25 October 2005

Health Workforce Study
Productivity Commission
PO Box 80
Belconnen
ACT 2616

Dear sir/madam,

My name is Lee Lawrence and I trained in Perth, Western Australia as a registered nurse at Edith Cowan University and graduated in 1996.  I completed my nursing graduate year programme at Fremantle Hospital before moving to a cardiac ICU at a private hospital in Murdoch Perth.  One year after this, my wife and I moved to England.

In England, I worked for three years at the Cardiac Intensive Care Unit (CICU) at Glenfield Hospital in Leicester.  Now, for the past three years, I have been working in the operating theatres as a Cardiothoracic Surgical Assistant (SA). This name has now been changed to Surgical Care Practitioners (SCP).

Basically, I am a Registered Nurse who performs actual surgery.  A first assistant in cardiac surgery.  (And to my knowledge the only Australian SCP in the UK).  I have been trained in the correct surgical procedure for sternotomy, sternal closure, vein and radial artery harvesting, Intra Aortic Balloon Pump insertion and removal, and acting as a first or second assistant to the consultant surgeon or senior surgical trainee during open heart surgery. Just recently (and with supervision from the consultant cardiothracic surgeon or senior surgical registrar) I have begun cannulating the heart prior to bypass.

There are four cardiothoracic SCPs here at Glenfield Hospital and the operative workload consists of Coronary Artery Bypass Grafting, cardiac valve repair and replacement as well as adult and paediatric congenital repair surgery.  There are also post-operative CICU care requirements that we are involved in.  We complete around 1500 - 1700 cardiac cases per year.  Other duties include Angiogram and X-ray interpretation and
supervision of junior surgical trainees (medical doctors on their basic surgical trainee programmes) with vein and radial artery harvesting.
There are around 50 cardiothoracic SCPs working in the UK.
The training period for a SCP has been two years (education in this field never stops).  In November 2003 I completed a Cardiothoracic Surgeons Assistant examination at Papworth Hospital in Cambridge. The exams (written and viva), are arranged annually by the Royal College of Surgeons of England (RCS) and Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS).  I have also completed the Basic Surgical Skills course approved by the RCS.
 
SCP roles have also developed in other surgical specialities such as Orthopaedic and General Surgery.  These roles were developed initially to meet the European working time directives (EWTD) on reducing the hours doctors worked and they are continuing to be developed in response to improvements in workforce planning.  Training is now being given to suitably qualified healthcare personnel, in specialised areas of practice, to deliver services that would have previously been provided by doctors.  

These roles (in the NHS) that involve nurses trained to deliver primary care, are having a large impact on surgical waiting lists and pre and post- operative care.  There are Nurse Practitioners, Surgical assistants, Anaesthesia assistants and recently Physicians assistants have been introduced.  There is no evidence at all that these roles are having a detrimental effect on patient morbidity or mortality.  In the United States, Surgical Assistants and Physicians Assistants have been in practice for many years and are well trained and highly regarded in the operating room, hospital and community.  There is absolutely no reason why these roles cannot be commenced and managed in Australia.

I have been reading the various Inquiry papers and media releases regarding the future direction of Australian healthcare. I must commend you on a thorough examination of the issues, difficulties and multi faceted problems you face regarding workforce planning.  If I may, I wish to give you a quick personal perspective of what it was like for us.  And, what it has been like sitting on the fence between the traditional boundaries of nursing and medicine. 

First of all, there have been a high number of enhanced/extended practice roles as well as managerial roles developed here in the UK.  These roles have taken a large number of experienced nurses from the clinical setting and placed them in a new one.  With the UK having the same problems as other countries with recruitment and retention, we ended up with a “robbing peter to pay paul” scenario.  Large holes were left in the skill mix left on the shop floor as senior clinical staff numbers dwindled.  
Sadly, improved remuneration comes from moving away from the clinical setting.

Initially the consultants were not pleased at the thought of nurses entering theatre and operating on their patients, or, running nurse led specialist clinics. Hostility also came from within nursing itself, including our theatre nurses who did not like the idea of cross boundary working or, “nurses playing doctor”.  It was like “enemy at the gates” every time we came to theatre.  

We have seven cardiothoracic consultants at Glenfield.  We work for all seven.  One of them is the clinical lead for the SCPs and is in charge of our continued professional development.  Strangely, even though we work alongside medicine, overall control is still through the UK Nurses Board who does not have a shred of an idea what we do.  Professional registration and professional body issues continue to plaque us.  

All of the SCPs, across Britain, have become a victim of their own successes.  Here at Glenfield we cover three cardiac theatres. Our workload consists of a four-day week with up to nine cardiothoracic cases completed each day.  We are in theatre, harvesting conduit, opening and closing chests and acting as first or second assistant.  We are highly proficient, and offer a great deal of surgical expertise and skill to each case.  That is what we have been trained for.  Now, the consultants and the senior registrars prefer an experienced SCP to assist them with their surgical workload rather than a junior medical officer.  This is happening across England and within all surgical specialities that have SCPs.  Naturally, this has caused some complaints finding their way into the Royal College of Surgeons and the British Medical Association. 

However, these complaints are going nowhere.  The assistants in surgery are filling a workforce shortage that will never again be staffed by medicine alone.  The traditional roles and boundaries of surgeon, doctor, nurse and workforce allied to medicine are going. What we’re seeing is a collaborative team effort of those most capable of adapting to meet the challenges ahead to produce a modern healthcare system.

Australia stands dangerously close to being left out by keeping its archaic and decaying health model because it is no longer workable.  The Royal Australasian College of Surgeons and the Australian Medical Association has to stop scare mongering government and the public.  They have to face facts that most countries are now engaged in innovative role design and production to meet their individual needs.  Here in the UK , the eager predictions of doom, gloom and a decline in standards have all fallen silent.  As they will inevitably do in Australia.

If you find this response of interest and have any questions then please contact me.  I would be very happy to respond.

Yours sincerely,

Mr Lee Lawrence
47 Totland Road 
Leicester
LE3 9AN 
England
tel:  0116 225 8910 
e-mail  lee.lawrence@uhl-tr.nhs.uk

Please feel free to circulate this text, electronically or in paper form, whole or part, to any interested persons, parties, working groups, professional & government bodies involved in health workforce issues, for comment within Australia.

Encs:  Photocopies of ;
Nurses Board of WA Licence to Practice (now expired)	
UK NMC Licence to Practice
Basic Surgical Skills certificate
Cardiac Surgeons Assistant exam certificate
Disk with entire text for electronic version.