Evidence submitted by the Society of British
Neurological Surgeons (WP 25)
SUMMARY
— Neurosurgery is one of the smaller
specialist surgical disciplines in the Health Service.
— Nevertheless, it makes a major contribution
to the nation's emergency services and provides a wide range of
technologically advanced treatments.
— The health gain of many of these
treatments is considerable. They are often directed towards the
most disadvantaged and disabled members of the community.
— Neurosurgical services are provided
by a network of 34 regional centres in the United Kingdom serving
populations of 1-3 million.
— The neurosurgical patient case-mix
is complex and heterogenous. It demands high levels of consultant
expertise and sub-specialisation with support from a wide range
of related hospital departments and disciplines.
— Neurosurgery has a strong tradition
of consultant-led and consultant-provided services.
— The SBNS and SAC are concerned to
note that approximately one third (12/35) of recently qualified
neurosurgeons are yet to secure definitive consultant appointments
in the Health Service.
— Effective national manpower planning
for a small speciality is difficult when consultant appointments
are based on local business plans.
RECOMMENDATIONS
— The overall planning of neurosurgical
services should take place at a national level with the commissioning
of services secured at a regional level, in order to ensure equitable
and effective service delivery.
— Manpower planning for the four nations
should be coordinated by a single body which includes representation
from the profession (SBNS), training body (SAC), national commissioners
and regional specialist service providers.
Neurosurgical Workforce Planning
The Society of British Neurological Surgeons
represents 215 consultant neurosurgeons in the United Kingdom
and Eire, of which 180 are based in England and Wales. Neurosurgery
is undertaken in 36 units in the United Kingdom and Eire of which
29 are in England and Wales. Neurosurgical services require expensive
radiological and specialist operating equipment and multi-disciplinary
support from critical care, oncology, neurovascular and neurological
services and other specialties such as orthopaedics, otolaryngology
and ophthalmology. Neurosurgery plays a key role in a variety
of service frameworks with concentration of the key resources
at the hub, but responsible for patients drawn from a wide population
and partly managed outhwith the centre. Paediatric Neurosurgery
became a sub-specialty in the middle 1980s and has been strengthened
following the Bristol enquiry.
Neurosurgery has a strong tradition of workforce
planning. In 1993 Safe Neurosurgery was published setting
out the standards and resources required for a safe neurosurgical
service. This was followed in 1999 by the SBNS Workforce Plan
2000-15 which examined the requirements of the Working Time
Directive for junior doctors and predicted that 250 consultant
neurosurgeons would be needed for the United Kingdom and Eire
by 2015. In 2004 a further manpower review took account of the
new consultant contract and a more detailed understanding of the
implications of the working time directive. This predicted an
increased requirement of between 325 and 375 consultants across
the United Kingdom and Eire.
This year the SBNS and SAC will undertake a
national census of the neurosurgical manpower and activity in
the light of the new consultant contract, the consultant job plan,
the extended surgical team, and the implications of modernising
medical careers. The census is to be distributed to the neurosurgical
units by the end of March 2006 and the information will be collated
by the end of June 2006.
Neurosurgical Services
The planning of neurosurgical services must
take into account clinical and technological advances, demographic
changes and the development of new roles and working practices.
Examples of significant advances in the last 10 years include:
1. Endovascular treatment of intracranial
aneurysms and arterio-venous malformation.
2. The development of spinal instrumentation
for degenerative and malignant spinal disease.
3. The widespread adoption of computer-guided
approaches enabling more accurate and less invasive surgery with
shorter hospitalisation.
4. The development deep brain stimulation
for Parkinson's disease, vagal nerve stimulators for epilepsy
and baclofen pumps for the management of spasticity in children.
5. Neuroendoscopy for the treatment
of hydrocephalus and as an adjunct to open or microscopic surgery.
Many neurosurgical units have embraced the concept
of the extended surgical team and are using nurse practitioners,
extended scope practitioners and surgical care practitioners.
These teams are essential if a balance is to be achieved between
service delivery and the training of neurosurgeons following the
introduction of the Department of Health's initiative on Modernising
Medical Careers. Training in neurosurgery, which will take nine
years from qualification to the award of a CCT, will comprise
two foundation years, two years of core neuroscience training
and five years higher training in neurosurgery. All trained neurosurgeons
at CCT level will be emergency competent and will be able to contribute
to specialist services. Major concerns remain regarding the capacity
of units to maintain 24 hour emergency services following the
changes in working hours and practices.
The size and distribution of neurosurgical units
must take into account patient access for the commoner neurosurgical
conditions as well as journey times for emergency admissions.
Some neurosurgical conditions are rare and must be managed at
a supra-regional level. Units will require a minimum of six consultant
neurosurgeons working with an extended team. They will have a
population base sufficient to provide a workload that balances
the neurosurgical needs of the population and the ability of the
consultant staff to maintain competency and to train. Except where
geographical considerations dictate otherwise, the optimal population
for a neurosurgical unit will be greater than two million. For
paediatric neurosurgery and some other subspecialty conditions
this figure is nearer five million.
Mr A Steers, President, and Mr R Netron,
Society of British Neurological Surgeons & Specialist
Advisory Committee in Neurosurgery
5 March 2006
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