We present a large-scale survey of the clinical practice and opinions of consultant surgeons and anaesthetists who care for children in the UK.
There are a number of limitations of this study. While every effort was made to identify all consultant surgeons and anaesthetists in the UK who are involved in the treatment of children <16 years of age this information is not readily available. In 1999, when NCEPOD last collated data on this subject 72% of anaesthetists and 67% of surgeons said they had a paediatric practice (children up to their 16th birthday), but this may have changed in the intervening years.17
Further, although consultant numbers have been collated by the Royal College of Surgeons of England and the Royal College of Anaesthetists those with a paediatric practice have not been identified separately. Thus, a denominator for this survey cannot be determined. As stated earlier, many methods were employed to inform consultants of the survey and encourage them to complete it. However, it is possible that respondents with a particular interest in the underlying issues relating to children's surgery and anaesthesia were more likely to respond. Despite this, the survey provides an interesting insight into the practice and opinions of UK consultant surgeons and anaesthetists.
In retrospect, more detailed information could have been sought on some aspects of clinical practice: for example, workload and case mix, team working and on call arrangements as well as deficiencies in postgraduate training. However, the number of questions was kept relatively short to encourage compliance.
A striking finding of this survey was the similarity in the answers provided by surgeons and anaesthetists. The type of hospital in which the respondents worked and their years of employment were similar. About half of the surgeons completing the survey were general surgeons. Although the precise number of general surgeons with an interest in paediatric surgery is unknown the survey should reflect the views of a large proportion of this group. Certainly the number of surgeons who replied must represent a large proportion of the 138 (elective surgery) and 147 (elective and emergency) non-specialist hospitals in England, Wales and Northern identified in a survey published in 2008.11
Nevertheless, the low number of responses from other surgical specialties must be recognised before generalising the findings of this survey.
There has been considerable debate over the last two decades about who should operate on and who should anaesthetise children in the UK.2
Further, numerous strategies have been suggested to ensure that consultants obtain and maintain their competencies; these include postgraduate training, years of experience, workload load by age of child and CPD.12
In this survey we have attempted to explore some of these factors. Thus, we found that many consultants from DGHs and University Teaching Hospitals (UTH) would care for younger children, or without limit to age for emergency surgery while restricting elective surgery to older children. This is not surprising and has been reported previously by NCEPOD and the Children's Surgical Forum (CSF) of the Royal College of Surgeons, England.2
This reflects the necessity of providing an emergency service, particularly in DGHs that may be geographically isolated where the ability to provide rapid transfer to a larger centre may result in unacceptable delay. Further, these children may present to at a DGH where there is an insufficient workload to justify a separate consultant on call provision for children. Consequently, consultant surgeons and anaesthetists who have no alternative but to care for the child locally, particularly out of hours, will have varying paediatric experience. There is no easy solution to this situation other than good cooperation and funded arrangements between STPCs, DGHs and UTH.12
Formal-managed networks of care for children's surgery have been advocated as a means for achieving this.9
While case numbers may facilitate the maintenance of skills and competence, time allocated to paediatric practice is also important. Given the new consultant contract the number of PAs for paediatric care by surgeons and anaesthetists should be easier to measure. Data from this survey reveal that many consultants, particularly from DGHs, have <1 PA devoted to paediatric practice each week and thus maintenance of competencies will be particularly difficult for them. In these circumstances detailed review of their paediatric practice will be essential for appraisal and revalidation purposes. It is encouraging that the majority of consultants who completed this questionnaire collected this information in one form or another.
Postgraduate training is the bedrock of future consultant practice. Thus, a curriculum that includes an adequate component of paediatric training is essential. It is therefore of concern that 9.3% of surgeons and 8.9% of anaesthetists completing this survey believed that their postgraduate training had not prepared them for their current level of paediatric practice. This was particularly the case for those who trained in the last 10 years where it was felt that inadequate time and emphasis were devoted to paediatric training. Furthermore, 45.4% of surgeons and 39.2% of anaesthetists felt that the curriculum for their specialty should have a greater paediatric component. Revision of the general surgery curriculum in 2010 now includes three modules in paediatric surgery, but these are special interest modules and paediatric surgery was even less formal in earlier versions. From a trainees’ perspective there is the risk that they see themselves as surgeons in their chosen specialty, and with the exception of paediatric surgery, it is not until they are appointed as a consultant that they may realise that a period of training in children's surgery would have been of benefit. In this respect the UK general surgical curriculum has had no mandatory paediatric component for more than 10 years and both the availability and take-up of optional modules in children's surgery has been poor. In contrast, the anaesthetic curriculum includes compulsory paediatric modules at intermediate and higher levels29
However, most anaesthetists who felt there were deficiencies in training thought that 20–25% of training time should be dedicated to paediatrics.
Continuing professional development is an essential part of consultant activity and should be proportionate to clinical practice. In the current economic climate within the NHS there is considerable pressure on supporting this for consultants both in terms of time and funding. In this survey, one in five consultant surgeons and anaesthetists reported that these factors prevented adequate CPD to maintain their expertise in paediatric practice.
In summary therefore inadequate postgraduate training, limited clinical time within job plans (PA allocation), and difficulty in accessing CPD are important factors that consultant surgeons and anaesthetists believe adversely affects the quality of service that they are able to deliver for children's surgery.
There are other factors that may limit an individual consultant's practice in relation to children's surgery. Surgeons considered that the skills of anaesthetic colleagues were paramount while anaesthetists reported that a child's comorbidities were the most important factor. It is logical that most surgeons considered that anaesthetic skills were the most important factor limiting their ability to undertake safe surgical care. Without this surgical practice is severely restricted.
A safe surgical service also requires adequate hospital facilities and thus it is concerning that 32.6% of surgeons and 43.5% of anaesthetists considered that there were deficiencies in their hospital's provision of a safe paediatric service. Although this could be a counsel of perfection among respondents recurring themes were the lack of trained paediatric staff in the operating theatre, insufficient paediatric nurses on children's wards and inadequacies of the organisational arrangements for the care of children in their hospital. These are all are potentially remediable if prioritised by Colleges, professional organisations and Trusts.
Clinical governance and audit is now embedded in every aspect of healthcare. Hospitals are required to adhere to guidelines on clinical governance and medical practitioners are required to undertake regular review of clinical practice.31
Furthermore multidisciplinary team review is an integral part of modern healthcare and has a valuable role in determining the best care. Thus, it is of concern that only 55.3% surgeons and 42.8% of anaesthetists participated in any form of multidisciplinary review of children undergoing surgery. In the latest NCEPOD study reviewing surgery in children we found that only 50% hospitals undertook audit and/or morbidity and mortality meetings that included children. While this deficiency was particularly an issue in DGHs it might be argued that a forum for sharing clinical experience is particularly important for DGH consultants with a relatively small the workload.
In conclusion, while one might argue whether the findings of this survey are representative of all consultant surgeons and anaesthetists who care for children in the UK, it is disturbing that this group of clinicians reported so many obstacles in place to providing a safe paediatric service. Those responsible for postgraduate training of should review the current curricula to ensure that they more adequately support the clinical responsibilities of prospective consultant surgeons and anaesthetists in DGHs who, by necessity, will have a paediatric component to their practice. Furthermore, to ensure that these consultants do not feel exposed and under undue pressure to practise at the limit of their competency, greater cooperation will be required between all categories of hospital that care for children requiring surgery. Finally, all hospitals that provide children's surgery have a responsibility to ensure that consultant surgeons and anaesthetists who have children in their patient caseload are supported in their practice, that they have adequate opportunity to enhance and maintain their skills, and have the necessary facilities in place for children's care, within a clear clinical governance structure.