Annex A > Chapter 6 - Funding and Resources > Resources > Increasing the number of anaesthetists and surgeons
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Increasing the number of anaesthetists and surgeons
178 Efforts made by the surgeons at the BRI to obtain additional operating sessions were affected in 1987 by the need to appoint a further consultant anaesthetist. Mr Gerald Keen, consultant cardiothoracic surgeon, wrote to Dr Robert Johnson [245] in November 1987:
`I believe that my anxieties concerning the consultant anaesthetist cover from July 1988 onwards stems from a chronic shortage of consultant availability in cardiac surgery. We have been dogged by this for many years, and it seems to me that this situation will not really improve following the commencement of our expanded service. There are two causes of this problem.
`In the first instance we are barely covered by consultant anaesthetist sessions and this is highlighted on Wednesday when the consultant anaesthetist is legally obliged to work a morning session only. To anybody with the faintest understanding of cardiac surgery and cardiac anaesthesia, it is clearly wrong that cardiac surgical patients should be attended by the anaesthetist in charge for the first half of a case only, and that the completion of the operation and perhaps the management of important immediate complications, should have no official consultant anaesthetist cover. The second cause and to an extent associated with the first problem, is the very heavy commitment of the consultant cardiac anaesthetists to other legitimate duties.
`Although we are completely covered for cardiac surgery on paper (excepting for Wednesday afternoon), these prolonged and often simultaneous absences of consultant anaesthetists gives us poor and often inadequate cover. Unhappily in my view the acquisition of another consultant anaesthetist will not really improve the situation, bearing in mind the proposed expansion of the service, for the new anaesthetist will undertake four sessions only in the operating theatre. At the same time, other consultant anaesthetists who are heavily overworked will quite understandably see the arrival of the new anaesthetist as an opportunity to reduce their own commitment to their contractual obligation. I did of course, set out most of these points in my recent letter to you, but your response, although helpful, gives me no indication that the service provided by your colleagues will be adequate in the future.
`As you know, James [Wisheart], Janardan [Dhasmana] and I have set out tentative proposals concerning our own work programme for the expanded service, but this can only happen with appropriate consultant cover. For the time being I do not propose to send any of this correspondence to the Regional Health Authority, but they may at some time in the future, need to be made aware of the under-provision of support for a service which they are now heavily financing.' [246]
179 As regards the need for cardiac surgeons, in October 1988 Mr Keen wrote to Dr Alastair Mason [247] at the SWRHA:
`With the further development and extension of cardiac surgical facilities in the South West region, certain consequences have been accepted by the Regional Health Authority. We have increased the nursing staff considerably and at the same time appointed two further consultant anaesthetists to support this development.
`When Mr J P Dhasmana was appointed in 1985, his appointment was partly proleptic to enable a further increase in work to take place, and as you know in 1986, we undertook a total of more than six hundred open and closed cardiac operations on adults and children. It was agreed at that time that this unit would eventually undertake a considerable number of those patients in the south west requiring cardiac surgery, and to achieve this, the need to appoint, a fourth cardiac surgeon at some time was appreciated. It was generally understood that once we had achieved a level of about seven hundred open heart operations per annum (in addition to about one hundred closed operations per annum), a total of eight hundred operations, the appointment of a fourth surgeon would become mandatory.
`This topic was raised at the meeting of the South West Regional Cardiology Committee, held at Taunton on 6 October and after full discussion, it was agreed that the time to appoint this surgeon had now arrived. We are now operating on planned fifteen operations per week (apart from emergencies); that is approximately seven hundred and twenty five patients per annum. Whereas at the present time we are able to achieve this, it is only with the greatest difficulty, for the three surgeons in post, are working very hard and my two colleagues who also do paediatric cardiac surgery at the Children's Hospital, Mr J D Wisheart and Mr J P Dhasmana, are working all hours, day and night, and their weekends are rarely free.
`This really cannot continue, for even should these numbers be achieved during normal working periods, there is no way that this volume of work will be sustained during the summer, that is from the middle of May until the end of September, when one or other of the cardiac surgeons is away and at the same time, junior staff need to have their holidays staggered.
`It is anticipated that in the absence of a fourth surgeon, the volume of work undertaken will decrease to perhaps two thirds of its present level during that period, with consequent under-usage of our expensive, well equipped and well staffed cardiac surgical unit.
`With this in mind, it was recommended by the Committee that steps are taken to consider the appointment of a fourth cardiac surgeon, whose work would be primarily in adults, that the successful applicant would be in post by the late spring of 1989.
`Financial support for this fourth surgical appointment has been agreed in all planning documents for this expansion, prior to 1987, but as far as we can tell, any mention of this fourth appointment has not appeared on recent documents. I am sure that this discrepancy will come to light when you have had an opportunity to study the background of this request and I look forward to meeting you, together with my colleagues in the near future.' [248]
180 Mr Dhasmana wrote to Dr Mason in November 1988:
`I am writing to you to express my views on the above subject especially in reference to Mr Keen's earlier letter dated 11th October and your recent meeting with Mr Wisheart and Mr Keen on 11th November. ...
`You are well aware that ours is a moderate sized Cardiac Surgical Unit which deals with both paediatric and adult cardiac surgery averaging about 520 cases per year over the past two years. During this period my own clinical work-load was not fully stretched due to lack of resources and it was a constant struggle for time, for theatre space and also for medical and nursing manpower to look after my cases. It is only since the recent improvement in the staffing level and an extension in the cardiac surgical unit that I am able to achieve the target for which I was appointed three years ago. We are now hoping to achieve a target of around 700 cases a year in the extended Cardiac Unit.
`This figure I feel is just right for the present level of medical staff of three consultants, two senior registrars, one registrar and four SHO's. An almost similar figure was recommended by the Joint Cardiology Committee of Royal Colleges for the organisation of a Cardiac Surgical Unit (Brit Heart J 1980; 43:211-219). There are a number of units in this country which are managing an even higher number of operations per year with three consultants and supporting staff. Even units like Guy's and the Brompton Hospitals which deal with adult and paediatric cardiac surgery have been managing about 800-1000 operations a year with a similar number of consultant staff. The Brompton has only recently appointed a fourth surgeon. It appears that the secret lies in providing and increasing the support service rather than appointing a fourth surgeon alone in order to increase the number of operations. The fourth consultant would need theatre space and ITU beds. At the present time we are allocated 4-5 operations per consultant per week which in my mind is just right for a cardiac surgeon to maintain a high standard in the technical skill and the post-operative management. The above Joint Committee further emphasises "Facilities should be available for each surgeon and his team to perform four to six open heart operations a week with additional time for emergencies" in their recommendations for surgical staffing (page 214).
`I personally feel that the consultant appointment should not be made to cover leave and holidays of other colleagues. Locum appointment of a registrar or consultant during that period should see the work continued unabated. The present resources are utilised to the maximum by the three of us. In my mind there is no spare facility to accommodate the fourth person unless some of us agree to cut down on their own work.
`I agree that there is a threshold beyond which a fourth surgeon would be needed and we are approaching that figure when 700-750 open heart operations are performed a year. We should then combine this demand with further expansion of the unit here at BRI or the transfer of paediatric services to the Children's Hospital which would certainly make the way for a fourth cardiac surgeon to cover mainly the adult side. It would also be feasible to appoint a further surgeon if we have agreed in principle to establish a transplantation unit with increased resources.' [249]
181 On 5 July 1989, Mr Keen, Mr Wisheart and Mr Dhasmana wrote a proposal for the appointment of a fourth cardiac surgeon addressed to the planning authorities:
`Cardiac surgical services in Bristol have developed in a step-by-step fashion during the last decade, increasing the number of open heart operations performed annually from 253 in 1980 to a predicted 675-700 in 1989. During this time, the numbers of surgical staff responsible for the work have increased as follows:- Consultants from 2 to 3, Registrars/Senior Registrars from 2 to 3, Senior House Officers from 3 to 4. During the planning processes, the initial target for the 1988 development was 600 cases, and it was agreed that three surgeons would be sufficient; in the light of experience and in the presence of a large outstanding demand in the region, this number was revised to 675; it was recognised that an additional surgeon would probably be needed, and this was formally accepted at a meeting at the SWRHA on 11.11.88 when the Region undertook to fund this appointment and a secretary.
`While the three surgeons have managed to sustain this heavy workload over the winter months of 1988/1989, it is not a load which could be carried indefinitely. In particular, it would almost certainly be impossible to maintain the volume of work during the holiday season, simply due to lack of sufficient surgical hands. Further, the high level of throughput has been made possible, partly by the presence throughout these winter months of three exceptionally experienced and competent registrars. We cannot expect to have junior staff of such experience and reliability as a general rule in the future. The exceptionally heavy load borne by consultant staff over the winter months has undoubtedly contributed to unsociable hours of working for the whole team, medical, technical and nursing, and this would be better avoided.
`The proposal is that four surgeons would undertake precisely the work done by the three at present in post, and the timetable of the proposed fourth surgeon is enclosed. Further development in cardiac surgical services will only take place after discussion with all parties involved and will not result directly from the proposed appointment.' [250]
182 The proposal [251] to appoint a fourth consultant cardiac surgeon was accepted and in 1989 [252] Mr Jonathan Hutter was appointed to this position. When Mr Keen retired in 1990, [253] rather than being replaced directly with the appointment of another cardiac surgeon, the funding for his post was used ultimately to finance the position taken up by Professor Angelini in 1992. Dr Roylance explained:
`... the plan when Mr Keen was retiring, is that we would appoint a Heart Foundation - I think it was the British Heart Foundation - funded Professor and we would use the resources, the salary of Mr Keen to appoint a supporting senior lecturer.
`It was an arrangement with the university we commonly pursued, and that is the university would pay for a Professor and we would pay for a consultant senior lecturer which was, the university felt, a minimum requirement for an academic unit. As a result of that deal, if you like, the university would have a whole time equivalent of one consultant for their academic purposes and the Trust would have a whole time equivalent for NHS work by each of us paying for an individual and having half their services shared.' [254]
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Footnotes
[245] Consultant anaesthetist and Chairman of the Division of Anaesthesia at the BRI
[246] UBHT 0138 0018; letter from Mr Keen to Dr Johnson dated 23 November 1987
[247] Regional Medical Officer, SWRHA
[248] UBHT 0174 0011 - 0012 ; letter from Mr Keen to Dr Mason dated 11 October 1988
[249] UBHT 0174 0013; letter from Mr Dhasmana to Dr Mason dated 16 November 1988
[250] UBHT 0174 0001; proposal dated 5 July 1989
[251] UBHT 0143 0084 and UBHT 0143 0085; letter from Mrs Willis, B&WDHA to Dr Johnson dated 15 May 1989 with attached job description
[252] WIT 0096 0002 Mr Hutter
[253] WIT 0080 0145 Mr Keen