Intended for healthcare professionals


Trust hospitals and vascular services

BMJ 1994; 309 doi: (Published 06 August 1994) Cite this as: BMJ 1994;309:414
  1. J H N Wolfe,
  2. P L Harris,
  3. C V Ruckley
  1. Vascular Surgical Society of Great Britain and Ireland, Royal Liverpool University Hospital, Liverpool L7 8XP.

    EDITOR, - We write to express concern over the detrimental effect that trust hospitals are having on strategic planning for vascular services. Many recent consultant appointments have been of singlehanded vascular surgeons in district hospitals as they adopt trust status. The proportion of singlehanded surgeons fell from 43% to 7% between 1988 and 1992 but will inevitably rise as a result of these appointments.

    This problem has recently been highlighted in South West Thames region, where retiring single-handed vascular surgeons have been automatically replaced at separate but adjacent hospitals and the opportunity for rationalisation and improvement in services and training has been missed. Despite inquiries by the regional adviser there seems to be no mechanism by which separate hospitals can combine to deliver a coordinated modern service. Furthermore, 30-50% of admissions for vascular surgery are either urgent or emergencies, and no singlehanded vascular surgeon can provide a round the clock emergency service - nor, for that matter, can a two person vascular unit - without considerable personal sacrifice and stress. In many district general hospitals this is solved by including general surgeons on rotas for emergency vascular surgery. Emergency vascular surgery, however, is often demanding, and it is inappropriate for surgeons who perform no elective vascular surgery to find themselves dealing with ruptured aneurysms or ischaemic legs. Transfer to an appropriate unit is preferable to inadequate cover in every hospital.

    The national confidential enquiry into perioperative deaths advised that aneurysms should be treated by vascular surgeons since their results are much better than those of general surgeons.1,2 The same argument applies to the treatment of ischaemic legs, in which a multiskilled team approach, allowing the appropriate selection of surgery, thrombolysis, and ballon angioplasty, is particularly important.3

    These considerations led a working party of the National Medical Advisory Committee for Scotland (population 5.1 million) to recommend that the number of hospitals providing vascular services should be reduced from the present 20 to six major centres and three intermediate units.4 The vascular advisory committee of the Vascular Surgical Society of Great Britain and Ireland therefore wishes to persuade trusts throughout Britain that patients are not well served by a sporadic service; to provide full cover for vascular emergencies a district general hospital needs three vascular surgeons and therefore a population base of about 600 000. The surgeon then provides emergency cover on a 1 in 2 rota for three to four months of the year and on a 1 in 3 rota for six months of the year, allowing for holidays and study leave. With the introduction of the shorter, seamless training scheme vascular surgeons will be much less protected by surgically competent junior staff and even this on call rota will be onerous.

    Trust hospitals have the right to work independently, but without a regional strategy patients will continue to suffer from the vagaries of an uneven service. The patients who suffer may resort to litigation, and improving audit will support their case.


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