PRESIDENTIAL ADDRESS, 2002 - MR JAMES MONRO

CAN WE DO BETTER?

The last two years have been very eventful and I have to admit that my time as your President has been rather busier than I had anticipated.

The appalling terrorist attacks that occurred last September 11th and the resulting war in Afghanistan have reminded us what a fragile environment we live in. Many millions of people are dying of starvation each year and although we are dedicated to the treatment of cardiothoracic disease, we should remember that 30 million people have died of malaria in the last 10 years and 22 million have died from AIDS. However, we as cardiothoracic surgeons, must inevitably concentrate on cardiothoracic disease and this is relatively speaking still a very big problem in this country. 110,000 people a year in England die from coronary heart disease and 38,000 die from lung cancer. In this country about 400 coronary artery bypass grafts per million are performed annually, compared to about 1500 per million in the USA. Thanks to considerable media interest, the general population should now be well aware of this. The proportion of lung resections for carcinoma in this country is about the lowest in Europe at 10% compared with 24% in Holland. The five year survival rates are disappointing.

We have less doctors and nurses per head of population than almost any other European country. Due to chronic under-investment by successive governments there has been a serious deterioration in the infrastructure of the NHS and the interim Wanless report has estimated that the cumulative underspend in the UK compared with European Union average spending is 267 billion. This, on top of the 20 to 30 billion a year we would need to match France or Germany makes the 2 or 3 billion that the chancellor may be hoping to raise for the NHS in his next budget, seem totally inadequate. According to the Wanless Report on future funding of the NHS, in the year 2000 the UK spent 66 billion on health and only 10% of this was spent on coronary heart disease, cancer, renal disease, mental health and diabetes put together, although these conditions accounted for 50% of the mortality. One in every 14 of the country's income is spent on health. If we want to improve our provision for these critical services, we have to spend more but at the same time we should cut down on beaurocracy and increase efficiency. There is no easy solution, rationing is politically unacceptable, taxes may have to go up, although this will be unpopular, and there is the other possibility of some combination with the private sector, as in other countries, but the present Government's dogma about this seems insuperable.

However, the Government does seem to have a real commitment to getting waiting lists down and from next July the so called Patient Choice Initiative will be introduced. Patients who have been waiting for 6 months for any type of cardiac surgery will be assessed and if they cannot be booked within the original 9 months, they will be offered treatment elsewhere, such as another NHS hospital, a private hospital or even abroad. I am sure we all applaud the aim of reducing waiting lists, but I think their ideas are rather over optimistic and there will not be sufficient slack in the private system to cope with this influx of patients. The private hospitals need time to build up their staff and facilities and the stop go arrangements that we have seen with small initiatives in the last few years, are very unsatisfactory. As for the thought of people going abroad, I find this strange, particularly as not long ago we were treating numbers of patients from Europe. I suppose in practical terms for people in Kent to get on the Eurostar and go to France is feasible, but it does not sound sense to me. What the Government needs to do is to allow us to fully use our present hospitals. Certainly the recent injection of funds into seven hospitals will help considerably to increase their cardiac throughput. This is welcome as is the creation of a new unit in Wolverhampton. However, I am sure we frequently all have the frustration of having to cancel patients for lack of intensive care beds. There are many reasons for this but it is often lack of nurses. Inadequate numbers of nurses have been trained and I think the Royal College of Nursing have a lot to answer for. Much more could be done to retain nurses and attract back those who have left. Also we should be more flexible and seek other ways to staff our intensive care units and operating theatres.

However, there are just not enough ITU beds and we are filling them with older and sicker patients. Fast track programmes allow much of our surgery to bypass ITU and the hospital stays get shorter, but there is a great need for more money to provide adequate facilities and staff.

It takes 12-13 years to train a consultant at a cost of £250,000 and three years to train a nurse at a cost of £36,000. We have already seen nurse practitioners taking over quite a lot of the work of doctors and I am sure this will increase in the future. Although some of us may find this difficult to accept, there are undoubtedly many jobs that doctors do that could be done equally well by nurses with adequate training. Similarly, the use of increasing numbers of surgical assistants and technicians would help our surgical throughput.

There have been markedly changing attitudes in recent years, particularly with regard to doctor patient relationships. Gone are the days of the bombastic consultant as depicted by James Robertson-Justice in Doctor in the House and although these cartoons may be going too far, I think there has been a real change.

Eighteen months ago I was privileged to represent the Society at the 200th Anniversary of the Royal College of Surgeons at a service at St. Paul's Cathedral. The Arch Bishop of Canterbury gave the sermon in which he exhorted surgeons not to be arrogant and to be humble and honest. I hope he didn't think we were all arrogant but we must do the best for our patients and they must have faith in us. A surgeon needs to be confident, but not over confident. Patients these days are much better informed. Apparently within two years, 40% of all adults in the UK will use the internet.

In the past, you might have been able to tell a patient that you were going to do an operation on them the next day and he said thank you very much doc, and did not want to know anything about it. Those days are over and the patient is now well informed and wants to know what you are going to do, usually in some detail, and what the outcome will be and what would happen if he did not have the operation, etc.One does, however, have to keep a sense of proportion about this, and I think the American way of giving a list of every possible complication starting with death is over the top, but presumably necessary in the litigious climate that prevails there.

Most of us will have experienced a member of their family or even themselves having been a patient and you can appreciate from the patient's point of view how difficult and irritating things can be. For instance, a long wait to see doctors or get drugs to take home, not being able to park and so on, are common place. We really could do more to consider the patient's convenience. Liaison with nurses to let you know when a patient is ready to be seen rather than just turning up at our convenience having been sitting at a desk for an hour or so would go a long way to making things more bearable for our patients.

Imagine the frustration of a young adult with congenital heart disease who may have had several operations and has a pile of notes 6 inches thick. Every time he comes to outpatients he sees a different registrar who has little time to discover the story from the notes and is not much use to the patient who probably knows much more about his condition anyway. If only, as in the USA, there was more time to see the patient, do an echo and see the same consultant each time. We estimate that just to do this for adult congenital heart disease would need at least another 20 suitably trained cardiologists. The number of adult patients with congenital heart disease is likely to increase from 110,000 to 140,000 by 2010, so we will need even more cardiologists and they will refer the patients for more operations.

Because of inadequacies in the system and the wish to fill every bed, cancellations are inevitable. There were 80,000 operations cancelled last year in the UK up 29% from the previous year and this is probably a considerable underestimate. It is frustrating for us knowing that when there is a cancellation, theatre space etc, is being wasted, but it is far worse for the patient who may have been waiting more than a year for their operation and who has made a lot of arrangements. I personally go and see every patient on my list who is cancelled, I think it is the least we can do.

Although we probably all think we are doing our best to avoid cancellations, we almost certainly can do better. Booking patients too far ahead probably makes them more likely to be cancelled. Booking at short notice may be inconvenient for the patient, but they are so pleased to come in that they usually will. However, to give someone who has been on a waiting list for a year, 24 hours to come in seems unreasonable. Communicating more with the patients and having a co-ordinator to organise admissions helps. The co-ordinator must liaise with the surgeon regarding what can be done within the time constraints on any operating list, bearing in mind training, fast tracking, likely space in ITU, the length of operations, etc.

When things go wrong, although the complaints procedures are now fairly standardised, patients should be compensated quickly and there should be a no fault system, which should not drag on for years, enriching the lawyers. We should, however, have systems in place to ensure the least possible chance that anything can go wrong. If some accident happens, for instance, a problem with perfusion apparatus, this should be circulated to every unit so that they can avoid the same problem. One should certainly learn from ones own mistakes, but it is better to learn from the mistakes of others.

Several booklets have been brought out regarding good medical and surgical practice, but sadly suspension of consultants is all too common and has apparently increased by 50% in the last year. More than 100 surgeons are currently suspended, some of them cardiothoracic. There are always two sides to the story and a surgeon may feel that he has been unreasonably suspended by an over zealous management, whereas the management side may see the surgeon as having liabilities involving patient safety and litigation costs. Instead of getting together and discussing things at a local level, there is often a quick fire suspension which then may drag on for even years. The Royal College Rapid Response Team has been very useful, but is now being superseded by the National Clinical Assessment Authority. However, we can look forward to a most interesting session on this subject in two days time.

It is not only individual surgeons who have been under fire. There has been a spate of inquiries into hospitals, two of which produced reports the size of telephone directories.

Events at Bristol have had profound effects, not only on cardiac surgeons, but on medicine in this country as a whole and I therefore feel I must mention it. We all know the events leading up to the Kennedy Report on Bristol and some of us may have had time to read the over long report of this £14 million inquiry. There were failings at Bristol and we must all learn from them and make sure that they never happen again. However, as is so often the case in the NHS, it is the story of hard working, dedicated people striving to provide the best for their patients with inadequate resources. Rather like the captain of a ship, the surgeons got the blame, but it is amazing how little the report has to say about the other members of the team. There were 198 recommendations, many of which are sensible and have already been addressed. However, some are rather far fetched.

Probably one of the most important messages to come out of the Kennedy report is that there should be one comprehensive data collection system and it must be adequately funded. No doubt these results will be available to all and this will probably result in better outcomes at the expense of the sickest patients not being offered surgery. Alan Milburn, our Secretary of State for Health, thinks otherwise. It may be that in our inadequately funded health service, this is the preferred form of rationing. We have all seen the desperately ill emergency patient who staggers through the post operative phase, staying three to four weeks in the intensive care room, only to go home and die within three months. Perhaps it would have been better if he had not had an operation.

I was interested to see that in his response to the Bristol Report, Alan Milburn did not agree with all the recommendations. After discussions with Roger Boyle and our overworked secretary he announced that surgeon specific results would be published for the 2 years beginning this April and subsequently on a rolling 3 year basis. There are reasons for and against this and we will have an opportunity to discuss it in 2 days time.

It is so important to consider casemix and results should be risk adjusted. Also we should consider not only early mortality, but near misses, morbidity, long term follow up, etc, and perhaps we should be looking more closely at the deaths to see which could have been prevented. So often there is more than one factor.

I imagine all cardiothoracic surgeons keep their own logbook of operations. Some units have always produced annual figures. Terence English and I used to exchange Papworth and Southampton figures for some years and then he introduced the UK annual figures in 1977. The Australians had had an annual register for some time before that. The UK Registrar, though criticised, particularly in the Kennedy Report, was the first of its kind in the UK and we have been far ahead of other specialties. Its main weakness is that it has not been validated and is often filled in retrospectively by disinterested registrars. Few units have had salaried staff to collect the data. Some units failed to return in some years. However, overall it has been a pretty good record and showed trends from year to year. In exchange for publishing surgeon specific data, Bruce Keogh extracted a promise from Mr Milburn that "he would ensure that all Trusts in England provide the infrastructure for collection of data including software and data managers.

About 20 years ago I wanted to computerise our own results and asked John Kirklin for his advice. He said keep it simple, as long as you know the name and number of the patient, what operation they had, when they had it and the outcome, if you are going to go back and look up a group of patients, you will still have to get the notes out anyway. So I took his advice and we set up a computerised programme for our own results and back dated it to 1972 and this has been extremely useful over the years. If ever I was going to a meeting and saw an abstract quoting some figures, I could just get our own relevant figures in a few minutes for comparison.

However, this has now been eclipsed by the Adult Cardiac Surgical Database Report, produced by Bruce Keogh, and nearly all units in the UK contribute. As soon as everybody contributes, which should be April this year, we can drop the register altogether. At the same time, the paediatric results have been collected by the Central Cardiac Audit Database and we have already dropped the paediatric register as all the paediatric units have contributed their results and in fact the results for the year ending last March will be published in unit specific form shortly. There now seems to be a real commitment by the Department of Health to fund this data collection and it is absolutely vital that this is adequate and there is one good source of information.

As you know, we have been moving towards publishing unit specific data quite rapidly and spurred on by the threatened publication by Dr Foster of the coronary artery surgery league table last November, the Society decided to publish the overall results and unit specific coronary surgery results at the same time on our website. We have since published the results for aortic valve replacement with and without coronary artery bypass grafting.

One of the problems that has been difficult to overcome in this data collection exercise, is patient confidentiality and the Central Cardiac Audit Database (CCAD) has gone to great lengths encrypting data to avoid this, but of course if you want to follow patients up, you need to know the NHS number to ask the Office of National Statistics (ONS) whether the patient is still alive, so we cannot have it both ways. Fortunately the Government seems to be seeing sense on this and particularly with regards to the paediatric results, David Cunningham of CCAD, who has collected all the results of all units for the last year, is able to cross-check on mortality and hopefully in due course get actuarial survival as well. However, by checking with the ONS he has discovered that a number of deaths were initially unreported. Some may have been babies with PDAs who were discharged to different hospitals and may well have died of non-cardiac causes.

The benchmark results submitted with the annual figures are checked by the secretary and if any surgeon's results are outside the 95% confidence limits, these are referred to the president who would then contact the surgeon in question and ask him to check his results and if indeed there was a problem, try to discuss it and involve the Chief Executive if necessary. As you know, the Dr Foster report showed Walsgrave at the bottom of the isolated CABG league table. In fact, I had already looked into this and the results at Walsgrave had already improved very considerably and their mortality for isolated CABG is currently 1.2%. This was reassuring to them and very helpful when it came to encountering a somewhat hostile Press.

The elegant methods with cusums, VLAD plots and so on of analysing surgical results are well detailed in Bruce Keogh's Adult Cardiac Surgical Database Report and we should all be able to check our own results by such methods.

I personally am for keeping databases fairly simple, because in my experience, the more you ask for, the less likely you are to get all the answers. I collected the numbers of congenital cases performed in Europe in the year 1995 from the 20 biggest countries and just to get the actual numbers, without mortality was extremely difficult.

With regards to training, surgical exams seem to have changed considerably in recent years, but are now reasonably set and at least the trainees know what they are in for. I think one of the most difficult stages is the jump from SHO to getting a numbered registrar post. Perhaps extra senior SHO jobs followed by some research and a LATS post may increase the candidate's surgical experience and add a higher degree to his CV, but inevitably there are more good people applying for NTN posts than there are posts available and how do you make yourself more attractive for these.

There is a working group chaired by Professor George Bentley, Chairman of the Training Board, that is looking into all this. It will probably suggest that SHO training should be three years, with the MRCS taken after two, and higher surgical training should be six years. There also seems to be a recommendation to bring back parallel operating lists, but with proper supervision.

I personally feel it is a shame to go and do the research too early as you may well do it in something that you never use again, but if you come to an NTN interview and everybody else has got a higher degree or done the work for it, you might be at a disadvantage, even if you have done 100 open heart procedures compared with their 10. I think we all had misgivings about the Calman training system, but it seems to be working and in that there is an increased need for cardiothoracic surgeons, presumably our specialty will be able to find consultant posts for all going through it. We must remember, however, that being a registrar is an apprenticeship. Gone are the days of long hours and huge experience of the senior registrar. The restriction on junior doctors hours is already making it difficult for trainees to get enough time in the operating room where they are actually going to learn the trade. It is vital that the consultant takes the trainee under his wing, increasingly giving him more to do, working up until the trainee can do the operation with his assistance and then eventually on his own. I really think this is an area where we can do better. With the pressures on us to do more operations, it may be tempting for the consultant to do operations himself, particularly now with the degree of interest in getting good results. However, although obviously it depends on the experience of the registrar, we should try to give him the best possible training while guarding patient safety and achieving the appropriate throughput.

Gone is the time when the senior registrar would operate in one theatre with the consultant in the other theatre. To make matters more difficult for the trainee surgeon, much of whose training will involve coronary artery surgery, the cardiologists are creaming off the more straight forward patients for angioplasty and stenting. This graph (from the Wanless report on future funding of the NHS) shows that although coronary artery surgery is still increasing, the increase in angioplasty and stenting is dramatic. With the new drug eluting stents that are to be introduced shortly, the stent results should be even better, and the cardiologists may increase their activity further. However, there should still be plenty of work for the surgeons. Interestingly the graph shows the slight down turn in CABG numbers that Jules Dussek pointed out two years ago which was so hotly denied by the Department of Health.

The introduction of wetlabs and surgical skills courses has been a major advance and anything we can do to train our young surgeons on surgical techniques before they are let loose on patients must be good.

There is now a proposal to set up a Medical Education and Standards Board (MESB) to replace the Specialist Training Authority (STA). There would probably be 25 members of the board and as many as half, including the chairman, might be lay. The medical membership would probably include GPs and psychiatrists. The MESB would control all postgraduate education and the assessment and certification of both GPs and hospital doctors. The board would be accountable to the Secretary of State, opening a possible conflict of interest between responsibilities for training and service provision and it is likely that service provision would take priority.

If this proposal was fully implemented it could do considerable damage to postgraduate training programmes in surgery. The Senate has discussed this and is trying to ensure that the colleges and specialist associations are involved and that it should be independent of Government and answerable to Parliament.

When it comes to appointment as a consultant, our system does seem strange. Usually the candidate will visit the unit and speak to some or possibly all of the future colleagues and will then come for an interview. This seems a very superficial assessment compared with industry, where for even quite junior jobs, there may be at least three interviews, some lasting all day. Should we have arrangements for future possible colleagues to go and watch candidates operating. Clearly a surgeon could be appointed without anyone having a good idea whether they could operate or not. Obviously you get references, but some people maybe less forthcoming about deficiencies in their registrar's operating ability, particularly if they have been looking for a job for some time.

There is no place now for learning curves, and a new surgeon must be expected to achieve good results from the start. His colleagues must help by shielding him from the most difficult cases to begin with, and mentoring as necessary.

The whole thing is based on team work and communication. A new consultant must fit in with the team, as indeed must all the members of the department. Sadly I have been involved in enough disciplinary matters in the last two years to know that there are still many colleagues who do not get on and thereby jeopardise the smooth running of their departments. Most consultants work far in excess of their NHS commitments and the idea in the NHS Plan that new consultants would not be able to do private practice for 7 years certainly provoked outrage. This seems to have gone very quiet since then and maybe it is being rethought. However, if junior doctors' hours have been limited, the European Working Time Directive will also affect the working hours of consultants and indeed if extra hours are being spent over and above one's NHS commitment in private practice, the health and safety regulations may be a problem, rather like airline pilots not being allowed to fly longer than a certain number of hours. Reappraisal and accreditation are already upon us and it is not unreasonable that checks should be made to see that we are continually fit to practice.

There has been a significant increase in the number of cardiothoracic surgeons in recent years and one of my duties has been to check the job description and find a college assessor for each appointment. There have been 30 appointments of cardiothoracic surgeons in the last two years.

One of the chief worries is the lack of thoracic surgeons. If we are to get up to the percentage of resections of carcinoma of the lung undertaken in Europe, it has been calculated that we need 40 more thoracic surgeons. Although a few thoracic registrar posts have been created, we need to attract far more people into this specialty. The recent paper produced under the chairmanship of Professor Treasure has helped to guide us but unless oesophagectomies are to become the domain of the upper GI surgeons and more lung surgery is to be performed by cardiothoracic surgeons, a major rethink has to happen and soon. How do we encourage our young trainees to become thoracic surgeons? Are there suitably trained surgeons from abroad to fill these posts? Perhaps Magdi Yacoub will find some.

I was pleased to see that in response to the Society's joint report with the British Thoracic Society, chaired by Professor Tom Treasure, and the accompanying BMJ editorial by Professor Partridge, the Department of Health has said that respiratory disease in older people would become an NSF priority. Also there would be additional consultant and training posts.

With regards to continuing professional development, it is very important that we keep up to date and go to meetings. Presenting papers not only improves the CV, but makes us look into various subjects in depth and the general discussion educates us all. However, we should not have to pay from our own pockets to go to these meetings. Sadly study leave reimbursement is mostly inadequate and there has to be a sound and legal way of us being reimbursed. Frankly, there are so many meetings that we could go to one every week and perhaps more should be done via the internet.

Research is by and large clinical or laboratory and laboratory research is more likely to be undertaken by younger people trying to get a higher degree in order to improve their CVs which in turn may help them to get a better job. Clinical research is likely to be undertaken by all of us throughout our professional careers. It used to be rather easier to undertake new techniques, but now everything has to go through an ethics committee, which requires tedious form filling, and some of the things that were done even 30 years ago which proved then to be major advances, would just not have been done. There are good examples in this meeting of randomised controlled trials, for instance, should we have our coronary artery surgery off pump or on pump, should you have an IMA graft to an isolated LAD lesion or have an angioplasty and stent, should all our grafts be arterial, etc. It is very difficult to compare things as there are so many different factors that affect us. I remember attending the AATS meeting in Boston in 1979 and someone was discussing internal mammary artery use and the chairman asked for a show of hands in the room as to who was using the IMA and of about 1000 people in the room, only three hands went up. Five years later everybody was routinely using the IMA. However, veins can still look good even 20 years later as in this picture, and other factors such as run off are important. However, laboratory research will help us understand what makes vascular grafts occlude and how we can prevent this and the enormous potential of gene therapy is yet to be realised.

With regards to communication, I really feel this is one of the most important things in our lives and if only there was good communication throughout the world, it would solve so many problems. The IT explosion, and particularly the CTS Net, have done so much to help us. I assume that everybody in the Society has an e-mail address and if only they would put it on the CTS Net, it would be so helpful and assist in contacting people.

I came rather late on to the computer scene, but the last four years would have been impossible without e-mail, which I seem to have conquered. However, the more complicated aspects, such as powerpoint are more challenging and I am very grateful to my colleagues who have helped with this presentation.

Another effect of the Bristol Inquiry was that the Department of Health set up a committee to look into the future of paediatric and congenital cardiac services in the UK. I have been Co-Chairman of this committee which consists of representatives of all units undertaking paediatric cardiac surgery and all disciplines related to it. This has been an extremely difficult task, but we will make recommendations to the Minister of Health shortly and it remains to be seen what action is taken.

With regards to the media, who have been very unfriendly to doctors in recent years, I get the feeling that we have done a bit better lately possibly because the media are realising that the deficiencies in the NHS relate more to lack of money than bad doctors. It certainly does not pay to be confrontational. I became rather involved with the media when the Bristol Report was published and with the help of the Royal College of Surgeons' Public Relations Team, this was much less formidable than I had anticipated.

What of the future. Surgeons will no doubt try to do more difficult things through smaller holes. The use of robotic surgery may increase, though its expense and cumbersome nature may limit this. Undoubtedly surgery with cryoablation or possibly more sophisticated ablation techniques will increase dramatically for the treatment of atrial fibrillation. I think that with regard to the treatment of heart failure, the insertion of permanent assist devices as used by Westaby in Oxford will probably be the way to go, particularly when the power supply problems have been overcome. In 10 years time it will be rather like putting in a pacemaker.

However, if only we could overcome post operative atrial fibrillation and renal failure, it would be a major advance.

All work and no play makes Jack a dull boy. We all work far too hard and it is important that we find time to see our families and use our spare time enjoying ourselves.

In conclusion, I think we can do better. We mustn't be arrogant or neglect our patients. We must be considerate and reassure them that we are competent and will do our best for them. We should be decisive but not over confident. We should explain the reason for the operation and what is to be done and give the risks, based on our own results, and wider figures. We must ensure that we have been adequately trained, are well informed and have a good team. We must audit our results carefully and ensure that they are as good as possible. To do this we must have appropriate facilities and supporting staff and the government must give us adequate resources.