General paediatric surgery provision.

We read with interest Pye's article on general paediatric surgery (GPS) provision. This topic is of particular interest to all specialist paediatric surgical trainees: the imminent increase in the amount of GPS coming to tertiary centres has the potential to affect our training adversely, and the nature of our future consultant practice will be dictated by where GPS is carried out and by whom. Pye rightly describes the ‘tipping point’ that GPS provision has reached with many consultants currently carrying out the work in district general hospitals (DGHs) set to retire in the fore-seeable future and ambivalence towards the work amongst general surgical trainees. We are presented with a monopoly on GPS provision that we have not sought. Currently, this is occurring with little overt planning and our tertiary centres are at risk of being burdened with cases previously undertaken in DGHs, with no planned increase in theatre space, manpower or funding. We must, therefore, and with some urgency, devise solutions to this problem in order to ensure we can continue to provide the safe, quality service our patients expect and deserve. We also strongly believe this should be done locally if possible, a view shared by the DGHs, where both consultants and senior managers have expressed a desire to continue to offer GPS.1 The attitude amongst specialist paediatric surgical trainees is that whilst we wish to be specialist paediatric surgeons, we recognise that GPS is a significant part of our practice and will remain so in the future. A recent survey of our peers (unpublished personal communication) demonstrates a willingness to undertake GPS in DGHs. Some 75% are prepared to do so in combination with specialist work in tertiary centres for all or part of their careers with a further 10% ready to make DGH GPS provision the whole of their consultant practice. Pye surveyed 235 hospitals, of which 25 already had a tertiary level paediatric surgical service and a further 72 did not offer an elective GPS service. This leaves 138 DGHs that will need cover for GPS in the future. If each specialist paediatric surgeon was appointed to a tertiary centre with a day a week spent in a DGH undertaking GPS then these hospitals could be covered by specialist paediatric surgeons, particularly given the proposed optimum workforce provision of four specialist paediatric surgeons per million population.2 Similarly, Pye calculated an elective case load of 22,490 cases per year. Assuming five cases on a list and one list a week for 40 weeks of the year, this would require 113 surgeons to cover the work load. This is an achievable estimate and well within the proposed target expansion in workforce numbers. Emergency cover is rather harder to model due to its inherent unpredictability. The majority of this work will be appendicitis and acute scrotal pain, in otherwise healthy patients over the age of 5 years, both of these conditions should be well within the remit of any competent general surgeon and anaesthetist. It is hard to envisage how removal of elective day-case surgery would cause de-skilling sufficient to render them unable to manage these conditions. Indeed, the surgeon who takes on prime responsibility for the elective cases could be encouraged to take on training for the management of the emergency cases. In younger patients and those with more complex presentations, transfer to a tertiary centre may well be the most appropriate action. However, having a paediatric surgeon on call for every DGH 24 h a day will not be practical, even given expansion in paediatric surgery, and the routine transfer of all emergency cases is impractical for logistic and geographical reasons. On balance, we therefore support the development and promotion of a ‘hub-and-spoke’ model of joint appointments between tertiary centres and DGHs for the provision of elective GPS, with examples of successful implementation shared nationally to support development elsewhere. Of course, one size will not fit all and some areas, notably Scotland and perhaps the South West of England, will be better served by local general surgeons continuing to undertake the GPS. In such centres, training adult general surgery trainees to undertake GPS is a logical step. Provision should be made to enable any general surgeons who may choose to undertake this work to get the training they require in their local DGHs. What is clear is that strong and decisive leadership is required in order that we can make use of the limited time available to plan the workforce that will be needed, put in place the necessary training systems and agree funding streams for new appointments. Accurate data will be necessary to allow correct decisions to be made. We feel discussions should be taking place between all the specialties involved, particularly between paediatric and general surgeons and we would welcome the opportunity to contribute to these discussions as future consultant paediatric surgeons.