doing EGS work in existing centres must be considered part of the solution. In the Nuffield Trust’s review, we have suggested that the rising tide of sub-specialisation and erosion of general surgical skills needs reversing. While the ASGBI strongly supports the development of “Emergency General Surgeons,” there is some evidence to suggest that the majority of trainees would take on roles including emergency general surgery only if they were badged with a subspecialisation. [9] It is therefore possible that training will need to be examined across the board to ensure that all surgeons retain generalist skills and are better equipped to serve the population’s needs. We therefore support the RCS’ moves to start this process via Improving Surgical Training. [10]
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, local interventions need to 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 must also play a major part.
Robert Watson is a junior doctor with an interest in healthcare policy and research. He did an academic placement at the Nuffield Trust.
Competing interests: None declared.
References:
1. Saunders D, Murray D, Pichel A et al. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network, British Journal of Anaesthesia 2012; 109(3):368-75
2. Watson R, Crump H, Imison C, Currie C, Gaskins M; Emergency General Surgery: Challenges and Opportunities, Nuffield Trust 2016
4. Harrison E, O’Neill S, Meurs T et al. Hospital volume and patient outcomes after cholecystectomy in Scotland: retrospective, national population based study. BMJ 2012; 344:e3330
5. Ozdemir B, Sinha S, Karthikesalingam A et al. Mortality of emergency general surgical patients and associations with hospital structures and processes. British Journal of Anaesthesia 2016; 116(1):54-62. doi: 10.1093/bja/aev372.
6. Chowdhury M, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. British Journal of Surgery 2007; 94(2):145-61.
7. NELA 2015: The First Patient Report of the National Emergency Laparotomy Audit (2015).
8. Huddart S, Peden C, Swart M, et al. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. British Journal of Surgery 2015; 102(1):57-66.
9. ASGBI survey of surgeons in training (2014). Unpublished.
10. Eardley I and Smith K. How do we improve surgical training?