The past decade has seen an increasing number of publications linking improved surgical outcomes with increased surgical volume.

But most of our hospitals are not set up as specialised centres concentrating on a small number of highly specialised procedures.  Instead, most Australian hospitals perform a wide range of surgeries catering to the local population whose needs are varied.

Is it therefore worth a patient driving a few more kilometres to a hospital that specialises in the procedure that they need?  The published literature would suggest that this is worthwhile.

It is not just the technical expertise of the surgeon performing the operation that offers benefit; it is the support staff as well that make a difference in surgical outcomes.  If the staff are experienced and aware of all the possible complications that could occur from this type of operation, and have seen multiple cases, then they are prepared for complications.  They can act more quickly and know the signs to look out for to possibly prevent any serious complications from even occurring.

There are multi-disciplinary teams of doctors who are involved in larger surgical cases.  These doctors include radiologists, pathologists, oncologists and surgeons who meet to devise the best treatment plan for individual patients.  If these multi-disciplinary teams specialise and experience high volumes of similar cases, then the patients should experience better outcomes.  These multi-disciplinary teams are located in the larger metropolitan hospitals, so currently many country patients are referred to these large city hospitals for major operations to experience the best outcomes.

But what if these city hospitals start specialising in their strengths and focusing on high volume procedures?  The recent medical literature would suggest that the patients benefit.

Unfortunately it is very difficult to change current surgical practices for many reasons.  The current referral patterns and resistance by surgeons to change their “patterns” of work especially how they operate in private practice all make it politically difficult to change to centralised operative care.  The training of surgeons will also need to change if centres of specialisation are to be achieved.

Surgeons would also need to give up certain surgeries in order to specialise even further.  There is resistance by many in the profession to do this.

One way to ensure that specialist centres who perform low volumes keep up their skills to maintain the best outcomes for patients, is to have members of the surgical team spend time working in other centres that specialise.  If the staff are well trained and experienced in their specialty surgeries then the best outcomes are maintained even if they are low volumes centres.

Health care costs are rising across the country.  If more hospitals are specialising in complex cases and there is Centralisation of Care, the costs can decrease.  Specialised centres can accurately identify whether a patient needs a costly procedure or not, therefore saving money and unnecessary discomfort for the patient if their expertise can offer some other sort of treatment.  The costs of serious post-operative complications can also be kept to a minimum with specialised care.  Even having very expensive specialised equipment located in fewer hospitals will make sense financially, as well as highly skilled staff and research facilities in fewer centres throughout Australia.

Evidence exists to support such initiatives and egos, politics and tradition should not stand in the way of demonstrated improved patient care and outcomes.

Guy Maddern, RP Jepson

Professor of Surgery, MBBS, MS, MD, PhD, FRACS
University of Adelaide, Discipline of Surgery,
The Queen Elizabeth Hospital,
Adeladie, SA, Australia

Publication

Appropriate Centralised Care – the Next Surgical Challenge.
Maddern GJ
Heart Lung Circ. 2015 Sep

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