Barriers to increase surgical productivity in Sierra Leone: a qualitative study

ObjectiveTo explore factors influencing surgical provider productivity and identify barriers against and opportunities to increase individual surgical productivity in Sierra Leone, in order to explain the observed increase in unmet surgical need from 92.2% to 92.7% and the decrease in surgical productivity to 1.7 surgical procedures per provider per week between 2012 and 2017.Design and methodsThis explanatory qualitative study consisted of in-depth interviews about factors influencing surgical productivity in Sierra Leone. Interviews were analysed with a thematic network analysis and used to develop a conceptual framework.Participants and setting21 surgical providers and hospital managers working in 12 public and private non-profit hospitals in all regions in Sierra Leone.ResultsSurgical providers in Sierra Leone experience a broad range of factors within and outside the health system that influence their productivity. The main barriers involve both patient and facility financial constraints, lack of equipment and supplies, weak regulation of providers and facilities and a small surgical workforce, which experiences a lack of recognition. Initiation of a Free Health Care Initiative for obstetric and paediatric care, collaborations with partners or non-governmental organisations, and increased training opportunities for highly motivated surgical providers are identified as opportunities to increase productivity.DiscussionBroader nationwide health system strengthening is required to facilitate an increase in surgical productivity and meet surgical needs in Sierra Leone. Development of a national strategy for surgery, obstetrics and anaesthesia, including methods to reduce financial barriers for patients, improve supply-mechanisms and expand training opportunities for new and established surgical providers can increase surgical capacity. Establishment of legal frameworks and appropriate remuneration are crucial for sustainability and retention of surgical health workers.

A Nationwide Enumeration of the Surgical Workforce, its Production and Disparities in Operative Productivity in Liberia

Background Any health care system that strives to deliver good health and well-being to its population relies on a trained workforce. The aim of this study was to enumerate surgical provider density, describe operative productivity and assess the association between key surgical system characteristics and surgical provider productivity in Liberia. Methods A nationwide survey of operation theatre logbooks, available human resources and facility infrastructure was conducted in 2018. Surgical providers were counted, and their productivity was calculated based on operative numbers and full-time equivalent positions. Results A total of 286 surgical providers were counted, of whom 67 were accredited specialists. This translated into a national density of 1.6 specialist providers per 100,000 population. Non-specialist physicians performed 58.3 percent (3607 of 6188) of all operations. Overall, surgical providers performed a median of 1.0 (IQR 0.5–2.7) operation per week, and there were large disparities in operative productivity within the workforce. Most operations (5483 of 6188) were categorized as essential, and each surgical provider performed a median of 2.0 (IQR 1.0–5.0) different types of essential procedures. Surgical providers who performed 7–14 different types of essential procedures were more than eight times as productive as providers who performed 0–1 essential procedure (operative productivity ratio = 8.66, 95% CI 6.27–11.97, P < 0.001). Conclusion The Liberian health care system struggles with an alarming combination of few surgical providers and low provider productivity. Disaggregated data can provide a high-resolution picture of local challenges that can lead to local solutions.

Lofty goals and strategic plans are not enough to achieve and maintain a diverse workforce: an American Association for the Surgery of Trauma Diversity, Equity, and Inclusion Committee conversation

The American Association for the Surgery of Trauma Diversity, Equity, and Inclusion (DEI) Ad Hoc Committee organized a luncheon symposium with a distinguished panel of experts to discuss how to ensure a diverse surgical workforce. The panelists discussed the current state of DEI efforts within surgical departments and societal demographic changes that inform and necessitate surgical workforce adaptations. Concrete recommendations included the following: obtain internal data, establish DEI committee, include bias training, review hiring and compensation practices, support the department members doing the DEI work, commit adequate funding, be intentional with DEI efforts, and develop and support alternate pathways for promotion and tenure.

TP8.2.30 Bleep paralysis: preventing inefficiency on the general surgical on-call

Aims The demand on surgical services is increasing. In our Trust, all surgical referrals and queries are directed through the Senior House Officer (SHO) on-call. This leads to inefficiency, with many hours spent on the telephone and away from clinical duties. Such constant intensity can cause increased stress and anxiety amongst those involved. Junior doctor burnout and stress-related sickness are increasing concerns amongst the current surgical workforce. In an attempt to alleviate these factors, we instigated an intervention to evenly distribute workload during surgical on-calls. Method The number of bleeps through the surgical SHO on-call were audited for four consecutive thirteen hour shifts. Each call was estimated to take an average of five minutes to resolve. A separate GP referral phone was introduced to reduce the volume of traffic through the SHO bleep. The number of calls through the SHO and referral phone were re-audited following this intervention. Results Before introduction of a referral phone, the mean length of time spent by the SHO per shift answering calls was 232.5 minutes, with a maximum of 330 minutes. Post intervention, the SHO spent an average of 92.5 minutes per shift answering calls and referrals through the GP phone averaged 43.75 minutes. Conclusion The introduction of a single point GP referral system has significantly reduced the volume of calls through the SHO, thus has also minimised time spent away from on-call duties. Not only does this improve efficiency within the on-call team, but also reduces risk of burnout amongst trainees.

TP8.2.28 Can surgical advanced care practitioners provide a cost effective local anaesthetic minor procedures service? Results from a 5-year retrospective study

Aims Surgical Advanced Clinical Practitioners (SACP) form part of the extended surgical workforce and are drawn from allied health care backgrounds. The primary aim of this study was to determine if there is a financial benefit performing minor surgical procedures on dedicated SACP lists compared to consultant surgeon lists. Methods This was a retrospective cohort study including all patients who had a minor ‘lumps and bumps’ procedure undertaken between April 2014 and August 2019 at Anonymous Hospitals NHS Trust (AHT) under local anaesthetic by the general surgery team. Data such as lesion type, theatre staffing levels and operating time was collected. The cost of the procedure was calculated by operating time multiplied by cost of staff of per minute according to local banding. Results A total of 1399 patients had a lesion excised; the majority were carried out by a doctor n = 907, the rest independently by a SACP. The majority of lesions excised were lipomas and cysts. There was no difference in the median surgical time (20 minutes, IQR 14) taken to operate on each patient by SACPs and doctors. Minor procedures carried out on consultant surgeon lists cost 62.4% (£21.72) more on average than those on SACP lists (£56.55 vs £34.83 median respectively, p &lt; 0.001) due to excess staff for these cases. Conclusion A dedicated and independent SACP ‘lumps and bumps’ list has shown to be a financially beneficial service. Operative times are similar to doctors. These lists free staff for consultant lists, potentially permitting more major cases.

SP10.2.4 COVID-19 impact on Surgical Training and Recovery Planning (COVID-STAR) - A Cross-Sectional Observational Study

Aims The COVID-19 pandemic has led to changes in the delivery of surgical services which impact on surgical training. This study aimed to investigate the qualitative impact of COVID-19 on surgical training in the United Kingdom (UK) & Republic of Ireland (ROI) Methods A national, collaborative, cross-sectional study involving 13 surgical trainee associations distributed a pan-surgical specialty questionnaire on the impact of COVID-19 on surgical training (11th May - 8th June 2020). Various aspects of training were assessed. This study was reported according to STROBE guidelines. Results 810 completed responses were analysed (M:401/F:390) from all deaneries and training grades. A significant negative impact of the pandemic on surgical training experience was observed. (Weighted average = 8.66). 41% of respondents (n = 301) were redeployed. Complete loss of training was reported in elective operating (69.5%), outpatient activity (67.3%) and endoscopy (69.5%). A reduction of &gt; 50% was reported in emergency operating (48%) and completion of work-based assessments (WBAs) (46%). 3.3% (n = 17) of respondents reported plans to leave medicine altogether. Cancellations in study leave and regional teaching programmes without rescheduling were reported in 72% and 60% of the cohort respectively. Elective operative exposure and WBAs completion were the primary reported factors affecting potential trainee progression. Overall, &gt; 50% of trainees (n = 377) felt they would not meet the competencies required for that training period. Conclusions COVID-19 has had a negative impact on surgical training across all grades and specialties, with implications for trainee progression, recruitment and retention of the surgical workforce.