General paediatric surgery: a survey of Northern Ireland general surgery specialist registrars.

Editor

INTRODUCTION:

From 1994 to 2005, paediatric surgical activity in district general hospitals (DGH) in England declined by 30% across all surgical specialities1. We surveyed current NI general surgery specialist registrars to establish their intentions as regards general paediatric surgery (GPS) for eventual consultant practice if appointed to a DGH.

METHOD:

Thirty-five speciality specialist registrars were sent an on-line questionnaire. Enquires concerned previous experience of paediatric surgery, conditions and age profiles of children the respondent would be prepared to treat in eventual consultant practice if appointed to a DGH.

RESULTS:

The response rate was 71% (n=25). Thirty-six percent (n=9) of specialist registrars had previous experience of specialist paediatric surgery. Operations trainees would offer if appointed to a DGH are reported in table 1. The age profiles of children with a minor head injury, appendicitis and an acute scrotum that trainees would be prepared to admit under their care or operate on are reported in figures 1, 2 and 3. Sixty percent (n=15) felt a period of paediatric training during registrar training would make them more attractive to an employing trust, yet only 52% (n=13) felt this should be mandatory.

Table 1

Service trainees would intend to provide in Consultant practice.

Operation	% Registrars (n=25)
Appendictecomy	88
Scrotal exploration	80
Suturing of minor facial laceration	76
Incision and drainage of abscess	84
Admit a child with a head injury	68
Trauma laparotomy	28
Elective circumcision	44
Toenail surgery	60
Orchidopexy	16
Herniotomy	20
No paediatric service	12

Fig 1

Minimum age profiles of patients trainees would admit with minor head inury

Fig 2

Minimum age profiles of boys trainees would operate on with an acute scrotum.

Fig 3

Minimum age profiles of patients trainees would operate on with appendicitis.

DISCUSSION:

The provision of GPS in the DGH has reached a crossroads. The fundamental problem has been a failure to train and appoint sufficient numbers of general surgeons with appropriate paediatric skills and experience. The major finding of this survey is that the majority of trainees are interested in emergency GPS and have indicated a desire to provide a service in the future. This is at odds with the findings of Craigie et al who conducted a survey of adult general surgeons and their paediatric practice in Scotland in 2005. At that time, 70% of DGH and 100% of remote and rural consultant general surgeons reported that they operated on children regularly, yet only 29% of these surgeons thought their successor would follow on in a similar role2.

“Delivering a First Class Service” published in 2007 by the Children's Surgical Forum recognised that not all DGHs would continue to provide GPS but that larger DGHs should have sufficient workload, staffing and facilities to continue to provide children's services. The forum proposed that “children and their families must be able to access minor/routine surgery and outpatient facilities for more specialised conditions locally” and that “children's services should be seen as an essential service”3.

If emergency GPS is to continue in the DGH, commissioning health authorities and trusts must recognise the needs of these willing surgeons in terms of additional support for CPD to ensure a quality service can be maintained locally. If solutions are not found, tertiary paediatric centres will undertake larger GPS caseloads at the expense of specialist neonatal and paediatric cases. This will have training implications for their own trainees4. Further, if this ‘drift’ towards centralisation is not stopped, it will eventually impact on the ability of DGH paediatric departments to safely accept emergencies. Eventually, this course will undermine the status of the hospital as a fully functioning DGH.