MODERNIZATION OF PAEDIATRIC SURGICAL SERVICES

Index:

  1. Introduction 
  2. Future scanning 
  3. Likely epidemiological, demographic and socio-economic impacts on need and demand for services in these specialities 
  4. Given the developments described above, and the services currently being delivered in these specialities which activities should be prioritised for additional investment and development? 
  5. Quality of care 
  6. How can these problems be addressed 
  7. Access to Services / Disparities in access 
  8. Efficient use of Resources 
  9. Which current practices (clinical and organizational) could be amended to improve efficiency without compromising patient safety or outcome 
  10. Education and Training 
  11. Public / Private interaction 
  12. Organization of Services 
  13. Overview = Paediatric Surgical Services around the RSA 

MODERNIZATION OF PAEDIATRIC SURGICAL SERVICES

Invited speakers: Professor GI Ionescu, Professor P Hartley, Dr D Sidler, Dr Saczek, Dr Mareiz, Ms Conner, Prof M Davies, Prof P Beale, Prof Prescott, Dr G Fieggen, Dr Breckon, Prof H Rode, Dr Hewitson, Dr R Grotto, Prof T Hoffman, Dr L Jee, Prof S Moore

Attended: Professor M Davies, Professor H Rode, Professor S Moore, Dr G Fieggen.

Professor Alastair Millar participated in the Transplant session at this meeting.

  1. Introduction

Perhaps the most significant advance associated with the surgical care of children during the past century has been the realization that "children are not small adults". Rather children develop distinct surgical conditions, present unique anaesthetic challenges and have special peri-operative needs. However, paediatric surgery has been viewed as too expensive and as a non-essential service, and has been excluded from many child health programmes.

Why is PS not simply a luxury that South Africa can ill afford?

Fully established services will:

CHALLENGES FOR PAEDIATRIC SURGERY

The challenges for paediatric surgery in a developing country are those of definition, policy and delivery.

Definition:

  1. Paediatric surgery is a branch of Child Health that encompasses a wide range of surgical disciplines. There are broadly two major groups:

  1. Health Care Policy. In general terms South African Health Care policies do not reflect the surgical needs of children. It is an essential component of basic health care, but due to lack of national and international recognition and policies, it has failed to progress. What is urgently needed is the formulation of a comprehensive action plan containing specific goals and outcome.

  2. Delivery of surgical services/Access to Surgical Care. The issue is not whether children can receive surgical care but whether children in general have access to appropriate services.

Long distances from the hospitals and prohibitive transportation costs prevent the timely treatment of paediatric surgical conditions. Conditions deteriorate leading to increased operative risks and mortality.

In many areas in South Africa there are limited facilities, equipment, human resources and drugs. Medical facilities at primary and secondary levels are often inadequate. Many facilities have poor diagnostic capabilities or none at all. As a rule, laboratory, histological and radiological facilities are only available on a limited basis. Equipment for carrying out anaesthesia and surgery is often deficient and facilities for sophisticated postoperative care are frequently minimal. Insufficient beds, shortage of surgical supplies and operating theatres and time often dictate that only urgent or emergency surgery can be performed.

Furthermore there is a chronic shortage of paediatric surgeons in South Africa of who many are within 10 years of retirement. Only a few South African surgeons are in paediatric subspecialty training. This situation is further compounded by the fact that paediatric surgery or any of the paediatric subspecialties are not recognised as a distinct speciality by the Health Professions Council of South Africa.

It is estimated that 70% of children’s operations in the UK are performed by surgeons who are not specific paediatric surgeons. In RSA the proportion is undoubtedly higher. The notion of the child as a small adult together with a brief encounter with the discipline during basic training emboldens many general surgeons to undertake surgery on children.

Paediatric Surgical Services - Demographics

 

JHB

Pretoria

Medunsa

OFS

TBH

RXH

Natal

ECape

Established

1968

1960’s

    

1966

1956

1978

1999

Accredited

1983

      

1985

1983

1985

1999

Professors

2

1

    

1

2

1

  

Consultant. Staff

4

1

    

2

4

2

5

Number of trainees

27

2

    

3

68

12

1

Paediatric Hospital

1923 1978

      

2001

1956

1931 1984

  

Beds

102

67

    

40

93

25

65

Operations

1960

1040

    

1200

5361

827

700

Research factors

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

In a recent survey, 60% of South African General surgeons recognized that they were not adequately trained to operate on children and would benefit from further training. The current ratio of Paediatric surgery to population in South Africa is 1:4 million of the population is compromised to accepted norms of 0.5 – 1 million of the population.

Spectrum of surgical operations performed currently by South African surgeons. Only a minority are trained paediatric surgeons, indicating that a large number of paediatric surgical conditions are still being performed by adult general surgeons

Of concern here is the rapid expansion of the private sector and pressure to treat patients locally may make non-paediatric surgeons feel obliged to enter the paediatric field without adequate training or facilities.

The current status in South Africa is for the majority of older children to be treated by trained general surgeons (the FCS final examination has a paediatric surgical component allowing successful candidates to register with the Health Professional Council as general surgeons with paediatric surgery accreditation)

  1. Future scanning

South African paediatric surgical care is based on universally accepted principles. Likely developments within the speciality over a period 2002 – 2010 as well as beyond include:

  1. Expansion of paediatric surgical services at primary, secondary and tertiary levels.

  2. The development of paediatric subspecialties in:

  1. A paradigm change towards minimally invasive and endoscopic surgery and techniques (nano technology).

  2. Foetal assessment, diagnosis and interventions.

  3. Consolidation of quaternary services (liver, cardiac transplantation, nanoneurosurgical procedures and oncology).

  4. Development of comprehensive paediatric trauma centres.

  5. Development and expansion of day care and ambulatory surgery Theoretically 40-60% of paediatric surgical procedures could be done o this basis. The worldwide trend is to perform more surgery on a day case basis and increasingly as part of outreach programmes (i.e. 70%, in New Zealand).

  6. Development of a Fellowship and full speciality in these disciplines and consolidation and enhancement of career pathways.

  7. Maintain close contacts with developments in adult surgery and paediatrics.

  8. Surgical outreach programs, especially in rural areas.

  9. Educational programmes.

  1. Likely epidemiological, demographic and socio-economic impacts on need and demand for services in these specialities

  1. Approximately 45% of the South African population in younger than 15 years.

  2. Urbanization of families and women electing to have their babies in urban areas.

  3. Consequences of poor surgical care: Inadequate care has tragic consequences. The input on child health remains poorly defined, but it is likely that poor surgical care contributes significantly to the high disability rates in South Africa.

  4. The high incidence of trauma, infections, malignancies and congenital abnormalities amongst the children of South Africa. The estimated cumulative risk for all surgical conditions in 85% by the age of 15 years. A significant proportion of children living in urban areas will require surgical care at some time during childhood.

  1. The Aids pandemic will have a major influence of paediatric surgery i.e. resource allocations, treatment programmes and outcome. New diseases and more frequent postoperative complications are seen. The total future input cannot be determined at present, but undoubtedly will have a profound influence on disease profiles, complications and economics of health care. Consensus was reached that ART must be available if major interventions are being undertaken.

  1. Given the developments described above, and the services currently being delivered in these specialities which activities should be prioritised for additional investment and development?

  1. Complex surgery on all children under 6 years of age including complex surgery in all the paediatric surgical subspecialties (Plastics, ENT, ophthalmology, urology, orthopaedics and neurosurgery)

  2. Oncology (Aim to have all children treated in HSS Units:

  3. Major trauma including burns; better outcome and revenue generation

  4. Epilepsy surgery (1 National Unit)

  5. Other functional neurosurgery such as rhizotomy linked to existing paediatric neurosurgical services.

  6. Craniofacial surgery (2-3 units)

  7. Liver transplantation (1 unit)

  8. Cardiac transplantation (1 unit)

  9. Chronic illnesses with surgical component or with disabilities.

  10. Minimal invasive surgery

  11. Development of ambulatory services – Fully staffed and equipped.

  12. Training and career development for younger Colleagues

  1. Quality of care

Shortcomings and limitations in quality of care.

  1. Lack of comprehensive vision for paediatric surgery. It is predominantly located at main centres and academics complexes.

  2. Deficient infrastructure at primary and secondary level.

  3. Implosion of academic and tertiary facilities due to budgetary restraints, personnel shortage.

  4. Financial restrictions. Government policy of redistribution of financial resources.

  5. Resource constraints such as ICU beds and anaesthetic paediatric services.

  6. Personnel: Restricted development of career pathways for medical and auxiliary staff

  7. Deprivation of new technological advances due to a high cost and inadequate equipment budget.

  8. Acute nursing shortages responsible for overall reduction in available beds and services.

  1. How can these problems be addressed

Health policy in South African cannot reflect the surgical needs of children, until there is data demonstrating that paediatric surgical diseases are a significant public health problem. There is a major need for data on the epidemiology of paediatric surgical diseases, the morbidity and mortality associated with poor surgical care and the cost of surgical services. This information can be expected to become increasingly important as evidence based methods are used to a greater extent in the allocation of resources.

  1. Maintain and expand existing paediatric surgical services. They have the basic infrastructure and should not be allowed to deteriorate further both in personnel and infrastructure. This has important financial consideration and implication.

  2. Define a cost effective package of paediatric surgical care, for both preventative and curative services. The package must include injury prevention, simple protocols for the management of uncomplicated paediatric surgical problems and criteria for referring children to secondary and tertiary services.

  3. Improve paediatric surgical care at the community level. It is vital to bear in mind that primary care can only success if supported by an efficient and reliable referral system with an infrastructure extending from the primary to the tertiary level.

  4. Amalgamate highly specialized services i.e. liver and cardiac transplantation, endoscopic neurosurgery, oncology and major trauma.

  5. Strengthening paediatric surgical education, both at under and postgraduate level.

  6. The creation of additional paediatric surgical services in the Provinces of Limpopo, Mpumalanga and North West. These could be at a secondary level – but must have a functional infrastructure and all supporting services.

  7. Foster and expand interaction between paediatric surgery, paediatrics and all other surgical disciplines.

  1. Establish a Fellowship in paediatric surgery and full specialization with the Heath Professional Council.

  2. Develop ambulatory and day care surgery to take care of >50% of paediatric surgery.

  3. Develop Telehealth and Telemedicine.

  4. Improve Private/Public interphase

  1. Access to Services / Disparities in access

  1. Paediatric surgical services are concentrated at tertiary facilities and large regional secondary hospitals. Hence the rural paediatric population and those not living in close proximity of established paediatric surgical facilities are disadvantaged.

  2. Rapid and effective transport systems are insufficient or not functional and it is common to final delays in transport of patients exceeding 7 days. Early diagnosis, resuscitation and transfer remains most problematic

  3. It would be very difficult to establish Paediatric Surgery services at multiple sites in South Africa without the required infrastructure. The latter must include appropriate surgical facilities, surgeons with an interest in Paediatric Surgery and with experience, equipment, high care or ICU facilities, trained nursing personnel, safe anaesthetic services, These are the minimum requirements.

  4. The South African Association of Paediatric Surgeons are not in favour of such proliferation of services for children in peripheral or rural areas. It would be more appropriate to upgrade existing services, improve primary and secondary care levels and back up with rapid and efficient transport systems / services.

  1. Efficient use of Resources

Serious obstacles to maximizing efficient use of resources have been identified.

  1. Infrastructure: Continued financial threat to tertiary care centres, maintenance of existing services.

  2. Manpower shortage – training facilities, case material, lack of career pathways.

  3. Finances, Inadequate funds for acquisition of modern technological advances i.e. endoscopic and minimal invasive equipment.

  4. Acute shortage of nursing personnel.

  5. Shortage of ICU beds and lack of dedicated theatre time.

  6. Paediatric surgical services – now predominantly service orientated with an acute reduction in pre and postgraduate teaching and research.

  7. Inadequate transport systems/services

  1. Which current practices (clinical and organizational) could be amended to improve efficiency without compromising patient safety or outcome

  1. Increased use of ambulatory services

  2. Shortened waiting lists

  3. Develop outreach programmes

  4. Outsourcing of services

  5. Educational programmes. Many outreach programmes to rural areas are being conducted on a regular basis with great success

  1. Education and Training

What are the service delivery requirements for effective education and training for the following groups within the sub-specialty:

  1. Medical - undergraduate MBChB V and VI

Intern/COSMO
Postgraduate  Registrars  Paediatrics
General Surgery
Surgical Sub-Specialties
Operating GP’s/MO’s

  1. Nursing - undergraduate, specialised, postgraduate

  2. Other (e.g. radiographers, specialists) – undergraduate, postgraduate

All faculties are involved in teaching at these various levels, although there is consensus of a progressive decline in the amount of teaching given to colleagues of other disciplines.

  1. Public / Private interaction

All registered Paediatric Surgeons in South Africa have at least a part-time affiliation to a Teaching Hospital and most Full-time Paediatric Surgeons do some RWOPS, hence there is very real interaction on a personal level.

RWOPS enables complex cases to be referred into the academic system for expert management. This relationship can be described as one of symbiosis.

Equipment is shared from time to time. Paediatric surgery is not a very equipment intensive discipline (although subspecialties may be).

Some units use imaging facilities in private.

  1. Organization of Services

  1. Each Province to have at least 1 to 2 specialized units

  2. At least 3 more regional Paediatric Surgical units to be developed.

  3. Responsibility of Paediatric Surgery fraternity to educate

  4. Use Telemedicine and Telehealth.

 

Regional Hospital

Provincial Tertiary Hospital

National Referral Centre

Which services to be provided

Basic + General Paediatric Surgery

All levels, core Paediatric Surgery

Organ transplantation (liver, heart)
Epilepsy
Craniofacial

Which personnel required

Surgeon/Medical Officer, Diploma in Surgery

Paediatric Surgeon
Consultants, Registrars, Interns

  

Which resources required (e.g. equip-ment, diagnostic facilities, inpatient & ICU etc)

Anaesthetic
Diagnostic
Paediatrics
ICU
Pharmacy

Comprehensive
All inclusive
All subspecialties

  

Which other linked/ supporting services/ specialties on site

Auxiliary services

All auxiliary services

  

Description of case-mix and referral system proposed by level

Basic

Basic + advance

  

Which teaching functions can be conducted by level

CME for staff

All levels

  

SUMMARY OF PROPOSAL

  1. development of Paediatric Surgical Services in second level hospitals

  2. improving career pathways

  3. improving nursing fraternity in terms of numbers and education

  4. adequate fiscal allocations

  5. outreach programmes clinics in rural areas/education programmes

  6. expanding ambulatory / day surgery

  1. Overview = Paediatric Surgical Services around the RSA

Geographic Area  Name  Sex  Race  Paediatric surg. training Comment

GAUTENG
Johannesburg  MRQ Davies  M  W  Full  Administrative duties only Professor of Surgery, Wits Medical School
P Beale  M  W  Full  Principle Specialist with busy private practice Johannesburg
G Pitcher  M  W  Full  Senior Specialist (trauma and paediatrics), Johannesburg
F Kalk  M W Principle Specialist, near to retirement. Baragwanath Hospital
J E Fonseca  M  W  Incomplete  Baragwanath Hospital Senior Medical Officer but de Facto Senior Specialist.
R Baniegal  M  W  Incomplete  Senior Medical Officer de Facto, Specialist, Baragwanath Hospital
Springs
W Saunders  M  W  Complete  General Surgeon in private practice – interest in paediatric surgery
B V Vuuren  M  W  Paediatric Surgery
PRETORIA
GI Ionescu  M  W  Full  Academic Head of Department Romanian Medunsa
M Marczek  M  W  Poland  Senior Medical Officer. Principal surgeon de facto
M van Niekerk  M  W  Incomplete  Private/hospital practice
NATAL
Durban  L Hadley  M  W  Full  Academic Head of Department
R Wiersma  M  W Full  Principal Specialist
Pietermaritzburg  O Fiersson  M W  Incomplete  Principal Surgeon, Pietermaritzburg
B Little  M W  Incomplete  Principle Specialist at Edendale Hospital – to transfer to TBGH to complete training.
P Cohen  M W  Incomplete  Private practice general surgeon with an interest in paediatric surgery

EASTERN CAPE SURGICAL SERVICES
Umtata  G Takie  M  B  Incomplete  Paediatric Surgeon at UNITRA
(Ghana & UK)  Single man practice
East London  C Lazarus  M  W  Full  Part-time Senior Lecturer UCT and Director of Eastern Cape Surgical Services
U Breckon  F  W  Full  Senior Paediatric Surgeon
Germany
M Chitnis  M  A  Incomplete  Senior Medical Officer
(India/UK)
Port Elizabeth  D Procter  M  W  Incomplete  Semi-retired
R Gonzales  M W Incomplete  Senior Medical Officer
(Cuba)  Will return to Cuba in 2001.
George  L Schoeman  F  W  Full  Private Practice
WESTERN CAPE
Red Cross  H Rode  M  W  Full  Head of Department
AJW Millar  M  W  Full  Principal Specialist
S Cywes  M  W  Full  Emeritus Professor currently 5/8 position, due to retire soon
A Numanoglu  M  W  Full  Senior Specialist
AB Van As  M  W  Incomplete  Paediatric Trauma Surgeon
L Jee  M  W  Adult  5/8, part-time Senior Specialist
Urologist With Paed Urology only Recent request to devote more time to private practice
Vincent Pallotti Private Hospital
RA Brown  M   W Full  Private Practice, Honorary Consultant at RXH
Tygerberg  SW Moore  M  W  Full  Chief Specialist, Head of Department Tygerberg Hospital
D Sidler  M   W Full  Senior Specialist
(Swiss national)
C Saczek  M  W  Full  Senior Specialist
ORANGE FREE STATE
Bloemfontein  SM Le Grange  F  W  Complete  Principle Paediatric Surgeon
A Laubscher  M   W Incomplete  Fulltime general surgeon with paediatric surgery interest

MPUMALANGA
Nelspruit  No paediatric surgical services
NORTHERN PROVINCE
No paediatric surgical services

NORTHERN CAPE
No paediatric surgical services
NAMIBIA
Windhoek  J Palmhert  M  W  Full  Combined Paediatric and General Surgery

Task group: Strand - October 2002

Addendum
Dr. R.H. Grötte

021 6585255
Fax 021 7940398

31 / 01 / 2003

Prof.Heinz Röde
Dept. of Paediatric Surgery
Red Cross Hospital

Dear Prof Röde,

I have read the document,Modernisation of Paediatric Surgical Services and have several comments.

There is nothing wrong with what the document says, the problem lies with omissions. This is obviously because people like me who should have been at that workshop never received the invitation that they were supposed to get.As I told you, to my surprise, I WAS invited to the second round and shall be attending in Durban.

As far as Paediatric Ophthalmology is concerned, (and all the other paediatric surgical specialties too like ENT Neurosurgery etc) there is no mention of their structure and manpower strength in the country.

As you may not know, although paediatric ophthalmology is a well recognised specialty in its own right in other developed countries of the world, it is not recognised as a sub specialty by the HPCSA. I am the only full time paediatric ophthalmologist in this country, I am not training any senior registrars because there are no posts for them to go to when they have been trained. Like most of the other paediatric surgeons around I am within 10 years of retiring.

As 45% of our population is under 15 years of age, there is a great need for at least one consultant in each province who has had extra training in paediatric ophthalmology.

Ophthalmology services at secondary level hardly exist. There are certainly none around Cape Town and there are no state employed specialists nearer than East London although there is a post in Port Elizabeth which is not filled. In future, one needs to set up state funded basic ophthalmic services at secondary level staffed by specialist general ophthalmologists for whom posts would have to be created. These people could perform routine adult ophthalmology and basic paediatric ophthalmology. They could do the very simple surgery, for example simple horizontal squint corrections and should also be able to supply basic follow up orthoptic services closer to the child’s home. Children from the tertiary centre could be referred back to secondary level for some of their post op management which often requires supervision for very many years until visual maturity is reached.

These are just some quick thoughts about your document. The plan is obviously that it should be further refined at the next meeting in Durban.

I think we should add in some points about what needs to be done with the so-called minor surgical specialties like Ophthalmology ,ENT ,paediatric neurosurgery etc

However, unless the powers that be are prepared to spend a greater proportion of the national budget on health care,we might spend our time and energy more profitably.

Regards,

Yours Sincerely,

Rhian H.Grötte
Head of Department of Paediatric Ophthalmology