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Reflecting on the cut and thrust of Irish surgery

By Mindo - 20th Aug 2019

Mr Kenneth Mealy, President, RCSI © Patrick Bolger

The President of the RCSI Mr Ken Mealy speaks to Catherine Reilly about some of the pressing issues facing Irish surgery and the wider healthcare system

Everyone wants to be a super specialist”, said RCSI President Mr Ken Mealy, speaking to the Medical Independent (MI) at his office on Stephen’s Green, Dublin.

Super specialisation is good for complex practice, but not for medicine and surgery generally. As Mr Mealy explained, most hospital patients have relatively low-acuity problems, so the decline of the generalist is challenging healthcare systems internationally.

It is among many issues facing Irish surgery, whose course is charted along the stormy waters of this country’s healthcare system.

The good news is that doctors completing RCSI surgical training programmes are typically high-quality candidates who are valued in centres around the world. But that is also the bad news.

Between 30 and 40 trainees per year complete higher specialist training in surgery. Yet the Irish public healthcare system is increasingly unattractive to these surgeons for various reasons, including poor professional supports and the new-entrant consultant pay cut.

Model 3 hospitals

Surgical appointments are a particular struggle for model 3 hospitals, partly because of the generalist job designation.

“If you look at the people we are taking on in our training programmes, they tend to be in the top 10 per cent of their graduating classes, so they are driven individuals, and there is a perception among them that being super specialised is better in some way than being a generalist, despite the fact that in reality, many of our hospitals don’t need specialists, they need generalists,” according to Mr Mealy.

“But also, the conditions you work in [impact on appointments] where you are on a one-in-three or a one-in-four roster… if you are on-call, the chances are your colleagues may not even be in the hospital, they may be on holiday, or whatever, so if you run into trouble and you need help, it is very hard to get that and our trainees understand that.”

There are a couple of problems. One is the hospitals are still block-granted, so they are not actually getting this money or losing this money until such time as activity-based funding is actually implemented… secondly, there is no incentive. As I said, if you have 100 gallbladder patients on your waiting list at the end of the year the NTPF will take them and do them for you…

One-quarter of the 76 general surgeons working in model 3 hospitals were locums, found a 2017 paper authored by Mr Mealy and colleagues in the Irish Journal of Medical Science. Over half had not undergone formal training in Ireland.

Part of making smaller hospitals more attractive to surgeons is optimising surgical care delivery nationally, according to Mr Mealy, who is a Consultant General Surgeon (with a special interest in gastrointestinal surgery) at Wexford General Hospital.

 “Really, we need a configuration of surgical services so that major surgery is done in the bigger centres and smaller centres do low-acuity work. And the smaller centres are particularly useful for day case type surgery, and the example we use all the time is Roscommon.

“I mean, it was an awful political fuss; understandably, local populations and public representatives get alarmed. You can’t use the phrase — and I haven’t used the phrase — ‘reconfiguration’ or ‘downgrade’ hospitals, because it is just too emotive. But if you look at Roscommon now, Roscommon does more surgery, more day case activity, more diagnostics than it ever did before.”

For its part, the RCSI has designed a new training programme to attract more trainees into general surgery in smaller hospitals. An emergency and general surgical training pathway has been accepted through the intercollegiate structure, Mr Mealy revealed.

The College hopes to commence the programme in July 2020, but wider issues will also need to be addressed.

 “It begs the question, will our trainees apply for this training scheme, knowing it’s for general surgery in smaller hospitals?” Mr Mealy said.

“Because there are a load of HR and practice issues independently of us as a training body which we can’t address, although we can advocate for changes in those issues to try and make those jobs more attractive.

“But we propose setting this up next year and we will see who will apply. Now, it will take some number of years for trainees to go through this process but if we have any chance of staffing smaller hospitals in general surgery, we need to do this, but that has to go hand-in-hand with health service delivery reform.”

The surgeon estimates that up to 30 per cent of people who complete surgical training, and who go abroad for fellowships, stay away for a prolonged period — often until a suitable position arises in Ireland.

However, Mr Mealy warned that creating consultant positions independent of funded operating theatres and space for outpatient clinics and diagnostics isn’t a solution. 

Ireland has historically created new positions and appointed surgeons, only to find they were “not fulfilling their potential because they are looking for a few hours’ theatre space, begging different people to hand up a bit of their resource, and that is not the way to do it”.

Theatres are “under-powered”, particularly due to lack of theatre nurses, and this has meant rolling theatre closures have become depressingly common.

Elective hospitals

Every winter, there is a dip of about 17 per cent in terms of planned surgery because day wards are full of emergency patients. The key from a process perspective is separating the elective from the emergency stream, according to Mr Mealy. 

“The national capital plan [is] to build three elective hospitals. Now, will it happen because of cost over-runs in the kids’ hospital? But that is ideally what we want, where we have standalone, elective hospitals where you cannot be impacted by what is going on in the emergency departments… ”

In addition, capacity in model 3 hospitals needs to be optimised by “shifting a lot of the low-acuity work out of the bigger hospitals into the model 3 hospitals; yes, we [still] need standalone elective hospitals and whether they are built on the grounds of bigger tertiary hospitals or whether they are standalone elsewhere, I don’t feel strongly.”

Mr Mealy is not an advocate of outsourcing public waiting list surgery to private hospitals via the National Treatment Purchase Fund (NTPF). He believes that it has not resolved the waiting list crisis and does not promote efficiency. In combination with European Working Time Directive requirements, which Mr Mealy admits are sometimes “ignored”, it also means surgical trainees don’t get as much hands-on operative experience as they did 10 to 20 years ago.

 “Ideologically, I have no issue with surgeons in the private sector providing a service in terms of waiting lists, but it does provide problems in terms of the overall health service, because in a sense it’s a perverse incentive.

“If you are a really efficient hospital and you are really beating yourself up trying to organise your process and your staff to sort out your waiting lists and work really efficiently, that means you have no waiting lists, so the NTPF doesn’t need to be involved with you, but what is the incentive to do that? Because if the converse is that you are not efficient and you have a long waiting list, the NTPF just takes it off you; there is no incentive there to be efficient.”

Mr Mealy referred to a demographic time-bomb facing the country. Currently, surgery uses approximately 3,000 acute hospital beds per day, and projections indicate this would need to rise to about 5,600 in 2051.

 “That is just not going to happen, so we really need to emphasise quality assurance, quality improvement projects, and that isn’t emphasised to any huge extent in Sláintecare [as a document]…

“If you look at variation across the country in average length of stay, day of surgery admission rates, day case rates — there is huge variation, and if we could iron those things out and bring everybody up to a mean performance, we would save hundreds of beds every day.

“And yes, we have capacity issues, and yes, we need more beds, and yes, we need more consultants and diagnostics, but we also need to see how we rearrange things to get efficiencies. We need quality improvement programmes to iron-out all those glitches that stop some hospitals performing.”

The national surgical programme has engaged with the Healthcare Pricing Office to encourage efficiencies. For example, agreement was reached that day case laparoscopic cholecystectomies would be incentivised in the pricing structure, compared to elective admissions into hospital beds.

However, in the absence of implementation of activity-based funding (ABF), such measures have limited impact.

“There are a couple of problems. One is the hospitals are still block-granted, so they are not actually getting this money or losing this money until such time as activity-based funding is actually implemented… secondly, there is no incentive. As I said, if you have 100 gallbladder patients on your waiting list at the end of the year, the NTPF will take them and do them for you… ”

There is also no real rewarding system for healthcare teams that are efficient, added Mr Mealy. However, where incentives are applied, it has made a difference. The surgical programme reached agreement with the Healthcare Pricing Office for enhanced tariffs for best practice, which has been implemented in respect of the six ‘blue book’, or best practice standards, for treatment of hip fractures. 

Hospitals that meet these standards “get a preferential budget of €1,000 [per patient]. So this has worked, and one of the reasons it has worked is that the money is given back to the hospital in a tangible way… 75 per cent of that money can be used by the teams in question, so the wards buy pieces of equipment, the nurses can go on professional development courses.”

Data has shown a “very clear increase” in the number of patients whose care meets these standards since the initiative was introduced in 2017. 

ABF could also be applied to encourage hospitals to reduce rates of healthcare-associated infections and boost hand hygiene compliance, Mr Mealy said.

Surgical mortality

An Irish audit of surgical mortality within the National Office of Clinical Audit (NOCA) has been on hold since 2013. It would allow participating surgeons to engage in a confidential peer-review process, so that each participant could benchmark their practice against best national and international practice.

However, such an audit requires protective legislation, according to Mr Mealy. “A subjective, peer-to-peer review of each death needs to be confidential and [legally] privileged to allow for meaningful shared learning.”

Mr Mealy, formerly Clinical Director of NOCA, said an Irish audit would follow international practice, “where some countries have every single surgical death in a unit audited — peer review audited by somebody from outside the hospital.”

Most of the deaths do not require an in-depth analysis. “But a small proportion do, and that peer-to-peer commentary, that subjective commentary, needs to be anonymised, and it needs to be privileged in the sense that it cannot be accessed.

“And currently, legally it is not privileged, as no audit process is privileged in Ireland and we got senior counsel opinion at that time, so we never set it up.”

It was hoped the Patient Safety Bill may introduce a protection but from drafts seen to date, “we still think [it] problematic because the definition of clinical audit is so narrow, it would not encompass peer-to-peer reviews and that subjective opinion; it would not, does not, include MDT meetings [on morbidity/mortality]

“Most surgical departments would have these [MDT meetings] on a weekly or monthly basis, and a lot of opinion comes out and most of it isn’t recorded. The amount of learning that is shared from that is limited because most people are very careful what they say, because if anything is recorded, it is subject to discovery currently, and will be with the new Patient Safety Bill as far as I can see, although the final draft, we haven’t seen it yet… So I don’t see an Irish audit of surgical mortality coming any time soon.”

Mr Mealy was also critical of the Patient Safety Bill’s provisions on open disclosure, although he emphasises that engaging in open disclosure when something goes wrong is “professionally appropriate”.

However, he added that “the Bill as we see it will be bureaucratic and formulistic in nature, so that if something goes wrong, you need a whole series of documentation to sit down with the patient or family and explain whatever the issue is, and get them to sign it.

“Now, when things go wrong in surgery, frequently the family are outside the door and you have got to leave an operation and go out and explain immediately to somebody — and if you have to go off and look for seven or eight copies of documents to fill out and sign, which would take time and then present that to a family, I think that makes the whole process very adversarial,” said Mr Mealy.

“So that is our understanding of the Patient Safety Bill and open disclosure. We are fully committed to open disclosure and have been for some time… but the nature of how this will be done is problematic.”

Mr Mealy added that “many other countries have not gone down the road of mandatory open disclosure with criminal sanctions for doctors if they fail to abide with the process” (a Department of Health spokesperson clarifies it is “not the intention of the legislation to impose criminal penalties on individual health professionals on a personal basis”).

The RCSI President said the College’s position is that open disclosure will become a part of medical practice “if it relates to our understanding of medical professionalism and through education which occurs in a non-adversarial setting”.

Surgeons’ performance

The NHS publishes individual surgeon outcome metrics as part of its “world-leading transparency drive”.

Is it reasonable and expected that Ireland will follow suit?

“I certainly think there should be some transparent metrics by which we measure hospitals and outcomes from surgeons and departments,” responded Mr Mealy.

“There is a fair bit of disquiet in the UK because there is some sense that within high-risk specialties, surgeons are becoming risk-averse, and they are not engaging in high-risk surgery, and that is a problem… ”

Mr Mealy said, in principle, he would support the publication of “departmental metrics and departmental outcomes”.

Asked about RCSI’s role in identifying and managing a surgeon performing below expectations, Mr Mealy admitted this is “a real challenge here and internationally”.

“And one of the issues is, how do we know a surgeon is performing poorly? And that is generally dealt with within hospitals, the HSE, our employers, and it sometimes comes to us to take part in some form of inquiry and I have got to put my hands up and say, it is always challenging because we don’t have a process that works well and certainly, what I would like to see is a process that we see with our sister colleges [in the UK], for instance.”

The Royal College of Surgeons, London, has an invited review process where it can be invited in by a Trust, for example, to carry out an assessment if there is a problem with an individual surgeon or a process.

“We don’t have a process like that; in general, we are not invited in by Hospital Groups; sometimes we are, but seldom. So the only way we get involved would be in terms of professional development issues, in terms of individuals coming to us of their own volition, saying ‘I am in trouble’ or ‘I need to be upskilled’…

“Sometimes Hospital Groups come to us and say, ‘will you help in the upskilling of somebody who has had an issue?’ but that is at the discretion of the Hospital Groups. In many cases in Ireland, it is adversarial and ends up in the courts, which is problematic.

“So I would like to see a more structured, defined process. The invited reviewer process that the English college runs, I think is worthy of note, and I am aware that one or two hospitals here have started to use that process…”

Women in surgery

Meanwhile, an area of focus for the RCSI in recent years has been gender diversity in surgery. In 2017, the College published a comprehensive report on the issue, which was developed by its gender diversity short life working group.

Mr Mealy believes progress is being made.

“We are conscious that only about 11 per cent of our consultant surgeons are female, it was 8 or 9 per cent a couple of years ago. Five out of 21 of our council members are female, 46 per cent of our trainees are female.

“Following a negotiation with National Doctors Training and Planning and the HSE, we have managed to get more structure on less-than-full-time training, supports for people coming back from family leave.

“I think we have made huge progress because now it is not uncommon to see our female trainees, for instance, becoming pregnant, having children, taking time out and coming back into the training programme.

“Also, we are very proud that we’ve got support from J&J for a major scholarship in terms of fellowship support for female trainees, to try and help them structure their career.”

He concluded that there is a “palpable feeling in the College that we are here to support young professional women”.

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