Good communication, innovative service design and flexibility are essential for managing common surgical conditions and blurring the boundaries between primary and secondary care.
Hand surgery offers an excellent example of a range of conditions that a hospital consultant manages, from the complex, to the more common high throughput conditions requiring minimum technology.
Consultant surgeons get great satisfaction from being able to recognise and offer expert opinions in the rare conditions. All consultant surgeons including hand surgeons, can feel an immense sense of achievement following an operation to deal with a complex case.
This sense of achievement can, however, be felt elsewhere – by efficient managing of common conditions. If the common conditions are dealt with together as a service within a service, under senior clinician management, better outcomes and improved efficiency will follow, not only for the patient and their family but also for the consultant surgeon and the wider health care economy. Every patient deserves an opinion from the most appropriate clinician, followed by a management plan.
For example, accessory digits dangling off the little finger of a neonate are common. Traditional methods of tying off the digit can result in significant discomfort for the baby and a residual unsightly skin tag. If the digit can be formally excised and sutured under local anaesthetic in a baby under six weeks old, a safe, relatively painless procedure with no further treatment necessary can be achieved.
Centres like the Birmingham Children’s Hospital, which services a large urban population, can develop very efficient services with good outcomes for large numbers of patients. Other models of care can be developed locally depending on local arrangements. There are compelling arguments for creating local services for common conditions, but there are some services, which are better centralised. If families only need to travel on one occasion in order to have a problem seen and sorted efficiently they will be satisfied.
A one-stop ‘see and do’ service, offers minimal disruption to the family at a vulnerable time for them. The organisation of this sort of service requires direct communication from the senior clinicians to local obstetric unit staff, in order to enable appropriate referrals. The use of electronic proformas and a flexible hospital organisation will get the baby with the mother to an appropriate operating environment directly without going through traditional secondary care outpatient clinic appointments. Administrative staff can be tasked with this organisation without the consultant needing to see every referral letter, but senior clinicians need to drive the process for care to be delivered in the most efficient way.
Another example of where using senior clinicians on the front line encourages a one – stop approach to managing a common injury is with the closed hand fracture (found particularly in children). The majority of these injuries will heal spontaneously with no additional therapeutic intervention, and the child can usually be discharged on the first visit, but these injuries can be difficult to evaluate. An experienced clinician will need to be available, in a dedicated ‘walk-in’ clinic in order to ensure the timely diagnosis of the one child in five that needs the urgent surgical intervention, otherwise the treatment for that child will be much more complex. The experienced clinician will also be able to quickly assess an injury that does not require surgical intervention and will be able to offer an authoritative reassurance to the family as to the expected course of healing depending on the age, ability, and activities of that particular child (an individualised management plan). A consultant led clinic offers excellent teaching material as well.
Good communication between the specialist consultant and the A&E/walk-in centre staff is essential, and establishing this across primary care in one or more facilities in a city could make a big difference. Referral guidelines, direct clinic booking and an efficient electronic transfer of x-rays need to be co-ordinated.
To develop any surgical service, including the more common conditions, the most senior clinician (with management support) needs to ensure that a care pathway is created which gets the right patient to the right clinician at the right time with the right resources. Having a senior surgeon on the front line ensures efficiency for all.
Ruth Lester is an honorary consultant plastic surgeon at Birmingham Children’s Hospital and was recently awarded an OBE for her work on limb abnormalities in children and young people