Welcome to the fifth edition of the year – one more left! First of all, this edition carries the abstracts of the autumn meeting of the Society of British Neurological Surgeons to be hosted by the unit in Leeds. The content looks promising for a good meeting.
There are a number of challenges facing neurosurgery – some alluded to in the previous editorial and most have been themes in previous issues over the last few years. There is an obvious professional responsibility that a neurosurgeon has to his or her individual patients; equally obvious but less frequently to mind is the responsibility to the community for a service, which brings us to the subject of commissioning of services.
This is quite an influential area for policy and therefore budget. What follows is ambition to control this agenda. There are many with such ambitions and all have different agendas reflecting their personal interests, even if the declared agenda is better care for patients and value for taxpayers. Politicians have votes to secure, and budget deficits to maintain (code for ‘cuts’); medical administrators/ politicians (defining such a person as anyone whose frontline personal clinical time becomes less than their administrative time – another version of the 50% rule!!!) with committees to maintain; and the Royal Colleges and therefore the SBNS who have hitherto been the repository of professional standards, opinion and policy, and (rightly in my view) wish to maintain this sphere of influence. Somewhere missing from this is the value placed on the expertise of the neurosurgeon leading the team responsible for delivering this care, though it is not unheard of for practitioners to seek to protect their own patch by medico-political manoeuvres!
There is now, I feel, a clear change of environment of which the SBNS may need to be aware, and this is the process involved in specialist commissioning, and specifically the clinical reference groups. I have the impression that the NHS finds the colleges an ‘impediment’ to the commissioning process, but yet has to engage them in the commissioning process. It has chosen to select experts without formal consultation with the professional body – the SBNS – for its various clinical reference groups. The result perhaps is that the colleges find themselves left out! For myself – involved in the neurosurgical reference group – I find an uncomfortable feeling that there is no mandate, and therefore wariness as to expressing views that may not be representative of colleagues (although I know that efforts have been made to annul this potential criticism, and you may consider this editorial another such effort). Important issues have passed through the clinical reference groups already – consideration of commissioning for deep brain stimulation, the optimum management pathways for oncology and for trauma. There are artificial and arbitrary divisions of topics that overlap between reference groups – neurosurgery and spinal surgery; neurosurgery and paediatric neurosurgery; pain and neurosurgery and finally radiosurgery. There must be a powerful case for ensuring that British Neurosurgery has a significant and important input to this process and I hope the SBNS is able to lead this. I've written about the issue of outcomes previously in the journal, but it seems to me there is a huge opportunity here for the SBNS (i.e., its constituent neurosurgeons) to look properly into outcomes in a meaningful manner.
Obtaining understanding of outcome measurement is sufficiently challenging that I think we can demonstrate that it is only the profession – neurosurgeons – that can deliver this; if we concentrate on proper outcome measurement with all its difficulties then we can make our case for involvement extremely powerful. By outcome measurement I do not mean simple measures of process that the ‘target culture’ has made all too familiar, but proper measures of outcome, looking at survival, functional outcomes, independent measures of quality of life; the ‘PROM’, and all of it case mix adjusted, and population based.
Last but not least the contents of the issue itself. Again a mixture of themes, but more cranially focussed than the last issue that some may have found too spinal perhaps, but hopefully none the less interesting. I am grateful as always to see some correspondence evoked by articles, and there is more to come in the future!