Surgical care practitioners in orthopaedics

Introduction

In Europe during the Middle Ages, the Church’s control permeated the whole of society including medical and surgical training. Doctors at the time were predominantly members of the clergy. An edict from Pope Innocent III in 1215 forbade members of the clergy from performing surgical procedures. ¹ Hence, while physicians pursued a university education surgery became primarily the domain of craftsmen, local wise men and barbers. The predecessor of the Royal College of Surgeons was the Guild of Barbers and Surgeons of London. This collaboration was formed by an Act of Parliament ratified by King Henry VIII in 1540. It sought to unite this disparate body of practitioners of surgery as well as legitimatising the profession and maintaining standards. In Europe in the 1700s, surgeons began to engage in formal medical training similar to the system seen today. ¹ The 21st century has seen a revolution in the provision of healthcare in the Western World. It has witnessed the creation and expansion of the role of surgical care practitioners who, while not being medically qualified, are involved in varying degrees with the provision of surgical services. They are employed in trusts throughout the UK. With this article we explore the role of the surgical care practitioners in orthopaedic surgery.

Origins

Surgical care practitioners perform part or all of surgical procedures either independently or under supervision by the responsible surgeon. The role of the surgical care practitioner evolved organically and was only given the title retrospectively. The nomenclature has never been clearly defined and remains fluid and dynamic. ² There are now believed to be 300–400 surgical care practitioners practising in the UK though no firm figures have been published. The surgical care practitioners differ from the newly created physician assistant roles, of which from the UK Association of Physician Assistants 2015 Census there are 137 physician assistants and 132 physician assistant students in the UK.

In 1993, Susan Holmes was appointed the first surgical care practitioner in Oxford. ³ Holmes initially underwent a six-month secondment of intensive training and assessment in a leading cardiac centre in Ohio, USA. The history of the surgical care practitioner in the USA predates the UK experience by over 20 years.

In the late 1990s, the Association for Preoperative Practice began to define the role. They drew a distinction between a first assistant and a ‘surgical assistant’. The latter would actually perform surgical procedures under varying degrees of supervision. This distinction was a seminal step in the genesis of the surgical care practitioner. The Royal College of Surgeons further highlighted this distinction in its 1999 paper: ‘Assistants in Surgical Practice’. ⁴ The support infrastructure championed by Holmes came in the form of the National Association of Assistants in Surgical Practice (NAASP) in 2002. NAASP was tasked in creating a curriculum and establishing standards of practice.

In 2003, a collaborative of the NAASP and the Royal College of Surgeons re-named the first assistant as the advanced scrub nurse practitioner and the surgeon’s assistant as the surgical practitioner. ⁵ In 2004, the latter was re-named surgical care practitioner. Concerns had been raised following a public survey that the title Surgical Practitioner may mislead patients in to believing the practitioner was medically qualified. ⁶

The driving force for this revolution has been assigned to the NHS Management 1991 Report ‘the New Deal’, ⁷ the 1993 Calman Report on Surgical Training and subsequent reforms ⁸ and the European Working Time Directive in 2004. The New Deal significantly reduced the working hours of doctors. This was further curtailed by the European Working Time Directive. The Calman report sought to reduce the duration of training by improving the quality. These changes negatively impacted upon the availability of medically qualified personnel to assist in theatre.

Norfolk and Norwich was in many ways the birth place of the orthopaedic surgical care practitioner. In 1998, Edward and Keeley introduced the surgical care practitioner programme. The training of nurses as surgical care practitioners was visionary in that training was competence-based resembling current surgical training rather than time dependent. ⁹ Competence-based training was definitively introduced in the UK with the advent of the Intercollegiate Surgical Curriculum Project in 2007. A degree level course was developed to provide a knowledge base for trainee surgical care practitioners. The definitive title of Surgical Care Practitioner was announced by Mr Hugh Philips, President of the Royal College of Surgeons of England, in 2004.

Surgical care practitioners in practice

The surgical care practitioner initially came into being to address service shortfall. In 2008, the Department of Health introduced the 18-week referral to treatment time (RTT). The initial requirement in 2008 was that 85% of patients who required non-urgent surgery would receive this within 18 weeks of referral from primary care. ¹⁰ The target for 2012/2013 increased to 90% for inpatient care and 95% for outpatient care. ¹¹ The objective was to expedite the delivery of a high standard of safe patient care and reduce costs. New initiatives sought to determine if surgical care practitioners could be trained to perform procedures with greater independence and thus alleviate the pressure on the health service.

Palan et al. ¹² performed a multicentre study involving 1434 patients who underwent 1501 cemented hip replacements in which it explored the effects of trainees and surgical care practitioners as the first assistant. The mean operative time for consultant performed cemented total hip arthroplasty was 93 min with an orthopaedic trainee assisting. This fell to 65 min with a surgical care practitioner. The authors offer no explanation for this. It may be that during a trainee-assistant case the consultant dedicates more time to demonstrating steps and questioning the trainee.

It has been argued that the surgical care practitioner provides continuity of care in contrast to a trainee who may rotate four- or six-monthly. Martin and Purkayastha reported the results of a prospective audit at St Mary’s Healthcare Trust in London on the use of surgical care practitioners to perform minor surgeries. ¹³ The authors emphasise that the surgical care practitioner was a member of the multidisciplinary team and not an independent practitioner. The surgical care practitioner would see the patient in preoperative assessment, perform the surgery, see the patient following surgery and again in follow-up clinic. In cases where specimens were sent the surgical care practitioner would review the histological results and discuss suspicious results with the surgical team. In addition, the authors described the surgical care practitioner as ‘contactable by the patient at all times’. They reported very high patient satisfaction rates. At three months, 100% of the 59 patients canvassed were happy with their treatment. Like Newey and co-workers, complications rates were similar to those reported for surgeon-performed procedures.²⁰

Impact on training

The main gravamen against the surgical care practitioner relate to the impact on training. In institutions where procedures such as carpal tunnels are routinely performed by the surgical care practitioner, there are theoretically fewer training opportunities for junior trainees. With this in mind, some trusts have declined the opportunity of teaching surgical care practitioners to perform minor operative lists. The Intercollegiate Surgical Curriculum Project allows non-medically qualified staff to teach procedures to and assess trainees. ¹⁴ However, Annual Review of Competence Progression (ARCP) require trainees to have a large proportion of ‘senior assessed’ competencies. Not even associate specialists are deemed senior enough to complete these assessments. Thus, if trainees find themselves increasingly operating with surgical care practitioners, although skills will be obtained, the opportunities to formally document these achievements will be reduced.

It has been argued that the creation of the surgical care practitioner is not a sustainable solution to the problem of a shortfall in manpower. ¹⁵ The curriculum correctly stresses that the surgical care practitioner will not replace surgeons. Hence, the surgical care practitioner who is neither nurse nor surgeon may deprive theatre and surgical wards of much-needed nursing while surreptitiously diluting the training of surgeons. Theoretically, if a consultant is required to train and supervise a surgical care practitioner there will less time available for the training of trainees. However, in instances of direct conflict for example where both surgical care practitioner and trainee are in theatre the trainees’ needs tend to be addressed preferentially. ¹⁶

Another point of potential conflict lies in the fact that junior trainees and surgical care practitioners may wish to attend similar courses, for example the Basic Surgical Skills course organized by the Royal College of Surgeons which are already largely oversubscribed. While this course is not mandatory for surgical care practitioners, it forms a compulsory component of the training provided by a number of institutions and healthcare trusts for surgical care practitioners.^13,17 Now that the surgical care practitioner has mandate from the Royal College of Surgeons it would be antithetical to deny the surgical care practitioner access to these courses.

Some centres have reported the beneficial effects on specialty training. The trainees are required to perform a certain number produces with the supervising consultant un-scrubbed or completely unsupervised. Some centres report that the surgical care practitioner facilitates the transition from operating with consultant-assistant to independent operating. ¹⁸ The surgical care practitioner acts as skilled assistant.

Public perception

Public trust in healthcare providers is essential. Much of the criticism of the surgical care practitioner model turns on the pejorative perception the public may have of the role. Cheange et al. ¹⁹ performed a survey published in 2009. They surveyed otolaryngology patients regarding their perception of surgical care practitioners. They found that 53% felt that not every hospital visit required the patient be attended by a doctor. However, 92% thought that surgery should be performed by a medically qualified individual. Seventy-nine percent reported they would rather wait longer and have their operation performed by a doctor than have more expeditious surgery performed by a non-medically qualified clinician. Following actual experiences with surgical care practitioners, patients’ reports have tended to be positive. Martin and Purkayastha reported that 100% of patients were ‘totally satisfied’ in the surgical care practitioner-led minor operations service. Ninety-eight percent would recommend a surgical care practitioner to another patient.

However, fears that patients may conflate the roles of surgeon and surgical care practitioner appear to be justified. In 2006, Wraight and colleagues performed a study of 51 cardiothoracic patients. 43% believed that a surgical care practitioner was a nurse, 37% thought a surgical care practitioner to be doctor and 10% were uncertain. Asked if they preferred their operation to be performed by a surgeon or a non-medically qualified individual, 98% would prefer a surgeon and 2% had no preference.

Conclusion

The impact of the surgical care practitioner on surgical training remains controversial. The evidence of their beneficial effect upon service provision is persuasive and growing. However, their impact on a generation of current and future surgical trainees has not yet been fully assessed or recognised. Resources are finite and the demand for musculoskeletal services is on the increase. Orthopaedics has the greatest proportion of patients failing the 18-week target. To address the demand-service mismatch, healthcare systems must evolve. Surgeons and trainees must too evolve. Medical training has endowed doctors with the ability to adapt to changes in disease paradigms, changes in patient expectation and patient behaviours, changes in societal diversity and changes in the medico-legal and medico-political landscape that regulate practice. The surgical care practitioner–trainee conundrum is another manifestation of the service provision-training polemic. The rise of the surgical care practitioner need not spell the demise of the surgeon and indeed may be to their benefit if surgeons continue to apply their ability to adapt to changes in the protean and the evolving National Health Service. The very reason doctors have adapted is to ensure that patients receive the highest standard of care. This should remain our objective. To automatically reject the surgical care practitioner principle on the basis that only the medically qualified should perform parts or all of surgical procedures may be excessively legalistic. However, unmonitored, dysregulated independent surgical care practitioner practice is equally undesirable. A compromise can be struck whereby the surgical care practitioner is integrated into the surgical team and be an asset to the team and subsequently to safe and effective patient care. We should not, however, let the introduction of the surgical care practitioner detract from the fact that there is a lack of both trainee and consultant surgeons nationally. This is even more pertinent with the imminent introduction of a ‘7-day NHS’. Thus, the question of whether funds may be better spent on increasing the numbers entering medical school should not be forgotten.