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SRG 6 Part 1 - Surgical Services

The sixth Stakeholder Reference Group (SRG) for the Moving Forward Together (MFT) Programme took place on Wednesday 21st of February. The Group of 16 patient, service user and carer representatives (details at the end) heard two presentations and engaged in discussion about; how surgical services have and are continuously changing; and how long-term conditions could be managed differently using a cross system approach.

The first presentation was by Mr Mike McKirdy, a Consultant General Surgeon with a specialist interest in Breast Disease and is based at the Royal Alexandra Hospital, Paisley. He spoke about his experience as a surgeon from when he qualified in 1985 to how things changed in 2005 and what he thinks surgical service might look like in 2025. He said that in 1985 surgery looked very different and that a more generalised approach was taken with surgeons performing a variety of operations. As an example he said that to qualify he had to have an understanding of peptic ulcer surgery, but last year in Greater Glasgow and Clyde no one underwent this procedure due to advancements in oral medicines.

He explained that by 2005 surgery had diversified into more specialist practice as it was now known that this produced much better outcomes for patients. Driving this was a dramatic increase in the knowledge available via research, audit and trials that was now much easier to manage and communicate using computers and and the internet.  Also that the equipment and techniques had advanced and that due to these factors change was inevitable and the right thing to do. It had also resulted in a change of approach with surgical services delivered by a wider more knowledgeable team. Not only had this improved outcome, but communication with and involvement of the patient and the care and respect they received had improved.

To explore this more in-depth Mike discussed two examples, the first of which was appendicitis. In 1985 this procedure was carried out unsupervised by a senior house officer (a trainee consultant) out of hours, which often meant late at night or in the early hours of the morning. Without modern imaging techniques and scans the person had to be physically cut open, even if the appendix didn’t need removing. It involved two incisions that left large obvious wound scars on the lower stomach and afterwards required 5 days recuperation in a hospital. There was also no audit therefore complications and learning from them weren’t systematically captured.

By 2005 this procedure was done with a consultant in theatre to observe and advise and during working hours with access to emergency and other teams. It was done via keyhole surgery and left no obvious physical scars and most people had a two day stay in hospital. There was also a national audit of complications from which learning could be applied. The result of this is that by 2025 for most people they will get a correct diagnosis of appendicitis that will be treated as a ‘planned emergency’. This means most people will go home but have an appointment scheduled for day surgery and with complications rare most people will return home with no overnight stay in a hospital – most of which already happens currently.

His second example was about Breast Cancer and he explained that in 1985 there were 46 surgeons in Greater Glasgow and Clyde carrying out procedures. This was usually a full mastectomy and extensive lymph gland surgery i.e. removal of the whole breast and surgery to the underarm that often resulted in lifelong loss of moment and strength in the limb. There was no extra treatment provide and within 5 years half of the people affected were dead. By 2005 there were 12 surgeons who were part of 4 specialist teams that included breast care nurses. The surgery was much more targeted, resulted in less disability and with national protocols for extra treatment 90 percent of people were alive after 5 years.

Mike said that as more people live longer by 2025 the numbers of people with breast cancer will rise; nevertheless advances in treatment techniques and equipment; bigger teams of experts with access to information will mean that 95%of people will be alive 1 years after surgery. These approaches will also be mirrored across other types of surgery with highly specialised teams using more modern techniques e.g. the use of remote controlled robots to do highly precise surgery.  All of this will mean improved outcomes and a much better patient experience before and after treatment.

However, this will mean getting the right surgery at the right site. The specialisation, trained staff available, equipment cost and supporting infrastructure required to deliver this cannot be easily replicated in lots of sites across Greater Glasgow and Clyde. Some highly specialised procedures will also be done ‘once for Scotland’ and might be at sites elsewhere. This will mean people having to travel slightly further, but also that for most it will involve day surgery or a much shorter stay in hospital and the disruption to patients and their families will also be minimised.

Ian Ritchie thanked Mike for a very informative presentation, and being a retired surgeon mentioned the parallels he’d seen in orthopaedic surgery. He then asked for questions and led the group in discussion and Aileen asked about the cost of investing in new technology and would this limit what was available. Betty followed this up and although agreed with everything said that highly specialised teams and equipment meant that there were longer waiting times for some procedures. There was discussion that as technology, techniques and learning becomes more widespread that this might improve access and the group agreed that things had come a long way.

Thomas said that if the public were made more aware of the much better outcomes, then the majority of people would be okay with having to travel to a centre of excellence. He also asked if the standards applied in Scotland, such as having a consultant available in theatre, were common and there was discussion about how even with a free to access universal healthcare in some areas practice was way ahead of the rest of the world. Martin also raised concerns that many people have reservations about travelling, even when they know it’s the best place to go and often this pressure can be from relatives wondering how they will get them there and provide support. He agreed that more needs done to inform people that more modern approaches mean less time in hospital and quicker recovery reducing the time relative spend visiting and helping afterwards.

Anne Marie spoke how volunteer driver services like the one she organises can also help with this by supporting people to get to hospital, reducing non-attendance, and transporting visitors; however this needs recognised and invested in properly. Susan agreed and said the Voluntary Sector were central to this and other areas and should be considered in planning. Karen said that there also needs to be investment in community services so that people can receive the care they need at home to help recuperation or free up beds to prevent cancellations. She also spoke about the concerns some people have with the downgrading of emergency services ad for example people in Inverclyde worried about ambulance transport.

This led to wider discussion about ambulance transport and how it was essential to a lot of the Programme’s aspirations. Also that seeing the right person at the right time is more important than having a lesser local service – there are fewer complications, faster recuperation and much better outcomes.  With this being something that has been realised and accepted in other specialist services, such as cancer where people travel to the Beatson for the best possible treatment from across the west of Scotland. Morag McIntosh shared an experience from a previous role, where someone had chosen and preferred to have local surgery and although they got what they wanted their long-term outcome had, as been illustrated by Mike, suffered without the lack of specialist services and support.

Morag Cullen said that it was absolutely fantastic to see where we are now and the public need to be encouraged to accept that advancements might mean less sites but better treatment. Susan also agreed that it was great to see the advancements; however cautioned that day surgery might be daunting for some people who live alone. She also asked about the number of planned operations cancelled, for example in winter and would specialisation contribute to this. There was discussion that surveys had show high levels of satisfaction with day surgery and how more would actually lessen pressures as often cancellations are due to not having a bed to recover in.

Gordon said that with specialist teams the patient journey and support had seemed to improve and this was positive as it’s not only about the physical elements but emotional wellbeing is equally important. He asked about the impact this has had and did it result in additional workload and was informed that yes, doctors need to spend more time pre and post op explaining things; however advancements in technique, equipment and improved day surgery had also freed up time, but that this practice is accepted and recognised as the right thing to do.

Ian Ritchie thanked Mike for his presentation and then introduced Pamela Vaughn who presented on and answered questions about a cross system approach to Respiratory Care.

In Attendance

 

Dr Ian Ritchie (Chair)

NHSGGC Non Executive Director

Liz Porterfield (Co-Chair)

NHSGGC - MFT Core Team

John Barber (Facilitator)

NHSGGC - MFT Core Team

   

Presenting

Mr Mike McKirdy  

NHSGGC - Consultant General Surgeon

Pamela Vaughan

NHSGGC - Advanced Respiratory Pysiotherapist

 

Patient, Service User and Carer Representatives

Aileen Hills

 

Anne Marie Kennedy

 

Betty Graham

 

George Brown

 

Gordon McInnes

 

Helen Morgans-Wenhold

 

Ian Good

 

Janet Nicholls

 

Janice Woodburn

 

Karen Haldane

 

Margaret Telfer

 

Martin Brickley

 

Morag Cullen

 

Morag McIntosh

 

Stacey Highfield

 

Susan McDonald

 

Thomas Cassidy