RCoA response to ‘Who Operates When II’

The Royal College of Anaesthetists (RCoA) welcomes the 15th Annual Report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and endorses its key recommendations. The RCoA notes that the recommendations are reflected in those of other expert bodies of opinion. Each recommendation of NCEPOD is listed with the RCoA's comment.

Recommendation 1
Revise NCEPOD classification to include more specific classification and guidelines, which are relevant across surgical specialties (NCEPOD responsibility).

The RCoA welcomes this and has responded to NCEPOD’s consultation process.

Recommendation 2
Ensure the correct ASA physical status is collected as it is an essential part of the patient assessment and record keeping.

The RCoA1,2 and others whose remit includes setting of standards,3,4 support the use and recording of ASA physical status, the most commonly recognised tool for anaesthetists to grade patients’ overall condition.

Recommendation 3
Nominate an arbitrator who would decide the relative priority of theatre ‘cases’ in order to avoid queuing for theatre spaces.

Shortfalls of facility and more especially of staff compromise theatre efficiency.5 Clinical priorities should be ultimately decided or agreed by a medically qualified consultant.

Recommendation 4
Ensure that systematic clinical audit includes the pattern of work in operating theatres.

The RCoA supports this both in overall6 and specific areas.7

Recommendation 5
Assess the competency of staff grade and ‘trust’ doctors and take this into account when allocating anaesthetic and surgical sessions.

Irrespective of the grades of staff that deliver anaesthetic services, competency should be assured4 by training and by continued professional development.8 The competency of locum staff must be carefully examined and a mechanism for their quality established.9

Recommendation 6
Review guidance on which staff should anaesthetise and operate on day case patients.

The RCoA endorses this; Day case surgery should be a consultant based service with the majority of service provided by consultants;1 if there is a gap between guidance and practice, one or both need to be reviewed.

Recommendation 7
Review the level of supervision of trainee anaesthetists working on their own in dedicated day case units.

As a logical extension of ‘Recommendation 6’ it follows that the RCoA supports this. Dedicated day care surgery units may be isolated from the main buildings of hospitals. The more complex operative and anaesthetic procedures now being performed in day care units mean that the needs of patients can only be met by either trained anaesthetists or by trainees of adequate seniority who have rapid access to consultant support.

Recommendation 8
Debate whether in the light of changes to the pattern of hours of junior doctors’ working, non-essential surgery can take place during extended hours.

The RCoA welcomes debate. However, the matter of trainees ‘hours of working’ is only one of many things that should inform this debate. The matter of hours during which it is sensible for elective surgery to be safely preformed is more important. Many hospitals already work during extended hours and any debate must be intelligently informed by a clear understanding of what extended hours means. Early morning or early evening operating is not to be confused with late evening work that might then extend into the night. Elective surgery proceeding into times when there is only limited back-up from wards, laboratories, X-ray and general support5 does so with compromise to safety. Overnight surgery adds to this the impairment of performance to which night- time workers may be subject. The only clear arguments for trainees to work overnight are when their service obligations to the emergency service so dictate, and to understand the difficulties under which hospitals work at night.

Recommendation 9
Provide adequate information systems to record and review anaesthetic and surgical activity.

The RCoA7 is not alone in supporting this concept.5 An apparent shortfall identified by NCEPOD in many hospitals’ systems needs to be corrected.

Recommendation 10
Ensure that the information about hospital facilities is accurate in order to ensure that acute services are efficiently and safely managed.

Services need accurate information to enable their safe and efficient management (see also response to Recommendation 9).

Recommendation 11
Ensure that Strategic Health Authorities together with NHS Trusts collaborate to guarantee that all emergency patients have prompt access to theatres, critical care facilities and appropriately trained staff, 24 hours a day, every day of the year.

The RCoA supports this.4,5,10,11

Recommendation 12
Ensure that all operating theatres have sufficient numbers of trained recovery room staff available whenever those theatres are in use.

The RCoA supports this.4,6,12

Recommendation 13
Provide regular resuscitation training for all clinical staff, which is in line with Resuscitation Council guidelines.

The RCoA supports the Resuscitation Council’s guidelines.13

Recommendation 14
Ensure that all recovery bays have both a pulse oximeter and ECG monitor available. This applies whether (sic) patients are having local or general anaesthesia or sedation. The equipment used in recovery areas should be universally interchangeable and able to provide a printable record.

The RCoA supports this.6,12

Recommendation 15
Ensure that all essential services including emergency operating rooms, high dependency and intensive care units are provided on a single site wherever emergency/acute surgical care is delivered.

This should be the standard for care of ‘surgical’ patients.14

John Curran
Past Chariman, Professional Standards Committee, September 2003


1 Good Practice. A Guide for Departments of Anaesthesia. RCA & AAGBI, London 1998.
2 The CCST in Anaesthesia II. Competency Based Senior House Officer Training and Assessment. July 2000.
3 Risk Management. AAGBI, London 1998.
4 Clinical Standards: Anaesthesia – Care Before, During and After Anaesthesia. July 2003. NHS Quality Improvement Scotland.
5 Acute Hospital Portfolio: Operating Theatres. Audit Commission 2003.
6 Guidelines for the Provision of Anaesthetic Services. RCA 1999 (under revision).
7 Departmental Portfolio. Joint Committee for Good Practice. AAGBI & RCA 2002.
8 Cooper C. Personal Development Planning for the NCCG Anaesthetist. RCoA 2003.
9 Cover story. The use of locum doctors in the NHS. Audit Commission 1999.
10 Comprehensive Critical Care. A review of Adult Critical Care Services DOH 2002.
11 Standards for Intensive Care Units. Intensive Care Society 1997.
12 Immediate Post Anaesthetic Recovery. AAGBI, 2002.
13 Cardio-Pulmonary Resuscitation. Guidance for Clinical Practice and Training in Hospitals 2000.
14 Provision of acute General Hospital Services. Royal College of Surgeons, London 1998.


01 September 2003