Low Volume / High Complexity Paediatric Orthopaedic Surgery - BSCOS/GIRFT/BOA Position Statement
Children’s Orthopaedic Surgeons recognise the immense trust placed in them by families, and therefore their obligation to provide the highest quality of care with the best possible outcome for every child.
Professional standards require surgeons to practice within their scope of competencies to deliver consistently good results, underpinned by education and training. Guidelines to support this within paediatric orthopaedics have been described by GIRFT (2022)1 and BSCOS (2022)2.
The possible benefit of high case volume that might be achieved through centralised services must necessarily be balanced against the drawbacks of a service provision with long travelling distances for patients as well as infrastructure and capacity considerations. Nevertheless, there is a need for intentional, planned, cohesive team-working practices at local and regional levels to ensure appropriate decision making, safe interventions, and consistent outcomes, particularly for clinicians undertaking low volume, high complexity procedures. In general, the lower the case volume, the more vital is the scrutiny that a surgeon should exercise on their own practice, and in turn seek expertise from regional networks to validate decisions and monitor outcomes.
At an individual level, paediatric orthopaedic surgeons should keep a complete logbook or local register with the ability to track activity levels of all procedures and complications. This level of information should be a requirement for appraisal and revalidation and be available for unit level review at appropriate time intervals by service commissioners and /or professional bodies. Surgeons should contribute to relevant national registries and engage with the National Consultant Information Program. Employing Trusts must support participation with provision of appropriate administrative assistance, planned activity within an agreed job plan, and funded study leave to facilitate attendance at courses to refresh core knowledge and enhance surgical skills.
At hospital level, all medical professionals must be willing to work collaboratively in teams to maintain and improve performance and change systems where this is necessary for the benefit of patients3. Clinical and medical directors should monitor and be aware of working practices, and act to ensure that appropriate team working is established and maintained4. This is highlighted in the NHS Resolution Team reviews Retrospective 20215. Networking opportunities are key and low volume procedures should be discussed at unit and Operational Delivery Network level (or similar), with case planning and review meetings forming a formal component of intra-departmental collaboration, supported with appropriate job planning. Dual consultant operating is recommended for procedures that are complex and/or infrequent and this should also be reflected in job planning as an exemplar for consistent delivery of high-quality care. All complications must be discussed and supportively examined in an MDT context.
At a regional level, paediatric orthopaedic surgery should continue to be organised into a robust system of networks and pathways, that results in smaller trusts being supported by large providers. Service commissioners should work with regional networks to cohort low volume high complexity referrals and resources to increase experience and expertise. Structured visits to and between centres should be encouraged to review and audit practice. Continued professional development and education should be demonstrated to supplement experience and maintain skills. Feedback and recommendations should be provided to the clinical/medical directors and commissioners with follow up responses required after an appropriate period.
W G Atherton BSCOS President
J B Hunter GIRFT Paediatric Orthopaedic Lead
M G Bowditch BOA President
F Monsell BOA Vice President
- GIRFT Paediatric Orthopaedic Surgery Report. Available at: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2022/09/Paed-TO-4-4-22i.pdf.
- BSCOS Good Practice Statement. Available at: www.bscos.org.uk/Portals/0/downloads/resources/BSCOS%20GPS%201%20Low%20Vol.pdf?ver=ggZHSK4duwr2nnV9HbcRIg%3d%3d.
- GMC Good Medical Practice . Available at: www.gmc-uk.org/-/media/documents/good-medical-practice-2024---english-102607294.pdf.
- Bhugra D. Doctors working in teams. J R Soc Med. 2024;117(12):398-401.
- NHS Resolution Team reviews Retrospective. Available at: https://resolution.nhs.uk/resources/team-reviews-retrospective.