General Surgery in Childhood across Scotland. Service delivery and
sustainability remains an unresolved problem.
i. This paper is submitted from the Scottish Colleges Committee for Children’s Surgical Services (SCCCSS).
ii. The paediatric surgical community have major concerns over the provision and sustainability of general
surgery services for children in non-specialist centres (DGHs) across Scotland. Although our concerns relate
principally to General Surgery of Childhood (GSC), there are signs of similar problems affecting other
specialties.
iii. English figures from 2005 suggest that 50% of all surgery in childhood was done in DGHs. It has been
estimated that 400,000 children are treated by surgical specialties each year. Of these 25% are treated by
general surgeons, either in DGHs or in regional centres. In GSC, this relates to children needing
elective/planned surgery (hernia repair, undescended testis, circumcision, for example) and treatment for
emergency conditions (including head injury, abdominal pain, appendicitis, testicular torsion). Planned or
elective surgery is performed either by local surgeons or visiting surgeons from specialist centres (outreach
lists). These visiting surgeons may also do clinics. Emergency surgery is performed either by local surgeons
or where necessary, after transfer to regional centres. The latest figures we have suggest that ¾ of
Appendicectomies are performed in DGHs. It is important to note that only 1 in 4 of emergency surgical
admissions with abdominal pain require surgery. Of note, many, if not most children admitted to DGHs are
admitted under the care of a paediatrician.
iv. The concerns arise from the fact that there is a withdrawal of general surgeons from treating children.
The reasons for this are that senior surgeons are retiring and that successors are being appointed with no
preparatory training in children's surgery and no requirement to undertake children's surgery in their job
plans. A decline in the provision of elective surgery will be followed by a potential loss of emergency surgery
provision as surgeons lose confidence in operating on children.
v. This will lead to unnecessary transfers and overloading of specialist centres resulting in increased load on
both transport systems and specialist centres, with associated inconvenience, delay and distress for families.
There will be an increased workload for paediatricians in the DGHs as general surgeons withdraw from the
assessment and treatment of children – something they can ill-afford given the reduction in training numbers
and ever increasing consultant workload. Increasing the number of transfers to regional centres will overload
the transport services, putting a strain either on local nursing and anaesthetic services (who may have to
accompany the child) or the national retrieval service. Children are being put at risk. A delay in intervention
as a result of the secondary transfer of a boy with a testicular torsion can lead to loss of that testis.
vi. The extent of the problem is difficult to accurately quantify in Scotland.. In the last 5 years more elective
outreach lists, performed by specialist paediatric surgeons have been established in DGHs and additional
specialist paediatric surgeons have been appointed as part of the National Delivery Plan. Crude data from
ISD data suggest that there does not appear to be a major drift towards the regional centres and in some
areas the amount of work being done locally is actually increasing. Crucially the figures don’t reveal who is
actually doing the work in the DGHs. In many centres elective paediatric surgery is being delivered solely by
specialist surgeons delivering an outreach service with no involvement by the local team. This is not
universally the case, and in some centres cooperation does occur. In England, they have seen a drift of up to
12% per year in cases travelling to regional centres. The view from the Scottish regional centres is that
many more children with simple emergency conditions and without co-morbidities are being referred rather
than being treated locally.
vii. The reasons the problem has developed are as follows. Firstly, there has been a reduction in working
hours and the overall duration of training. This had lead to what has been described as a “constriction in the
surgical repertoire of general surgeons with more in-depth concentration in a narrower field.” This narrower
field does not usually include surgery in childhood. Secondly, there is a perception that outcomes relate to
number of cases performed. This view predominates in the adult sector, but less so in paediatrics where
there is greater diversity in surgical practice. There is little evidence to support the numbers issue. The Royal
Colleges have emphasised that surgeons should surgeons work within the limit of their competence, there
should be locally agreed guidelines about who should be transferred and who should be treated locally, and
that those who are on call and expected to treat children should have appropriate training. There is clearly a
need to provide training and continued professional development through strong links with the regional
centres.
viii. GSC is a small part of the syllabus of general surgical training published by the JCST. At the time of
receiving the certificate of completion of training (CCT) in general surgery a trainee is expected to be able to
assess and formulate management plans for children presenting with surgical emergencies and to be able to
perform independently an appendicectomy in a child ( categorised as competency level 4). With regard to
management of hernias, they are expected to have seen a herniotomy (level 2). They are also expected to
have seen (level 2) exploration of the testis for testicular torsion. Urology trainees are expected to be able to
manage torsions to Level 4 (manage independently). This is leading to a pattern whereby torsions are being
managed by urologists rather than general surgeons, who previously dealt with these children.
ix. There are fewer trainees coming through with an interest in GSC. A final examination in surgical training,
which allows those completing surgical training to indicate a sub-specialty interest, was introduced in 1990.
Between 1990 and 2005 approximately 1,400 candidates completed this examination; only 2 sat the
examination with an interest expressed in children’s surgery. There are a number of reasons for this. From
an organisational point of view, they are not encouraged to do so. There has been no attempt within general
surgery to match numbers within surgical specialties, unlike in paediatric medicine. The choice of a specialty
is left entirely to discretion of trainees. There are priorities on other conditions by NHS Scotland eg cancer.
The lower waiting times in paediatric sector also suggest a reduced need. The professional issues which
relate to a reluctance to train in GSC include the perception that the elective component is less challenging
and therefore less rewarding than adult work, that there is a relatively high proportion of emergency work,
and that one tends to be professionally more isolated. Surgeons who practice GSC in a DGH are also
perceived to be the “poor relation” of the specialist paediatric surgeon. There is a fear that adverse
outcomes will leave a prolonged legacy. There are also fewer opportunities in the private sector.
x. The problem is not confined to GSC. Paediatrics is a core component of training in orthopaedics, dentistry,
anaesthetics and ENT. Increasingly there are problems in delivering emergency care locally, with the
‘numbers issue’ being consistently reported as a concern. As in general surgery, the operations required in
children in a DGH are often much less complex than operations required in adult practice.
xi. Because of the fact that 50% children’s surgery is performed in DGHs this problem has caused concern
for many years. Failure to provide local treatment will have grave implications as outlined above. These
concerns have been discussed by many groups including the British Society of Paediatric Surgeons, the
Association of Surgeons of Great Britain and Ireland, the Royal College of Paediatrics and Child Health, the
surgical Royal Colleges, the CYPHSG, the Specialty Training Board and the SCCCSS. The National Clinical
Leads from England, Scotland and Wales wrote a joint letter to the JCST highlighting the problem. In
England, as in Scotland, the problem remains unresolved.
xii. As a result of these concerns several things have happened, but have only gone part of the way to
providing a solution. There have been publications from the RCSEng regarding standards of care in
paediatric surgical practice, similar to the ones produced by the RCPCH and the SCCCSS a year earlier. The
CYPHSG commissioned Prof Youngson to provide a report into the issue in 2006. Specifically, his remit was
 To undertake a review of current patterns of general surgical care, including elective/emergency and
day case surgery for children and young people up to 16 years of age across Scotland;
 To formulate and recommend care pathways, that will best support local surgical teams, and
consolidate collaborative working arrangements across the regions, through the development of
managed surgical networks;
 To consider solutions for those areas, which most challenge services, i.e. emergency care and those
cases in need of joint working and/or transfer;
 To evaluate implications of any proposed change for families in local communities and parallel
specialties, including medical paediatrics;
 To produce a report for consultation with relevant groups, including specialist and non-specialist
paediatric surgeons, surgical teams in remote localities, specialist and non-specialist anaesthetists
and the wider community.
xiii. The group consulted, conducted site visits, reviewed activity (diagnostic and procedural data), conducted
a review of local facilities, and compared with practice elsewhere and performed a literature review. The
group made the following recommendations.
1. General surgery is a core part of health services for children in Scotland and should be provided to
meet local needs. There is an urgent requirement for each Health Board to examine current
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provision in order to develop or sustain this service. Strategic planning needs to address local,
institutional and regional needs. This is a responsibility which all Health Boards should meet within
the next 12 months
Local services (including remote and rural hospitals) must have diagnostic care, resuscitation and
stabilisation as a minimum clinical standards set.
All hospitals must develop a multi disciplinary forum, where the surgical care of children can be
reviewed, discussed, planned, and audited on a regular cycle. Communication between specialist
centres and DGH’s must be reinforced.
In the short-term (0 to 5 years), 3/4 regional appointments should be made in Scotland, to support
the larger DGHs in the General Surgery of Childhood, and the children’s hospitals in their
requirement to expand their age group.
The care pathways described in this report should provide a basis for clinical decision-making across
Scotland for the conditions described.
Medical paediatrics should be involved jointly in the care of General Surgery of Childhood in the
following as a minimum:
• Emergency conditions in children less than 5 years;
• Children of all ages with diagnostic uncertainty; and
• Children of all ages in need of high dependency care.
Paediatric training should reflect this clinical duty. Inclusion of medical paediatrics in the care of
other general surgical children is at the discretion of local clinicians and is generally recommended.
The General Surgery of Childhood should be a mandatory part of core training in general surgery.
Formal arrangements should be made through NHS Education for Scotland, Colleges and Specialty
Associations for continuous professional development of surgeons and anaesthetists involved in the
General Surgery of Childhood, and for all clinicians (including nurses, therapists and anaesthetic
assistants) treating children.
Health Boards should determine their intended level of care for children at each location. NB it was
recommended that surgical treatment for torsion of testis should be available at every centre
including remote and rural/level 1 centres.
xiv. The recommendations have only been implemented in part. More paediatric surgeons have been
appointed. Outreach lists have been increased, but the increased involvement of local surgeons and their
trainees which was anticipated hasn't happened in most areas. The specialist paediatric surgeons tend to
operate and do the clinics by themselves. The Specialty Training Board has made it clear that trainees
attached to DGHs cannot be freed from their general surgical duties to attend paediatric lists or clinics.
Standards of care have been produced both in Scotland (by SCCCSS and the RCPCH) and in England
(RCSEng), which have been published within the last 2 years. It is not clear what impact the Scottish paper
has had at a local level.
xv. There is a variation in the scale of the problem across the country. All General Surgical trainees in the
North East of Scotland rotate through paediatric surgery during their training in general surgery.
Relationships between Aberdeen and the surrounding units appear stronger than elsewhere in the country.
The training programmes in the rest of the country do not feel that they have the capacity to send trainees
to paediatric surgery during their training. There is willingness in the regional centres to provide training in
GSC for those who wish it, however only 1 or 2 trainees have taken up this opportunity in the last 10 years.
There is a wide acceptance that strong links need to exist between DGHs and the regional centres. It is
reassuring to know that this relationship does exist in many areas, however in other areas there are local
issues which need to resolved with haste.
xvi. The geography of Scotland is often cited as being an obstacle to service provision, but the Youngson
report highlighted the fact that in New Zealand the provision of GSC training within the general surgical
curriculum helped to sustain services in remote and rural areas. Anecdotally some surgeons feel that children
in remote and rural parts of Scotland get a better service than in some parts of the central belt. Another
significant issue is that of the management of suspected testicular torsion. These tend to be treated by
urologists; the other common surgical emergencies in children are treated by general surgeons. In at least
two Health Board areas in Scotland the urology service is based in a different hospital to the surgical
department that provides treatment for children. Children (up to the age of 12 years and 9 months in
Lanarkshire) with suspected torsions are routinely being transferred to Yorkhill rather than being treated
locally. The potential outcome of a torted testis in this situation is catastrophic and would be difficult to
defend in a legal challenge.
xvii. We believe that the recommendations made in the Youngson report need to be re-examined. The
SCCCSS has attempted over the years to highlight the responsibility on Health Boards and regional planners
to provide an elective and emergency surgical service to children which is available locally, which is safe and
which is supported by strong links with regional centres. In many centres the provision of elective outreach
clinics and theatre lists by specialist paediatric surgeons has inadvertently led to further disengagement from
the adult surgeons. As predicted by Youngson’s group, this has had a knock-on effect on the provision of
emergency surgery.
xviii. Specifically, the paediatric surgical members of the SCCCSS recommend the following measures.
1. To ask, through the CYPHSG, that the Scottish Government insist that Health Boards include the provision
of an emergency surgical service to children in the job description of general surgical consultant posts
advertised for district general hospitals.
2. To ask through the CYPHSG that the Scottish Government get a declaration from the Health Boards of
what general surgical childhood is delivered and planned for each Health Board Region.
3. To approach the SACs in both Paediatric Surgery and General Surgery to insist that all applicants for the
CCT should be able to assess and manage independently the acute abdomen in children and manage and
treat suspected torsion of the testis.
Roderick Duncan FRCSEd(Orth)
Chair SCCCSS,
On behalf of the Scottish Colleges Committee for Children’s Surgical Services
September 2013