Editorial

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Concerns about UK emergency surgery death rates

For the report see http://www. rcseng.ac.uk/policy/documents/ RCS%20Emergency%20 surgery%20policy%20briefing.pdf

Emergency surgery has suffered as waiting time targets for elective surgery have been given priority, according to a report from the Royal College of Surgeons of England released last week. The report sets out the challenges facing emergency surgery and calls for high-level policy change to redress the balance towards emergency care. “We are concerned about the huge variations in death rates following emergency surgery and would like to see a greater focus across the NHS on providing a consistently high standard of care for these patients”, said Clare Marx, newly appointed president of the Royal College of Surgeons. Around 80% of all surgical mortality arises from emergency interventions, but this number varies between hospitals (eg, 3·6–41·7% for emergency laparotomies). Operating theatre capacity has failed to keep pace with increases in emergency attendance and although increasing sub-specialisation within surgery is advantageous for elective care, it has reduced the number of surgeons with the wider skill set needed for emergency surgery. Recommendations include separation of elective and emergency surgery,

and review of the tariff for urgent care, which currently diverts funding from emergency care to improve access to primary care—a strategy that may not decrease emergency surgical admissions. The College also called for all support services required for emergency surgical procedures to be available 7 days a week, for patients to be given clear rehabilitation information on discharge, and for subsequent readmission directly to the treating team. NHS England has committed to developing collaboration and patient transfer arrangements. To derive meaningful outcome measures in surgery is complicated, and concerns about interpretation of these data have been a barrier to widespread implementation so far. But Clare Marx explained: “We need clearer protocols and standards which set out how patients undergoing emergency surgery should be treated and for the NHS to measure outcomes for patients much more rigorously by publishing audit.” This report is a clear indication that quality improvement in surgery will be a central focus of her presidency and that published outcome measures are an integral part of this process. „ The Lancet

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Tuberculosis rates still high in the UK

For the Tuberculosis in the UK: 2014 report see https://www. gov.uk/government/uploads/ system/uploads/attachment_ data/file/358237/TB_in_the_ UK_2014.pdf For more on tuberculosis in the UK see Comment Lancet 2014, 383: 2195, Comment Lancet 2013 382: 1311–12, and Newsdesk Lancet Infect Dis 2013; 13: 836–37

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Tuberculosis rates in the UK are still unacceptably high. Public Health England notes in its annual UK report that 7892 cases of tuberculosis were notified in 2013, a decrease from 8729 cases reported in 2012. However, the incidence of 12·3 cases per 100 000 is still among the highest in western European countries. Another sobering comparison is that the incidence in the UK is four times that of the USA. Long recognised as a disease of social inequality and deprivation, according to the report, tuberculosis continues to disproportionately affect the most deprived communities, with 70% of all tuberculosis cases in England resident in areas in the two most deprived quintiles. In particular, the urban areas of London, Leicester, Birmingham, Luton, Manchester, and Coventry had more than three times the national average. Within London alone, 2985 cases were reported in 2013, an incidence of 35·5 cases per 100 000. 44% of patients aged 16 and older were not in education or employment, and 10% had at least one social risk factor—history of alcohol or drug misuse,

homelessness, or imprisonment. 73% of the cases were in people born outside the UK, but only 15% were diagnosed within 2 years of entering the UK, suggesting a preponderance of reactivation of latent tuberculosis infection. These data indicate the different demographics of the disease in the UK compared with other countries, but also a disjointed, fragmented approach to local tuberculosis services, and their funding. As noted in the report, improvements in tuberculosis control will need the social and economic determinants of the disease to be addressed, together with the provision of strong, accessible, effective screening, diagnostic, and treatment services, clearly targeted at the most susceptible groups. Public Health England and NHS England will soon publish a Collaborative TB Strategy for England 2015–2020, which will identify the key areas to achieve a sustained decline in tuberculosis. Although small gains have been made, it is essential the strategy enables firm steps to be taken to achieve a level of control that exists elsewhere. „ The Lancet www.thelancet.com Vol 384 October 4, 2014

Concerns about UK emergency surgery death rates.

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