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Mr Britton presents a plausible option for the reorganization of oesophageal cancer services (October 2001 JRSM, pp. 500-501). However, the final sentence undermines the overall plan particularly with respect to the single-handed or low-volume specialist. The proposed scheme, he says, ‘does not represent a threat to any specialist in the field provided his or her results withstand local and national review’.
A corollary of low caseload volume is that results will be unlikely to be amenable to meaningful statistical review. A large number of years of data will be needed, ensuring a long delay to closure of the audit loop. The way ahead is surely to review operators' processes rather than outcomes of care. Thus, participation in effective prospective audit and multidisciplinary discussion of cases are surely clinical governance issues as valid as, and more timeous than, outcome.
Regular multidisciplinary team discussion has the further advantage of facilitating peer review of management decisions before they are acted on, and thus might effectively form ‘pre-prospective audit’. The benefit to both operator and patient is clear: sanctioning of treatment decisions by a responsible body of peers, based on regional as well as local experience.