General Surgeons’ response

Dear Mr Kershaw,

We, the consultant general surgeons at Lewisham Hospital are writing to you to express our opposition at your recent draft proposals for SLT and Lewisham Hospital. We would like to start by saying that we wholeheartedly support the views already put forward by our colleagues from other departments.

The general surgical department functions well within the hospital as a whole. We depend on the Critical Care department and the medical departments, especially gastroenterology, and the A&E department depend on us.  While we can see that there may be benefits to a merger with the QE leading to a larger department we have grave concerns over how you propose to achieve this. We are not against a merger, but feel that Lewisham’s proven successful management team and senior clinicians should be trusted to do this as they see fit using successful examples developed in other regions.

In a recent emergency surgery services review Lewisham scored highly. The need to adhere to  evidence-based clinical quality standards, seems to be a real feature of your message. We already achieve the majority of those standards at Lewisham, so why would you want to change what we do, when we are already doing a good job for local people? Your report states A&E attendance could be reduced by 30%; clearly patients needing an operation cannot be looked after in the community.

It is suggested in section 9 of your report that there is not a senior surgeon available 24/7 at a hospital with an A&E in south east London. This is simply untrue. It is most certainly not the case at Lewisham. A merger would reduce the frequency with which we had to be on call, but would not alter that fact that if an elderly man with bowel obstruction needed to be seen, even at 3am, he would be seen, by a consultant if necessary.

Vascular surgery has centralised around the UK with teams providing the relevant service. Similarly 75% of breast consultant posts advertised do not involve emergency surgery. Thus service developments in these areas do not affect general surgical emergency on call as you have claimed

Our colorectal surgery department is very highly regarded, both within the surgical community and by our patients. We receive high satisfaction scores in our annual patient survey and a great many of our patients express a desire to be treated here, in their local hospital, rather than be asked to travel. We are a centre for bowel cancer screening, diagnosing early bowel cancer in almost 150 patients so far, 75% of patients diagnosed from outside our area have chosen to stay and have subsequent treatment here at Lewisham, rather than return to their local hospitals of QE, and PRUH. Lewisham’s colorectal surgical service is clearly what patients actually choose. Removing this will remove the people’s choice. We regularly exceed commissioner-set standards for the Enhanced Recovery program, and despite being centred in a deprived area where there is little traditional family support, we have a length of stay that compares favourably with benchmarking standards. We offer a full range of colorectal surgery including laparoscopic resections.

Our general surgery theatre utilisation percentage is 85%. This is a result of excellent theatre staff, ITU and anaesthetic support, good laboratories, a well established and functioning pre-assessment clinic and a supportive ethos. These things cannot just be picked up and transported 2 miles east. Our day case laparoscopic cholecystectomy rate is 68%, this is higher than the national average and exceeds targets of just under 50% set by the British Day Surgery Society. In fact, since 2008 we have been over the 90th percentile for their 25 “basket” of cases used to benchmark day surgery rates. Our vascular surgeons are national leaders in the treatment of venous disease.

We support the assertion of our medical colleagues that Lewisham residents and their families will find it difficult to access services at Woolwich. Travel times estimated in the draft proposals were calculated without traffic. Having experienced first-hand the delays that local traffic can cause at rush hour, you must see that these need to be revised upwards, by a considerable margin.

Another major concern of ours is Critical Care capacity, many surgical patients are among the most unwell in the hospital. We have a first class critical care facility at Lewisham. This cannot be removed without having a negative impact on clinical outcomes.

We know that there are successful examples of elective surgical centres such as SWLEOC, but there are also examples where such models have failed. The Elective Orthopaedic centre as part of the Imperial College/Charing Cross hospital “ran out” of patients to operate on after a few months and a similar situation occurred at the Diagnostic and Treatment centre at UCH. What would make an elective centre at Lewisham, surrounded by other local hospital all retaining their day surgery facilities, any more successful? Minor and intermediate cases will be done at all hospital sites, complex major surgery will need to be done elsewhere because of critical care backup. There will be very little left for a high volume elective centre and we cannot see how this would be viable in the long term without the retention of critical care facilities.

Training at all levels is recognised to be good at Lewisham, (London Deanery SAC). We have consistently maintained the number of trainees here at Lewisham. Other similar units have had trainee numbers cut because the training has not been consistently of a high quality. In addition to excellent training for medical staff we have an excellent track record in the training and development of nurses, we have specialist nurses that have been trained to specialise in colorectal cancer, upper GI cancer, endoscopy and enhanced recovery. The culture of training has been developed over years and we are a popular place for trainees to learn. Working over 2 sites, one “hot”, one “cold” may offer certain opportunities for trainees but the sorts of theatre efficiency on which your proposals are based is surely mutually exclusive with training the surgeons of the future.  Given that our training record at Lewisham is outstanding we feel that the culture of surgical training will be undermined, at the very least, if not destroyed altogether by your proposals.

We believe that the heart of a district general hospital is the emergency care it provides for local people. We demonstrably provide excellent emergency surgical care. This cannot be simply relocated. To remove emergency general surgery from Lewisham hospital would certainly mean that the sickest people of the borough receive worse care further away from home. How could anyone local support that?

 

Yours sincerely,

 

David Birch

Cynthia Borg

Clare Byrne

Jane Linsell

Adrian Steger

Aleksandras Uzkalnis

 

 

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