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BMJ No 7110 Volume 315 Editorial Saturday 20 September 1997
The future of vascular services: the need for a strategyWhich could also be a model for other specialist servicesHow big should an acute general surgical hospital be and what population should it serve? Patients want a local service, but technological advances, increasing expectations, and escalating costs make this difficult. Vascular surgery provides an important benchmark against which to judge the optimum size of acute surgical units. Since the 1960s vascular surgery has been one of the most rapidly expanding specialties. Indeed in 1994-5, 25% of general surgical appointments requesting a special interest were for a vascular surgeon (the next most popular request was colorectal surgery, at 10%). Patient morbidity and mortality have been dramatically reduced by (expensive) improvements in anaesthetic and perioperative care. A better understanding of the widespread nature of the disease has led to close cooperation between surgeon, cardiologist, renal physician, and neurologist. Furthermore, interventional radiologists have made an enormous impact over the past 20 years with balloon dilatation, thrombolysis, and more recently, the placing of covered stents. So why, chief executives may be asking themselves, are they now being asked not to reappoint singlehanded vascular surgeons? The answer, briefly, is that there has been a lack of strategic planning which we must now address. Vascular surgeons have three main goals: to prevent amputation (an aggressive approach to distal reconstruction is effective in terms of both quality of life and cost(1) ); to prevent stroke in patients with carotid disease(2); and to prevent ruptured aneurysms.(3) To do this we need all the facilities of a full vascular service. At the moment a district of 250 000 people is lucky to have two vascular surgeons and a vascular radiologist. It is unreasonable to expect these three individuals to provide the cover all the time, particularly since 42% of vascular interventions take place out of hours.(4) For four months of the year such a hospital would be covered by a singlehanded vascular surgeon. A pragmatic immediate solution may be a "hub and spoke" arrangement so that patients are transferred to a more central unit when no local surgeon or radiologist is available. In more sparsely populated areas, such as the Highlands, Northumberland, Cumbria, and East Anglia, transfer over long distances has logistic problems and this type of cooperative service may be the long term solution. Most patients in Britain, however, are in urban areas and we should coalesce units so that a critical mass of expertise is provided. In 1990 only four units in Great Britain had three vascular surgeons; in 1995 there were 24. We are clearly moving in the right direction, and, with the consultant:trainee ratio continuing to fall, a 1 in 4 emergency on call rota for consultants seems reasonable. These four surgeons need an appropriate workload, and three local audits in Great Britain produced a figure of 90 operations per 100 000 population per year (Belfast, Bournemouth, Sheffield; personal communications), which is identical to the figure in the Swedvasc registry in Sweden.(5) On this estimate the four vascular surgeons require a population of about 600 000 to provide an efficient service. If the unit is smaller the cost per case increases and the facilities are underused. Furthermore, there will be times during the year when a true vascular service is not provided. Obviously the development of larger units requires considerable strategic planning, which is difficult within the current system,(6) where hospital trusts tend to compete rather than cooperate. Many hospitals will not wish to lose their vascular service; others will not wish to be swamped by a major unit. There has been a plethora of advertisements for vascular surgeons for relatively small units, and these young surgeons will take up their task with enthusiasm. When they realise the chief executive's inability to provide the necessary facilities they may become dispirited. Vascular surgery is a young, dynamic, and rapidly expanding specialty that requires careful strategic consideration if we are to provide the high standard of care that patients with this endemic disease should expect. John H N Wolfe
References 1 Humphreys WV, Evans F, Watkin G, Williams T. Critical limb ischaemia in patients over 80 years of age: options in a district general hospital. Br J Surg 1995;82:1361-3. 2 European Carotid Surgery Trialists Collaborative Group. Risk of stroke in the distribution of an asymptomatic carotid artery. Lancet 1995;345:209-12. 3 Ingoldby CJH, Wejanto R, Mitchell JE. Impact of vascular surgery on community mortality from ruptured aneurysms. Br J Surg 1986;73:551-2. 4 Curley PJ, Spark Jl, Kester RC, Scott DJA. Audit of vascular surgical workload: use of data for service development. Ann R Coll Surg Engl 1996;78:209-13. 5 Bergqvist D, Einarsson E, Norgren L, Troeng T. A comprehensive regional vascular registry: how is the population served? In: Greenhalgh R, Hollier L, eds. The maintenance of arterial reconstruction. Philadelphia: Saunders, 1991: 441-54. 6 Wolfe JHN, Harris PL, Ruckley CV. Trust hospitals and vascular services. BMJ 1994;309:141.
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