Like many aspects of health care, surgery is undergoing a period of change. The introduction of new technologies, economic pressures and constant efforts to reduce patient waiting times have all contributed to major changes to the delivery of care. The European Working Time Directive (Department of Health (DH), 1998) triggered a shift in the cultural climate, as established patterns of care and training became unsustainable under the new regulations (Datta and Davies, 2014). Role redesign was a possible solution, identifying a need for additional, non-medical practitioners to provide an extended range of services outside of their traditional roles. Training programmes for several such roles therefore had to be developed and evaluated. More recently, this has led an umbrella term being used to categorise this emerging group, ‘medical associate professions’ (MAPs) (DH, 2017).
This development has not been without criticism. Concerns have been raised regarding the impact on doctors' training opportunities and the siphoning off of experienced frontline healthcare staff, but this has not been demonstrated by research to date (Quick, 2013; Briffa, 2019).
Surgical care practitioners: background
Surgical care practitioners (SCPs) are permanent members of the surgical team and therefore maintain service provision and provide continuity of care to the patient (Nicholas, 2010). According to the Royal College of Surgeons of England (RCS):
‘Surgical care practitioners are registered healthcare professionals who have extended the scope of their practice … They work as members of the surgical team and their main responsibilities are to support surgeons and other professionals before, during and after surgical procedures. They can perform some surgical interventions and carry out preoperative and postoperative care under the supervision of a senior surgeon.’
The genesis of the SCP role dates back to the late 1980s/early 1990s, with the development of non-medical surgical assistants (Holmes, 1994). Suzanne Holmes, a theatre nurse at John Radcliffe Hospital in Oxford, is widely regarded as the UK's first non-medical practitioner. After joint approval from the RCS and the General Medical Council (GMC), Holmes began a 3-year pilot scheme in 1989, taking on the role of cardiac surgeon assistant, involving the undertaking of simple surgical procedures during cardiac surgery, such as harvesting the patients' veins for coronary artery bypass grafts (Holmes, 1994).
Successful clinical results at the John Radcliffe Hospital led to new roles developing in surgery at local levels in various surgical specialties. In 1994, the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS) published Cardiac Surgeons' Assistants: Guidelines for heads of departments. This document stipulated the necessary standards of education, limits of responsibility and scope of practice for the cardiac surgeons' assistant (SCTS, 1994).
In 1999 the RCS initiated a consultation of its membership, non-medical surgical assistants and other professional associations (RCS, 1999; Jones et al, 2012). The findings recommended that education and training should be to nationally agreed standards; (Moorthy et al, 2006). At the turn of the millennium, the NHS began a series of workforce redesign initiatives that increased the number of doctors and nurses serving patients, expanded existing staff roles and developed new ones (DH, 2000). The NHS Modernisation Agency undertook these developments through the Changing Workforce Programme, which, from 2001 to 2005, pioneered and established the role design (DH, 2000). In 2005, a DH-led public consultation resulted in the national role title of ‘surgical care practitioner’, along with the formation of the educational curriculum framework in 2006 (DH and NHS National Practitioner Programme, 2006). This established graduate-level qualification and a 2-year education programme to enable core and surgical specialty knowledge and skills to be acquired in the clinical environment, in partnership with educational institutions (Jones et al, 2012). This was later revised to a master's level degree in 2014, providing level 7 theoretical perspective to the practitioners (RCS, 2014)
Recognition by the healthcare sector that the shape and composition of the medical workforce needed to adapt to deliver medical care more appropriately in light of a growing, changing and ageing population was reflected in the publication of the Shape of Training Review in 2013 (Greenaway, 2013). The Medical Associate Oversight Board (MAOB) was set up in 2014 to establish a common education and training pathway to statutory regulation for MAPs (Health Education England (HEE), 2020). Accreditation of university training programmes for SCPs has been undertaken by the RCS to ensure consistent course content delivery. HEE and NHS Employers set up information hubs, helping to inform lay members of the public, as well as employers and health professionals about the role. The RCS has performed a 3-yearly re-accreditation process since implementation of the 2014 curriculum, to ensure the robustness of the higher education institutions providing the SCP MSc courses and providing a quality assurance process for the programmes (RCS, 2021).
In 2016 the Royal College Surgeons of Edinburgh (RCSEd) formed the Faculty of Perioperative Practice (FPC) whose membership is drawn from those providing perioperative care, and aimed at SCPs and surgical first assistants (SFAs). The RCS followed shortly with the opening of the Associate Members scheme in 2018; however this was also open to the wider surgical team, including advanced nurse practitioners (ANPs), advanced clinical practitioners (ACPs), physician associates (PAs) and anaesthetic associates (AAs). This was designed to establish a common standard of educational and training support, which can be challenging to find for those undertaking MAP and advanced practice roles.
The RCS (2014) curriculum describes the SCP role as an ‘enhanced’ role, but it could be argued that it is in fact an advanced role. In its advanced clinical practice framework document HEE (2017) defined an advanced role as being qualified to a master's degree level and working in the four pillars of advanced practice: clinical practice, leadership and management, education, and research. The RCS curriculum (2014) brought the level of training of SCPs up to a full master's degree and many SCPs demonstrate work across all four pillars in their role, supporting this claim to advanced practice status.
Aim
The purpose of this audit was to highlight the SCP role's diversity via a brief and convenient snapshot of UK-based practitioners.
Method
The online questionnaire service SurveyMonkey was used (Box 1), allowing a 10-question survey to be distributed. The data collection period was from 18 March to 24 April 2019. The target audience was the SCP community on a closed membership group on the Facebook social media platform where users identified as qualified or trainee SCPs. This was used in the absence of a reliable national register. Completion of the questionnaire was purely voluntary.
Box 1.Audit questionnaire
- Which registered healthcare professional are you?
- In which part of the country are you based?
- Of which organisations are you a member or affiliated with?
- Which surgical specialties do you work in?
- What amount of you time do you spend in theatre, clinic or ward?
- Which of the following activities do you regularly take part in: ward cover, ward round, on-call rota?
- Are you a non-medical prescriber?
- In what form would you like to see CPD/continuous education courses available?
- What level of education is your SCP qualification?
- Do you have an operating/procedure list of your own?
Ethical considerations
Participation was voluntary and no incentives were offered for completion of the survey. The respondents were assured of their anonymity and informed that the data would be used for publication. There was an opportunity to contact the audit lead through the link on the Facebook page if required. The Health Research Authority (HRA) online NHS ethics test was used to provide confirmation that this was an audit and therefore no research ethics committee approval was required.
Results
Ninety-two respondents completed the online questionnaire. 75% (69) identified themselves as registered nurses, 23% (21) as operating department practitioners (ODPs) and 2% (2) as physiotherapists.
The geographical spread of the respondents showed most were from the south of England, with 27% from the south east and 16% from south west. South Wales was the next largest group with 11%. North Wales had no respondents at all and Northern Ireland only one. Other regions had between 3 and 8 respondents each (see Figure 1).
The specialty spread of the respondents was dominated by trauma and orthopaedics (T&O) (28%) and cardiothoracic (CT) (21%). General surgery (GS), however, was split into four categories: upper gastrointestinal (9%), lower gastrointestinal/hepatic pancreatic and biliary (HPB) (5%), colorectal (11%) and GS other (7%); collectively they account for 32% (see Figure 2).
The different aspects of care the SCPs deliver or are involved in were examined by assessing the settings they actively participated in along the patient's surgical pathway (see Figure 3).
The survey highlighted that SCPs spent a large part of their time in the operating theatre, with estimates of spending around half their time (36%), three-quarters of their time (29%) or almost all their time (23%) in theatre. Fifty-six per cent of respondents spent one-quarter of their time in clinics; however 30% claimed that ‘rarely if ever’ does their role take them to clinic. In comparison, the results for time spent in the wards saw a result of ‘rarely if ever’ of 53% and 35% for less than a quarter of their time.
Some SCP specialties spend more time than others in theatre, with 58% of CT SCPs estimating most of their time is spent in theatre compared with 6% of GS SCPs (see Figure 4).
When in the clinic or on the ward, a breakdown of which patients were seen was collected. This resulted in nearly half of SCPs seeing either new or follow-up (FU) patients in clinic, (new 43%; FU 54%) and with clinic diagnostics accounting for 24% of time. Nearly half of respondents (47%) took part in ward rounds, with a further 19% on ward cover (such as clerking). There was also evidence of pre- and postoperative assessment (28% and 20% respectively) and even being on call (15%) Figure 5 shows non-theatre activity for each specialty.
In regard to the educational level of SCPs, the responses demonstrated that 53% (46) of the respondents were qualified at MSc level, the level currently set by the RCS (2014) curriculum, with 37% (32) having completed postgraduate diploma and 14% (12) a BSc course (RCS 2006 curriculum level). Two respondents did not answer this question.
With regard to non-medical prescribing (NMP), of those eligible to complete the course, 17% (13/75) had the qualification, and a further 47% (35/75) had not yet completed the course but intended to do so. This left the number of those able to complete the NMP course but currently not required to do so as 36% (27/75). Those ineligible (ODP registered SCPs), due to current legislation, were split almost evenly with 9 respondents claiming they would complete the course when able to do so versus 8 that did not see the need to do so.
SCPs stated they were members of, or affiliated with, a number of professional organisations. The RCSEd FPC accounted for 16% compared to 12% linked to the RCS. This was significantly lower than the 41% who declared ties to the Association for Perioperative Practice (AfPP) and the 28% who had no links to such bodies. Of the ‘others’ option available in the question, (3%) the Association for Cardiac Surgical Assistants (ACSA) had the highest number of responses.
Discussion
The SCP curriculum covers the whole of the surgical patient's journey, requiring a diverse skill set, allowing for the flexibility of the role to mould around the individual department or specialty's needs. This brief audit of the SCP role across a mixture of specialties demonstrates that the role is not just theatre based. Examples of SCP input into the clinic setting, assessing new patients and completing follow-up reviews highlighted this. The nature of the clinic activity requires further investigation to unearth the type and number of patients being seen and reviewed, and the level of decision making. This type of information may be better collected in a specialty-specific audit to enable clear and concise data. The audit was able to discover that 24% of clinic activity involved the conducting of diagnostic clinic procedures, the nature of which was not uncovered by this audit.
Is there a need for non-medical prescribing as part of the SCP training? Nearly two-thirds of nurse/physiotherapist SCPs either had or intended to complete the NMP course and at least 50% of ODPs intended to do so, when legislation allows. Therefore this may need to be considered, and NMP courses added or offered as adjuvant module to the curriculum. Given the variety of activity and settings in which SCPs work, such as on the ward and postoperatively reviewing patients, the need to be able to prescribe becomes more apparent so that SCPs can provide the best care.
The move to an SCP master's degree-level workforce adds weight to the claim for this to be an advanced role, but more evidence is needed to demonstrate that the majority are meeting the four pillars set out by HEE to substantiate this claim. Individually, it can be argued that a number are achieving this, but this is not, unfortunately, quantified by this audit although the respondents' activities indicate that many are.
Conclusion
This simple audit of the activities and overall role of the SCP across the various surgical specialties is clearly limited. However, it begins to provide an insight into the day-to-day input of the SCP to the surgical patient's journey and demonstrates that the RCS (2014) curriculum is covering the various facets of the surgical patient's journey. SCPs are active in the clinic, the ward and of course the operating theatre and more needs to be done to clarify, in more detail, the levels of patient interaction.
In more recent developments, the DH published a consultation document on the regulation of MAPs (DH, 2017). The decision not to grant statutory regulation for SCPs, although doing so for PAs and AAs, has disappointed both surgical colleges, with the RCSEd formally requesting a review of this decision (RCSEd and Federation of Surgical Specialty Associations, 2019). It is, nevertheless, important to develop a common standard across all four MAPs in areas such as continuing professional development (CPD), ongoing competency assessment and appraisal, which should be consistently applied across the UK. The CPD issue has been recently addressed, after this survey data was collected, by HEE with recommendations being published (HEE, 2019).
More work needs to be undertaken to clarify the fine detail of the SCP role and more data should be collected on the achievements and future potential of these practitioners.
The overall development of advanced roles continues with new and revised curricula planned in the future, possibly with the aim of aligning the various groups and standardise core training before separating for specialty-based assessment. How this will impact SCPs remains to be seen.
KEY POINTS
- The Royal College of Surgeons of England's 2014 curriculum for surgical care practitioners (SCPs), aimed to provide a level of training to produce a practitioner able to work across the surgical patient's journey, providing care to an advanced level
- This study's authors undertook an audit to examine the reality of this aim
- The audit found that the majority of SCPs who responded worked in cardiothoracic, trauma and orthopaedics and general surgery
- The majority of surgical care practitioners had a role across the entire surgical patient's pathway
- This audit highlighted the diversity of the SCP's role, depending on the specialty
CPD reflective questions
- How can advanced clinical practitioners demonstrate that they work within the four pillars of advanced practice?
- Think about how your own work as an ACP—how can you clearly demonstrate and promote the activities you are involved in?
- In what ways can the surgical care practitioner (SCP) further develop as part of the surgical team?