Serious inequalities in the provision of elective versus emergency care

If you have rectal cancer, the ideal scenario is that it is picked up on screening (biannual FOB tests from 50 years of age followed by colonoscopy if positive), you then enter into a smooth and well oiled machine of investigation and treatment. Within 14 days of that colonoscopy and biopsy you will have had a CT scan of your chest, abdomen and pelvis, an MRI scan of your rectum and your case will have been discussed at a multi-disciplinary meeting of surgeons, oncologists, pathologists, radiologists and other interested and relevant parties.

You will be given a plan for your treatment and a specialist colorectal cancer nurse who is on speed dial for you with your questions and concerns. You will then begin either long course chemo radiotherapy followed by surgery or proceed immediately to surgery.

Wham, bam, we’ll whip your rectum out before you can say “pain in the ass”. It is as smooth and controlled and informed a ride as it can be, and you can be reassured that at every stage you will be looked after by the right person, who has been trained accordingly and is audited and checked up on.

If, however, you are unlucky and on the days of the FOB testing your rectal cancer isn’t in the mood to bleed, if you ignore the weight loss and the rectal bleeding and you present as an emergency with an obstruction, then your outcome is far from guaranteed. Your survival depends on where you decide to present to, which is terrifying and appalling.

If you were me, or a relative of mine, you would drive to somewhere like Bighospital and bend over one of their beds to present your obstructed rectum to one of my colleagues. The reason you would do this is because a hospital where there are more HDU beds, more ICU beds, that do more CT scans per bed per annum, that have more operating theatres per bed are significantly more likely to get you out of hospital alive than a hospital where that does not happen. (Symons et al 2013. British Journal of Surgery 100:1318-1325). And an early CT is associated with a decreased risk of death (Ng et al. 2002. BMJ:3251387

You wouldn’t be taken to one of these local hospitals with a knife in your chest or following a road accident, no way. Trauma goes to a Level 1 trauma centre because we know that these people die in District General Hospital Land.

You are much more likely to get rectal cancer than have a knife in your chest; and yet off you will be referred in the dead of night, vomiting shit out of your mouth to a tiny little dump that does no CT scanning out of hours and cannot stent your cancer anyway because they don’t have interventional radiologists and has no middle grade resident cover overnight.

This figure shown below is of a funnel chart, the line in the middle is the average mortality for emergency admissions, the dark dots are the badly performing institutions, the empty ones are the exceptional units. Age, social deprivation, comorbidities and female sex all correspond with poor outcomes but there still remains a worrying variety in mortality outcomes across the country. Without being a stats bore, everybody should be inside the funnel, that means you are within the average, some better some worse. It is the outliers outside of the funnel that are concerning or superbly impressive.

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If someone published the same data on breast cancer survival, or as happened many years ago on trauma survival, there would be an uproar. We urgently need to reshape and rethink how we organise emergency generally surgical provision and centralise services. We need more acute surgical beds, improved access to out of hours radiology (yes radiology I mean you, get out of your beds) and more HDU and ICU beds for emergency admissions. What we need most urgently, is for surgeons involved in the provision of this care (which makes up half of our workload) to start caring as much about the standard of emergency care as we do about elective care. One ass hole I work with said “what a great year, not a single elective death”, he couldn’t understand why I thought that was not worth bragging about.

The other people who need to listen to us are the politicians who do not allow us to ring fence resources and budgets towards emergency care. They have been beating us with the twin sticks of waiting times in A&E and waiting times for operations for years and it is time that we told them to shut up and show the public that the real problems are in emergency unscheduled admissions. The ASGBI issued a consensus statement to this effect which I would urge interested parties to read, but it failed to ignite a political and media debate on this issue.

This is an exciting time to be involved in general surgery as perhaps emergency care is slowly getting the attention it deserves. The government has to listen to us, we and they have to explain to voters that going to your local hospital might be nice, it might be handy for you to visit Granny, but it means that you have an increased risk of dying that a 30 minute drive can reduce by over half. We managed it with trauma care and we have managed it with cancer care we just have to do the same with provision of emergency surgery.

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