Good Surgical Practice 2008

Good Surgical Practice
February 2008 Review date: 2010

Good Surgical Practice
Published: February 2008 Review date: 2010

Good Surgical Practice is endorsed by: The Association of Surgeons of Great Britain and Ireland The British Association of Oral and Maxillofacial Surgeons The British Association of Otorhinolaryngologists – Head and Neck Surgeons The British Association of Paediatric Surgeons The British Association of Plastic, Reconstructive and Aesthetic Surgeons The British Association of Urological Surgeons The British Orthopaedic Association The Royal College of Physicians and Surgeons of Glasgow The Royal College of Surgeons in Ireland The Royal College of Surgeons of Edinburgh The Society for Cardiothoracic Surgery in Great Britain and Ireland The Society of British Neurological Surgeons

Published by The Royal College of Surgeons of England Registered Charity No. 212808 Professional Standards and Regulation The Royal College of Surgeons of England 35–43 Lincoln’s Inn Fields London WC2A 3PE Tel: 020 7869 6032 Fax: 020 7869 6030 Email: [email protected] www.rcseng.ac.uk © The Royal College of Surgeons of England 2008 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of The Royal College of Surgeons of England. While every effort has been made to ensure the accuracy of the information contained in this publication, no guarantee can be given that all errors and omissions have been excluded. No responsibility for loss occasioned to any person acting or refraining from action as a result of the material in this publication can be accepted by The Royal College of Surgeons of England. Designed and typeset by Close to Water Ltd, Crayford, Kent Printed by Latimer Trend & Company Ltd, Plymouth, Devon

Contents
The duties of a doctor registered with the General Medical Council Note on terminology Introduction Clinical governance Appraisal Revalidation, recertification and relicensure 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 2 2.1 2.2 2.3 2.4 2.5 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Good clinical care Providing a good standard of surgical practice and care The treatment of emergencies Working with children Organ and tissue transplantation Record keeping Generic guidance: examples of individual standards Presenting examples of your evidence Maintaining and improving good surgical practice Maintaining and improving your knowledge and performance Adverse events New techniques Generic guidance: examples of individual standards Presenting examples of your evidence Teaching, training and supervising Medical students Surgical trainees Staff and associate specialist-grade surgeons Locum surgeons Responsibilities of surgical trainees Generic guidance: examples of individual standards Presenting examples of your evidence 5 5 6 7 7 8 9 9 11 12 13 14 15 16 17 17 18 19 20 20 21 21 22 23 23 24 25 25

4 4.1 4.2 4.3 4.4 4.5 4.6 5 5.1 5.2 5.3 6 6.1 6.2 6.3 6.4 6.5 7 7.1 7.2 7.3 8 8.1 8.2 8.3 9 9.1 9.2 9.3 9.4 10 10.1 10.2 10.3

Relationships with patients Consent Consent for transfusion Maintaining trust Communication Generic guidance: examples of individual standards Presenting examples of your evidence Working with colleagues Working together Generic guidance: examples of individual standards Presenting examples of your evidence Probity in professional practice Provision of information Private practice Research Generic guidance: examples of individual standards Presenting examples of your evidence Health Patient safety Generic guidance: examples of individual standards Presenting examples of your evidence Additional guidance: armed conflict, developing countries and prisons Armed conflict Developing countries Prisons Further reading Department of Health General Medical Council The Royal College of Surgeons of England Other bodies Useful contacts Surgical royal colleges in Great Britain and Ireland Surgical specialist associations and societies Other contacts Acknowledgements

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The duties of a doctor registered with the General Medical Council
Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must do the following: > Make the care of your patient your first concern. > Protect and promote the health of patients and the public. > Provide a good standard of practice and care: > keep your professional knowledge and skills up to date; > recognise and work within the limits of your competence; and > work with colleagues in the ways that best serve patients’ interests. > Treat patients as individuals and respect their dignity: > treat patients politely and considerately; and > respect patients’ rights to confidentiality. > Work in partnership with patients: > listen to patients and respond to their concerns and preferences; > give patients the information they want or need in a way they can understand; > respect patients’ right to reach decisions with you about their treatment and care; and > support patients in caring for themselves to improve and maintain their health. > Be honest and open and act with integrity: > act without delay if you have good reason to believe that you or a colleague may be putting patients at risk; > never discriminate unfairly against patients or colleagues; and > never abuse your patients’ trust in you or the public’s trust in the profession. You are personally accountable for your professional practice and must always be prepared to explain and justify your decisions and actions. Good Medical Practice, GMC, 2006.

Note on terminology
Good Medical Practice came into effect on 13 November 2006. In Good Medical Practice the terms ‘you must’ and ‘you should’ are used in the following ways: > ‘you must’ is used for an overriding duty or principle; > ‘you should’ is used when the General Medical Council (GMC) is providing an explanation of how that overriding duty is to be met; and > ‘you should’ is also used where the duty or principle will not apply in all situations or circumstances, or where there are factors outside your control that affect whether or how you can comply with the guidance. The same convention is used in this document. ‘Ensure’ is used where surgeons must do all that is within their control to make sure that the event takes place.
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Introduction
Good Surgical Practice sets standards for surgeons. The first edition of Good Surgical Practice, published in 2002, followed the publication of the GMC’s Good Medical Practice in 2001. This new edition follows the revision of Good Medical Practice published in 2006. The document combines a modified and revised text of Good Surgical Practice (RCS, 2002) and Criteria, Standards and Evidence (RCS, 2004). A significant range of new references have been added to both the text and the further reading list. The standards set are intended to be reasonable, assessable and achievable by all competent surgeons. They complement those standards required of all doctors by the GMC as set out in Good Medical Practice (GMC, 2006). Good Surgical Practice uses the same headings that appear in Good Medical Practice and is the surgical companion to the GMC document. Details of other useful guidance and information are also provided. Good Surgical Practice is written primarily for any surgeon, whether consultant, staff or associate specialist, or trainee, working within and/or outside NHS practice. It may be used as a framework for providing evidence for appraisal and revalidation based on the criteria and standards set out in Good Medical Practice. The standards set out in this document may be used both by surgeons to confirm their good practice and by those who may have to make judgments about surgeons’ performance. Good Surgical Practice is also intended for the use and benefit of patients, to give them an informed understanding of the standards they can reasonably expect from a competent surgeon. It is recognised that good surgical practice depends not only on the personal attributes of the surgeon but also on effective team-working and adequate resources and time. All surgeons are responsible for the standards of clinical care that they offer to patients and should bring to the attention of their employing authority any deficiencies in resources that impact on the quality of clinical care and patient safety. Although it is acknowledged that a document of this kind may be seen as being either too prescriptive or ambiguous, it is for individuals to reflect on their practice and work to the standards set out in this document.

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Clinical governance
Clinical governance is a statutory duty across all NHS Trusts.* It can be defined as a framework through which the NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish (A First Class Service – Quality in the New NHS, Department of Health, 1998). Clinically focused practice depends on the governance of clinicians by clinicians. The process is supported by the chief executive of the Trust who is required to confirm and facilitate the process and is individually legally accountable for the service provided in the Trust. Similar arrangements should exist in the independent sector. Further useful information can be obtained from: > the Department of Health; > the Clinical Governance Support Team (a learning organisation that uses the knowledge of its staff and its relationships with other NHS organisations to support those who shape the health care experience for patients, carers and the public); and > the Healthcare Commission (the independent inspection body for both the NHS and independent health care in England).

Appraisal
Appraisal is the process that gives surgeons an opportunity to formally discuss their professional roles and clinical practice (Supporting Doctors, Protecting Patients, Department of Health, 1999). Its dual role is to improve on good performance and also to recognise poor performance at an early stage. A national appraisal scheme was introduced in 2001 and is now a contractual requirement for all consultants working in the NHS. Consultants who practise in both the NHS and the private sector have the opportunity to submit their private practice activity as part of their NHS appraisal. Consultants in independent practice who do not have an NHS contract will need to make independent arrangements for appraisal. Appraisal is based on the seven core headings presented in Good Medical Practice (GMC, 2006), which sets out the standards required of all doctors. They are: 1 2 3 4 5 6 7 good clinical care, maintaining good medical practice, relationships with patients, working with colleagues, teaching and training, health, and probity.

Each of these headings is addressed in this document.
*This document has been written from an English perspective. Different health services operate in other parts of the UK and in Ireland. Nevertheless, the standards remain relevant.

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Revalidation, recertification and relicensure
Since the publication of the last edition of Good Surgical Practice, there have been significant changes proposed in relation to revalidation. The white paper, Trust, Assurance and Safety: the Regulation of Health Professionals in the 21st Century (Department of Health, 2007), which builds on the responses to Sir Liam Donaldson’s report, Good Doctors, Safer Patients (Department of Health, 2006), reaffirms the government’s commitment to the introduction of a system of revalidation. The white paper is complemented by the government’s response to the recommendations of the Fifth Report of the Shipman Inquiry and to the recommendations of the Ayling, Neale and Kerr/Haslam Inquiries, Safeguarding Patients, which sets out a range of measures to improve and enhance clinical governance in the NHS. Medical revalidation will have two core components: relicensure and specialist recertification. All doctors wishing to practise in the UK will require a licence to practise. The GMC will issue these licences as soon as it is practicable to do so. The licence will be subject to five-yearly renewal, based on a ‘positive affirmation of the doctor’s entitlement to practise, not simply on the absence of concerns’ (Trust, Assurance and Safety, paragraph 2.11, Department of Health, 2007). Specialist recertification will apply to only those doctors who are on specialist practice or general practice registers. They will be required to demonstrate that they continue to meet the particular standards that apply to their medical specialty. Recertification will be carried out at regular intervals, of no more than five years, where possible coinciding with relicensure. The medical royal colleges will have specific responsibility for developing standards and systems for doctors in their particular specialty. The Department of Health will be asking the GMC ‘to consult with its key constituencies to translate the recent update of Good Medical Practice (GMC, 2006) into an effective framework against which individual doctors’ practice can be appraised and objectively assessed’ (Trust, Assurance and Safety, paragraph 2.21). The Department will be consulting widely on the ways in which all these proposals will be put into effect in the future. As plans for revalidation are developed, information will be available from: > the Department of Health (http://www.dh.gov.uk/); > the GMC (http://www.gmc-uk.org/); > the Academy of Medical Royal Colleges (http://www.aomrc.org.uk/); and > royal colleges including The Royal College of Surgeons of England (http://www.rcseng.ac.uk/).

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1 Good clinical care
Definition
Good surgical care starts at first consultation and diagnosis, with the patient as either an outpatient or inpatient. It is given in conjunction with other colleagues in the health care team. It concentrates particularly on the practice of safe, timely and competent surgical intervention, ensuring that patients are prioritised and treated according to their clinical need. Surgery should be avoided where the risks outweigh the benefits. The decision of intervention is assessed on the basis of the surgeon’s ability and experience, patient need and available resources, taking into account the requirements of both emergency and elective activity. Surgeons must demonstrate competence in their own area of practice and a willingness to refer where necessary. They must demonstrate knowledge and understanding of the necessary ethical and legal issues relating to their area of surgical practice. They must communicate clearly with patients and their supporters* and ensure that comprehensive, legible and contemporaneous records are kept of all their patient interactions.

1.1 Providing a good standard of surgical practice and care
In meeting the standards set out in Good Medical Practice (GMC, 2006), surgeons must provide good clinical care by: > ensuring that patients are treated according to the priority of their clinical need; > communicating compassionately and clearly with patients and, with the patient’s consent, with their supporters and, in the case of children, with their parent(s)/responsible adult(s); > carrying out surgical procedures in a timely, safe and competent manner; > providing elective care for patients with non-urgent conditions and carrying out procedures on them that lie within the range of the surgeon’s routine practice; > ensuring patients are cared for in an appropriate and safe environment that takes into account any special needs they may have, ensuring that adequate resources are available for safe patient care and postponing planned procedures if they are not. If patient safety may be compromised by a lack of resources, this must be recorded by the surgeon and communicated to the chief executive and medical director; > ensuring patients receive satisfactory postoperative care and that relevant information is promptly recorded and shared with the appropriate team, the patient and their supporter(s);

*The term ‘supporter’ is used throughout this document to refer to the relative, carer or friend who has been identified by the patient as someone with whom they wish to share information about their treatment/operation. Information should only be shared with the supporter with the patient’s consent. (See section 4.1.) The name of the supporter should be recorded clearly in the patient’s notes.

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> ensuring that, on the discharge of a patient from hospital care, appropriate information is shared with the patient and/or their carer(s); > making good use of the resources available; > ensuring that any instruction to withhold or withdraw treatment (for example, resuscitation categorisation) is normally taken in consultation with the patient or family and authorised by the appropriate senior clinician (see Withholding and Withdrawing Life Prolonging Treatments: Good Practice in Decision Making, GMC 2006); > accepting patients on referral from GPs, consultant colleagues or as an emergency through the accident and emergency department. If a surgeon agrees to see a patient directly without referral, the patient should be informed that the GP will normally receive a report; > utilising the knowledge and skills of other clinicians and transferring the patient, when appropriate, to another colleague or unit where the required resources and skills are available; > being aware of current clinical guidelines in their field of practice and the advice they contain. Surgeons should explain to patients the reasons for not following such guidance if an alternative course of clinical management is undertaken; and > discussing with patients and their supporters alternative forms of treatment, Including non-operative care and recording the reasons for their decisions. 1.1.1 Further reading Improving Your Elective Patient’s Journey, RCS Patient Liaison Group, 2007

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1.2 The treatment of emergencies
Emergency care is a major component of surgical practice. When on call, surgeons must: > accept responsibility for the assessment and continuing care of every emergency patient admitted under their name unless, or until, they are formally transferred to the care of another doctor; > be available either within the hospital or within a reasonable distance of the hospital to give advice throughout the duty period; > ensure they are able to respond promptly to a call to attend an emergency patient; > be aware of protocols for the safe transfer to another unit of emergency patients when the complexity of the patient’s condition is beyond the experience of the admitting surgeon or the resources available for their proper care; > delegate assessment or emergency surgical operations only when they are sure of the competence of those trainees and staff and associate specialist grades to whom the patient’s operative care will be delegated; > ensure that rotas are published in advance and that any alternative cover arrangements are specifically made and clearly understood; > ensure the formal handover of patients to an appropriate colleague following periods on duty; and > ensure appropriate handover by junior staff and be available for a ward round between shifts. In an emergency, unfamiliar operative procedures should be performed only if there is no clinical alternative, if there is no colleague who is more experienced available or if transfer to a specialist unit is considered a greater risk. 1.2.1 Further reading Guidance on safe handovers can be found at: http://www.rcseng.ac.uk/service_delivery/wtd/docs/Safe%20handovers.pdf Advice on designing safe rotas is available at: http://www.rcseng.ac.uk/service_delivery/wtd/rotas

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1.3 Working with children
Surgeons must: > when communicating with a child or young person: > treat them with respect and listen to their views, > answer their questions to the best of your ability, and > provide information in a way they can understand; > be aware of the needs and welfare of children and young people when seeing patients who are parents and carers, as well as any patients who may represent a danger to young children (Good Medical Practice, GMC, 2006); > communicate effectively with parent(s)/responsible adult(s); > protect the child’s privacy; and > treat children only if they have the appropriate training and ongoing experience in the clinical care of children in their specialty, except in the case of an emergency.

1.3.1 Further reading Getting the Right Start: National Service Framework for Children, Young People and Maternity Services: Standards for Hospital Services, Department of Health, 2003 Surgery for Children: Delivering a First Class Service, RCS, July 2007 Children in Hospital: Rights and Responsibilities of Children and Parents, RCS Patient Liaison Group, June 2007 0–18 Years: Guidance for all Doctors, GMC, September 2007

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1.4 Organ and tissue transplantation
Surgeons undertaking organ or tissue transplantation must: > comply with current laws and ethics (see The Surgeon’s Duty of Care, Senate of Surgery of Great Britain and Ireland, 1997, pp. 23–25) and follow the guidance set out in Towards Standards for Organ and Tissue Transplantation in the UK (British Transplantation Society, 1998); > choose recipients solely on the basis of medical suitability; > fully inform recipients of hazards and likely outcome when gaining informed consent; > fully inform living donors of risks and outcome to themselves and of the benefits and risks for the recipient. Living organ donation must never be acquired by coercion or for profit; and > when using cadaver donors or other tissue, conform to current regulations regarding, for example, prior agreement, assent of relatives and certification of brain death. Information regarding removal, storage and use of human organs can be found at the website of the Human Tissue Authority (http://www.hta.gov.uk/).

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1.5 Record keeping
Surgeons must do the following: > Ensure all medical records are legible, complete and contemporaneous, and have the patient’s identification details on them. > Ensure that when members of the surgical team make case-note entries they are legibly signed and show the date, and, in cases where the clinical condition is changing, the correct time. > Ensure that a record is made of the name of the most senior surgeon seeing the patient at each postoperative visit. > Ensure that a record is made by a member of the surgical team of important events and communications with the patient or supporter (for example, prognosis or potential complication). Any change in the treatment plan should be recorded. > Ensure that there are legible operative notes (typed if possible) for every operative procedure. The notes should accompany the patient into recovery and to the ward and should be in sufficient detail to enable continuity of care by another doctor. The notes should include: > date and time; > elective/emergency procedure; > the names of the operating surgeon and assistant; > the operative procedure carried out; > the incision; > the operative diagnosis; > the operative findings; > any problems/complications; > any extra procedure performed and the reason why it was performed; > details of tissue removed, added or altered; > identification of any prosthesis used, including the serial numbers of prostheses and other implanted materials; > details of closure technique; > postoperative care instructions; and > a signature. > Ensure that follow-up notes are sufficiently detailed to allow another doctor to assess the care of the patient at any time.

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1.6 Generic guidance: examples of individual standards
> A surgeon must communicate clearly with patients and their supporters, checking concerns and ensuring understanding by asking questions to test knowledge. > A surgeon should ensure that the patient knows the name of the person responsible for their care. > Whenever possible, a surgeon should ensure that only one team is responsible for the patient’s care at any one time. > A surgeon must carry out emergency or elective surgical procedures in a timely, safe and competent manner, delegating or referring to colleagues where appropriate; for example, when treating children or complex cancer. > A surgeon will be aware of and follow current guidance in their field of practice and will be able to justify their actions, where appropriate, when that guidance has not been followed. > A surgeon should demonstrate that patients are treated according to the priority of their clinical need. > In their absence, the surgeon must arrange safe and effective cover and handover for the assessment, treatment and continuing care of emergency and elective patients for whom they are responsible. > A surgeon must comply fully with current ethical and legislative guidance in relation to their area of expertise. > A surgeon must maintain legible, comprehensive and contemporaneous records. > A surgeon will bring to the attention of those responsible any resource shortfalls that might jeopardise safe and effective patient care.

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1.7 Presenting examples of your evidence
Sources of evidence might include: > job plan/work programme; > information regarding annual caseload; > examples of resource shortfalls that may have compromised patient care; > record of examples of cancellations or deferment, for example, on account of patient safety; > demonstration of knowledge of best practice as advised by College and associations; > results of clinical outcomes as compared with relevant College/association recommendations or national or international benchmarks where available; > record of attendance at audit meetings, of clinical audits and of implementation of audit recommendations; > records of attendance of morbidity and mortality meetings and compliance with audits of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Surgeons should be present at, or receive minutes of, mortality meetings, where patients who died under their care were discussed; > on-call rotas; > results of random audit of medical records/minutes of meetings where records and notes have been audited against agreed standards. Sample audit of clinical notes should also include an audit of operation notes; and > contribution of relevant data to national audit programmes and national registries.

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2 Maintaining and improving good surgical practice
Definition
Surgeons are specialist doctors who offer effective, informed and up-to-date care to patients through surgical intervention. They ensure that their knowledge of surgical procedures is maintained on a regular basis by a variety of measures, including regular evaluation of patient safety incidents. Surgeons work within teams, which include a range of professionals. All team members should learn continuously from each other, further enhancing the quality of care. They are committed to learning in many ways, including learning from mistakes. They recognise that good surgical practice requires constant review and regular continuing professional development (CPD) activities as an essential part of their professional practice. They must record the progress of their career and CPD in a portfolio that reflects their professional practice.

2.1 Maintaining and improving your knowledge and performance
All surgeons must: > keep up to date with the relevant literature; > attend and contribute to regular meetings with colleagues in the same and related specialties; > attend multidisciplinary meetings with, for example, pathologists, radiologists, oncologists and other physicians; > establish and maintain an up-to-date and valid portfolio of all procedures and clinical activity, which includes an accurate log book; > include CPD and the need to maintain knowledge base in job plans; > take part in annual appraisal; > take part in quality-assurance and -improvement systems; > take part in national enquiries and audits, for example, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and the Scottish Audit of Surgical Mortality (SASM); and > take part in regular morbidity/mortality and audit meetings.

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All surgeons should: > be aware of the immediate results of operations and participate in the audit of the long-term outcomes; > be aware of the results obtained by peer groups and seek advice from colleagues if there is a major discrepancy; > share their results through the audit process; > keep an accessible record of their surgical activity complying with the Data Protection Act 1998; > contribute to ongoing clinical trials wherever possible; and > recognise when they are unfit to work through fatigue, illness or the influence of alcohol or drugs.

2.2 Adverse events*
Surgeons should inform patients of any adverse events that occur during their care, report the event to the responsible officer of the Trust and, if considered necessary, to: > a local audit meeting; then > the National Patient Safety Agency. All surgeons must be aware of the ‘alert’ and ‘hazard’ notices issued by the Medicines and Healthcare Products Regulatory Agency (MHRA; previously the Medical Devices Agency, or MDA). Adverse incidents arising from the failure of medical devices must be reported to the MHRA (http://www.mhra.gov.uk/). The Committee on Safety of Devices has been set up to advise ministers and complement the work of the MHRA (Devices sector).

*National Patient Safety Agency guidance defines the term ‘patient safety incident’ as ‘any unintended or unexpected incident that could have or did lead to harm for one or more patients receiving NHS funded healthcare’. Seven Steps to Patient Safety, NPSA, February 2004.

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2.3 New techniques
New techniques include: > a new or personally developed operation; > any major modifications to an established procedure; and > the introduction of a procedure not previously performed in the Trust/organisation. When a new technique is to be used, the patient’s interests should be considered paramount. Therefore, surgeons must: > first discuss the technique with colleagues who have relevant specialist experience and the medical/clinical director; > follow local protocols with regard to local ethics committee approval; > contact the National Coordinating Centre for Health Technology Assessment (NCCHTA) to learn the status of the procedure and/or to register it; > liaise with the relevant specialist association; > ensure that patients and their supporters know when a technique is new before seeking consent and that all the established alternatives are fully explained prior to recording their agreement to proceed; > be open and transparent regarding the sources of funding for the development of any new technique; > audit outcomes and review progress with a peer group; > where possible, obtain necessary training in the new technique; > take part in regular educational activities that maintain and further develop competence and performance; > enable the training of other surgeons in this new technique; and > ensure that any new device complies with European standards and is certified by the competent body.

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2.4 Generic guidance: examples of individual standards
> A surgeon must keep up to date with the literature and developments in their own and associated fields of practice. > A surgeon should take part in annual appraisal. > A surgeon must keep an accessible record of their surgical practice complying with the Data Protection Act 1998. > A surgeon must ensure that they have undergone a period of appropriate training before undertaking a significantly new procedure (for the individual concerned) on a patient (where that procedure has been shown to be of value). > A surgeon undertaking a new procedure should ensure that appropriate ethical approval has been sought and confirmed by the medical director and should also contribute to the evaluation of that new procedure, complying with NCCHTA guidelines or similar standards.

2.5 Presenting examples of your evidence
Sources of evidence might include: > a detailed summary of annual CPD activity, and how practice has been altered; > record of attendance at multidisciplinary meetings, for example minutes/register of the meeting and certificates of attendance at courses; > use of journals and other educational and evidence-based tools; > authorship of publications, authored guidelines, etc; > record of last appraisal, personal development plan (PDP) and subsequent changes in practice; > record of all surgical procedures and clinical activity, which will be required for recertification; > record of any patient safety incidents and their outcomes, and how they have influenced practice; and > when employing a new technique or new technology, proof that there is a good evidence base for its use, that it is registered with or has been reported to the NCCHTA or that it is being tested formally by research. Surgeons often have new ideas or employ modifications of an older technique.

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3 Teaching, training and supervising
Definition
Surgeons should be willing, as part of their professional practice, to engage in the training and supervision of students, trainees and other members of the surgical and health care team. They have responsibilities for creating a learning environment suitable for teaching, training and supervising students, trainees and others. They should contribute to the theoretical and clinical training of students while ensuring that patients have the right to refuse to be seen by students if they so wish. They must ensure that effective supervision arrangements are in place for all grades of trainee, allowing for the acquisition of the necessary experience while ensuring that patient safety is paramount. Individuals with whom trainees can legitimately share concerns should be identified. Surgeons should understand and demonstrate effective skills of delegation, assuring themselves at all times of the competence of those to whom they delegate across the health care team.

3.1 Medical students
Surgeons should: > encourage and support medical students; > involve themselves actively in teaching if students are attached to their team; > be aware of the professional competencies to be achieved by students; > explain to patients that they have the right to refuse to participate in student teaching and reassure patients that such a refusal will not prejudice their treatment in any way; > ensure that students are introduced to patients; > ensure that privacy and confidentiality are maintained and that students understand and respect this requirement; and > ensure that when a student is involved in specific examinations or procedures on patients under general anaesthesia, written consent has been obtained giving the full extent of the student’s involvement. 3.1.1 Further reading The Doctor as a Teacher, GMC, 1999 Generic professional competencies are set out on the Intercollegiate Surgical Curriculum Programme (ISCP) website.

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3.2 Surgical trainees
Consultant surgeons must accept overall responsibility for any duties that are delegated to a trainee or other doctor. Surgeons must: > delegate duties and responsibilities only to those specialist trainees and foundation doctors or other doctors whom they know to be competent in the relevant area of practice; > indicate to trainees when more senior advice and assistance should be sought; > be present throughout an operation until they are satisfied that the trainee is competent to carry out the procedure without immediate supervision; > when on duty, be available to advise/assist the trainee at all times unless specific arrangements have been made for someone else to deputise; > ensure that the trainee maintains an up-to-date portfolio that complies with the Data Protection Act 1998 that is accurate, legible and frequently updated; > attend a Training the Trainers course, or equivalent, and an approved course in appraisal skills if undertaking the role of supervisor or trainer of any junior doctor; > take reasonable steps to ensure that the trainee is fit to undertake their responsibilities, particularly with reference to fatigue, ill health or the influence of alcohol or drugs; > ensure that assessment and appraisal of trainees is carried out regularly, thoroughly, honestly, openly and with courtesy; and > not assign as competent someone who has not reached or maintained a satisfactory standard of practice.

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3.3 Staff and associate specialist-grade surgeons
Surgeons must: > ensure that staff and associate specialists are only appointed to standard, recognised grades. Staff and associate specialist surgeons must: > perform to the standards detailed in this document; > be accountable for their activities to a named consultant; > identify and agree the extent of their delegated responsibilities with a named consultant, including the level of independent activity expected; and > undertake CPD.

3.4 Locum surgeons
Consultant surgeons practising in the same specialty, or the specialty nearest to that of the locum concerned, must ensure that the locum is: > fully conversant with the routines and practices of the surgical team; > familiar with, and takes part in, the audit processes of the unit; > not isolated and knows from whom to seek advice on clinical or managerial matters; and > not required or expected to work outside their field of expertise. A locum consultant, not on the GMC Specialist Register, must be under the supervision of a named substantive consultant in the same specialty. Locum surgeons must perform to the standards detailed in this document.

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3.5 Responsibilities of surgical trainees
(Foundation Year 1; Foundation Year 2; Specialist Trainees 1–6) In addition to the requirements of all surgeons set out in this document, trainees must: > ensure continuity of care for patients for whom they are responsible by formally handing over the patient’s care to a responsible colleague at the end of their period of duty; > know which consultant is on call and seek advice or assistance when appropriate; > understand the importance of seeking advice from someone with more experience; > recognise the circumstances in which they are expected to seek advice and assistance from a more senior member of the team; > be available according to a rota published in advance; > maintain all records relating to their training; > maintain legible and up-to-date clinical records; > support and assist their colleagues, in particular those junior to them; > be prepared to share concerns about possible shortcomings in patient care that they perceive in those with whom they work, whether senior or junior to them; > inform the responsible consultant before a patient is taken to theatre for a major surgical procedure; and > recognise when they are unfit to work through fatigue, illness or the influence of alcohol or drugs.

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3.6 Generic guidance: examples of individual standards
> A surgeon must maintain the privacy, dignity and confidentiality of patients while working with all members of the surgical team, including undergraduates. > A surgeon should contribute to the provision of a learning environment suitable for teaching, training and supervising students, trainees and others. > A surgeon must only delegate duties and responsibilities that are appropriate to the level of competence of those with whom they are working and check that the delegated duty has been performed. > If involved in teaching, a surgeon should ensure that they have the necessary skills and have taken part in training. > A surgeon must be honest and open when assessing and appraising. > A surgeon should be courteous when working with all members of the surgical team.

3.7 Presenting examples of your evidence
Sources of evidence might include: > evidence of attendance at an appropriate teaching course, for example Training the Trainers or equivalent. This could include a piece of self-reflective work on teaching style or peer review for a teaching session; > for surgeons responsible for undertaking the assessment of trainees, evidence of attendance at an appropriate course; > a summary of formal teaching/lecturing activities and supervision/mentoring duties; and > results of formal and informal feedback from trainees on the effectiveness of postgraduate and undergraduate teaching and training.

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4 Relationships with patients
Definition
Surgeons must make every effort to establish and maintain the trust of their patients at all times. Surgeons must establish and maintain effective relationships with patients and, where appropriate, their supporters, in a number of ways. They must allow sufficient time to explain surgical procedures, risk and alternative treatment options; they must ensure understanding of the surgical and associated processes involved; and they must ascertain and respect patients’ wishes. Surgeons must understand that seeking informed consent for surgical intervention is a process, not merely the signing of a form, and one that requires time, clarity of explanation and patience. Surgeons must take every opportunity to demonstrate to patients that their safety is paramount and treat complaints with courtesy and respect, responding promptly, openly and honestly. The following principles are laid out in Good Medical Practice (GMC, 2006) but are of particular relevance to surgeons.

4.1 Consent
The Department of Health has published a Reference Guide to Consent for Examination or Treatment (Department of Health, 2001). All surgeons must be familiar with the processes and details in this document before seeking agreement to proceed with any intervention. Obtaining consent involves a dialogue between surgeon and patient, which leads to the signing of the consent form. In addition, surgeons must: > establish whether a patient has a supporter as early as possible in the relationship and mark this clearly on their notes; > meet with the patient prior to surgery to discuss operation and implications; > ensure that patients, including children, are given information about the treatment proposed, any alternatives and the main risks, side effects and complications when the decision to operate is made. The consequences of non-operative alternatives should also be explained; > provide time for patients and their supporters to discuss the proposed procedure and provide an opportunity for the patient to make a fully informed and unharassed decision to agree to the treatment suggested and to indicate by signature their willingness to proceed; > carefully consider any ‘advance decision’ (living will) that the patient may have written under the Mental Capacity Act 2005 (c. 9);
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> give the patient the opportunity to indicate any procedure they do not wish to be carried out; > make sure that the patient understands, and is agreeable to, the participation of students and other professionals in their operation; > gain agreement from the patient if video, photographic or audio records are to be made for purposes other than the patient’s records (for example, teaching, research or public transmission); > follow appropriate guidance for the retention of tissue; > clearly mark the site to be operated on with the patient’s agreement while they are awake and prior to premedication; > verify the operation to be undertaken by checking the records, including images and consent form and, where possible, with the patient, rather than relying solely on the printed operating list for the procedure being performed; > ensure that the written consent and the notes include, when appropriate, the side to be operated on using the words ‘left’ or ‘right’ in full; > ensure that digits on the hand are named and on the foot numbered and similarly marked with the patient’s agreement while they are awake and prior to premedication; and > record all discussions about consent in the patient’s records.

4.1.1 Further reading Seeking Patients’ Consent: The Ethical Considerations, GMC, 1999 Confidentiality: Protecting and Providing Information, GMC, 2004 Confidentiality FAQs, GMC, 2004 Patient Rights and Responsibilities, RCS Patient Liaison Group, 2002 Improving Your Elective Patient’s Journey, RCS Patient Liaison Group, 2007 Explaining the Risks and Benefits of Treatment Options: Suggestions for Hospital Doctors, Royal College of Physicians, 2006

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4.2 Consent for transfusion
Surgeons must establish the views held by individual patients regarding their position in relation to transfusion as certain forms of transfusion may be unacceptable. 4.2.1 Further reading Code of Practice for the Surgical Management of Jehovah’s Witnesses, RCS, 2002

4.3 Maintaining trust
In addition to abiding by the recommendations of Good Medical Practice (GMC, 2006), surgeons must: > ensure their working arrangements allow adequate time to listen and properly communicate with patients and their supporters. The chief executive and medical director must be informed if there are inadequacies; > fully inform patients and their supporters of the plans and procedures for their treatment, the risks and anticipated outcomes and any untoward developments as they occur, or as soon as possible afterwards; > support any request for a second opinion and give assistance in making the appropriate arrangements; > obtain the patient’s verbal consent before carrying out any clinical examination; > support a request by a patient for a third person to be present while they are undergoing a clinical examination; > explain the purpose and nature of any examination of the breast, genitalia or rectum and observe GMC guidance on intimate examinations; > be aware of cultural differences and sensitivities and respect them; and > contribute to patient surveys and respond to their findings. 4.3.1 Further reading Maintaining Boundaries, GMC, 2006

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4.4 Communication
All surgeons must: > listen to and respect the views of patients and their supporters; > listen to and respect the views of other members of the team involved in the patient’s care; > recognise and respect the varying needs of patients for information and explanation; > insist that time is available for a detailed explanation of the clinical problem and the treatment options; > encourage patients to discuss the proposed treatment with their supporter(s); > fully inform the patient and their supporter of progress during treatment; > explain any complications of treatment as they occur and explain the possible solutions; and > act immediately when patients have suffered harm and apologise when appropriate. 4.4.1 Further reading Personal Beliefs and Medical Practice: A Draft for Consultation, GMC, 2007

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4.5 Generic guidance: examples of individual standards
> A surgeon should ensure that, as part of the ongoing process of obtaining consent, they give patients and, where appropriate, their supporters, relevant and adequate information, including benefits and risks, in a timely manner. > A surgeon should observe the relevant legislation and guidance in respect of honouring the wishes of a patient in their care. > A surgeon should ensure that details of all proposed surgical procedures are, where possible, checked with the patient, as well as with the written record. > A surgeon should ensure that patients and, where appropriate, their supporters are aware of their rights with respect to appropriate national and local guidance on the retention of tissue and that patients and their supporters are aware of their part in the processes involved. > A surgeon should gain agreement from the patient, in accordance with the policy of the relevant Trust, when video, photographic or audio records are to be made for any purpose. > A surgeon should contribute to appropriate means of testing patient satisfaction. > A surgeon should ensure that a patient’s dignity is respected at all times, for example with unconscious patients and in clinical demonstrations. > A surgeon should respond appropriately and professionally to any comments or complaints from patients or their supporters about the service they have received and cooperate fully with any complaints procedures, offering an apology where appropriate.

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4.6 Presenting examples of your evidence
Sources of evidence might include: > examples of participation in validated patient surveys and other methods of patient involvement; > applying/implementing results from participation in random audit of patient consent forms; > examples of approach to handling informed consent; > examples of plaudits from patients and colleagues; unsolicited expressions of satisfaction and gratitude and compliments on management; and > a summary of complaints made against the surgeon, the process by which they are handled and details of the outcomes and, where appropriate, evidence of changes to practice.

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5 Working with colleagues
Definition Surgeons work in partnership with others in the health care team – which includes other professionals, technicians, support staff and management – in order to offer safe and effective care to patients. They must work to develop effective relationships, respecting the professionalism of all colleagues. Knowledge and understanding of, and respect for, the roles and views of others are essential to achieving good patient outcomes. Surgeons must ensure continuity of patient care by arranging effective cover for their own patients where possible and be prepared to cover for colleagues in emergencies.

5.1 Working together
Apart from in exceptional circumstances, surgeons must always make formal arrangements for cover. However, in such exceptional circumstances, surgeons must take responsibility for patients under the care of an absent colleague even if formal arrangements have not been made. Ineffective team working must not be allowed to compromise patient care. Surgeons must: > work effectively and amicably with colleagues in multidisciplinary teams, attend multidisciplinary team meetings, share decision making, develop common management protocols where possible and discuss problems with colleagues; > continue to participate in the care of, and decisions concerning, their patients when they are in the intensive care unit or the high-dependency unit; > willingly and openly participate in regular appraisal of both themselves and trainee surgeons and other staff; > always respond to calls for help from trainees and others in the operating theatre and elsewhere as a matter of priority; > ensure there is a formal handover of continuing care of patients to another colleague at the commencement of leave; and > ensure that, when acting as manager or director, their practice and appraisal processes are subject to the same scrutiny as others. 5.1.1 Further reading The Leadership and Management of Surgical Teams, RCS, 2007 Management of Healthcare: the Role of Doctors, paragraphs 19–21, GMC, 1999
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5.2 Generic guidance: examples of individual standards
> A surgeon should willingly and openly participate in regular appraisal of both themselves and trainee surgeons and other staff, where appropriate. > A surgeon should always respond to calls for emergency help from trainees, colleagues and other members of the surgical team in the operating theatre and elsewhere as a matter of priority. > A surgeon should ensure that there is a formal and explicit handover/cover of continuing care of patients to another named colleague when unavailable for any reason. > A surgeon should recognise their own technical and professional limitations and refer to colleagues where necessary or appropriate. > A surgeon should share their concerns about the physical or psychological health or well-being of any members of the health care team, through appropriate channels. > A surgeon should work together with other members of the health care team in a professional and supportive manner to maintain continuity of patient care, regardless of patient location.

5.3 Presenting examples of your evidence
Sources of evidence might include: > description of the setting within which you work and the structure within which you practice; > evidence of multi-/interdisciplinary relationships, for example minutes of multidisciplinary team meetings; > details of additional responsibilities within the team, for example clinical director or surgical tutor; and > evidence of attendance at team development events and compliance with agreed procedures and behaviours, including 360-degree appraisal/multi-source feedback.

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6 Probity in professional practice
Definition
Surgeons must understand the need to demonstrate probity in all aspects of their professional practice and adhere to the principles set out in Good Medical Practice (GMC, 2006), regardless of where they may be working (for example, the NHS or private sector). They must demonstrate honesty, objectivity and courtesy in their dealings with others. They must declare any commercial involvement, which may give rise to actual or potential conflict of interest and ensure that neither their name nor practice is used inappropriately in the promotion of personal commercial advantage. Surgeons working in the private sector must ensure transparency in their dealing with patients in respect of costs for services and any actual or potential limitations of clinical care.

6.1 Provision of information
Surgeons should adhere to all the principles set out in Good Medical Practice (GMC, 2006). In particular, when providing information surgeons must: > avoid any material that could be interpreted as designed to promote their own expertise, either in general or in a particular procedure; > declare any commercial involvement that might cause a conflict of interest; > avoid denigrating others; > ensure that the literature provided by the institution where they work and any interview they give to the media does not make unreasonable claims; and > demonstrate honesty and objectivity when providing references for colleagues and team members.

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6.2 Private practice
All surgeons working in the private sector, including independent sector treatment centres (ISTCs), must: > make arrangements for the continuity of care of any inpatients; > maintain the standard of record keeping as listed in section 1.5 and audit all surgical activity; > be honest in financial and commercial matters relating to work and in particular: > ensure that patients are made aware of the fees for their services and cost of any treatment by quoting, where possible, their professional fees in advance, > inform patients if any part of the fee goes to any other doctor, and > not allow commercial incentives to influence treatment given to a patient; > make clear to patients the limits of care available in any independent hospital used; for example, the level of critical care provision provided and the qualifications of the resident medical cover; and > if working solely in private practice, enable peer review of their surgical activities and participate in meaningful audit, CPD and appraisal. Doctors working in England and Wales who are wholly engaged in private practice in premises that are otherwise unregistered must register under the Care Standards Act 2000. Surgeons who work in both the NHS and the independent sector should: > undertake similar types of procedures in both; > fulfil their NHS contracted duties; and > not use NHS staff or resources to aid their private practice unless specific arrangements have been agreed in advance.

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6.3 Research
Surgeons who undertake research must: > submit full protocols of proposed research and details of intended new technical procedures to the research/ethics committee before starting; > treat patients participating in research as partners; > fulfil the regulations of the World Medical Association Declaration of Helsinki 1964 (http://www.wma.net/); > fully inform research participants about aims, intentions, values, relevance, methods, hazards and discomforts and record this in their notes; > fully inform patients in randomised trials about the procedures being compared and their risks and benefits and record this in their notes; > inform participants how their confidentiality will be respected and protected; > accept that a patient may refuse to participate or withdraw during the programme, in which case their treatment must not be adversely influenced; > seek guidance from the ethics committee concerning the need for consent for the use of tissue removed during an operation for research purposes in addition to routine histopathology; > seek permission to remove tissue beyond that excised diagnostically or therapeutically; > acquire specific permission to use any removed tissue for commercial purposes; for example, to grow cell lines or for genetic research; > fulfil the strict regulations of the Animals (Scientific Procedures) Act 1986 when obtaining permission to carry out research on animals; > discourage the publication of research findings in non-scientific media before reporting them in reputable scientific journals or at meetings; > disclose any financial interest in, for example, pharmaceutical companies or instrument manufacturers; > ensure that anything regarding the project that may be published on the internet or elsewhere follows ethical principles; > report any fraud that is detected or suspected to the local research/ethics committee; and

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> recognise and be familiar with the Human Tissue Act 2004 regulations and obtain appropriate licenses where necessary. Further information on research governance can be found at http://www.dh.gov.uk/ and on the Scottish Executive website at http://www.show.scot.nhs.uk/cso/. 6.3.1 Further reading Research: The Role and Responsibilities of Doctors, GMC, 2002

6.4 Generic guidance: examples of individual standards
> A surgeon should declare any actual or potential conflict of interest in line with national guidelines and local policy. > A surgeon must demonstrate honesty and objectivity when providing references for colleagues and other team members. > A surgeon who works in the NHS and the private sector must maintain identical standards and performance in both sectors. > A surgeon must ensure that their professional practice is based on best clinical evidence, and not influenced by commercial considerations. > A surgeon undertaking research should ensure that there is an audit trail of documentation and that research is carried out under appropriate ethical standards and complies with research governance, including the careful recording and storage of data.

6.5 Presenting examples of your evidence
Sources of evidence might include: > details of actual or potential conflicts of interest, which must be declared; and > evidence of meeting local policy on probity.

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7 Health
Definition
Surgeons have a duty of care to maintain patient safety at all times and not to work in any health state that might impair judgement and/or jeopardise patient safety. They must take particular precautions against the transmission of blood-borne diseases, in both their own and their patients’ best interests. They must understand and honour the importance of reporting serious communicable disease in the public interest, in either themselves or their colleagues.

7.1 Patient safety
Surgeons must not compromise patient safety because of ill health, fatigue or the effects of drugs or alcohol. Surgical operations place surgeons at particular risk of acquiring and transmitting blood-borne viruses that can cause serious communicable diseases, such as hepatitis and HIV. (See Serious Communicable Diseases, GMC, 1997 and related note in section 9.2). In the event of a needlestick injury, surgeons must follow established Trust/ organisation guidelines. Surgeons must take precautions and follow established guidelines when operating on high-risk patients. All surgeons have a duty of care to their patients and must seek advice from an appropriately qualified doctor if they believe they have a serious communicable disease. Surgeons also have a duty of care to inform the appropriate authority if they know of a colleague who may have a serious communicable disease or any illness that is liable to put patients at risk. They must ensure that health risks are addressed and that patients are not put at unnecessary risk due to transfer of blood or tissue infection.

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7.2 Generic guidance: examples of individual standards
> A surgeon must not work when their health state is adversely influenced by fatigue, disease, drugs or alcohol. > A surgeon must exercise a duty of care in terms of reporting serious communicable disease or health states that might jeopardise safe patient care, in either themselves or colleagues. > A surgeon must be aware of health and safety regulations in respect of their practise and follow Trust guidelines and relevant legislation.

7.3 Presenting examples of your evidence
Sources of evidence might include: > a signed declaration by the surgeon of evidence of adherence to local practice; for example, that health issues have not and do not affect their fitness to practise; > hepatitis status; and > record of absence through sickness.

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8 Additional guidance: armed conflict, developing countries and prisons
Additional guidance is given for surgeons working in the following circumstances.

8.1 Armed conflict
> In armed conflict, standards of surgical practice should be, as far as practically possible, as laid out in Good Surgical Practice, given the conditions and environment in which one is practising. > Only operate at the request and with the consent of the patient. If the patient is incapable of giving consent, then act only in the patient’s best interests. > Do not discriminate between the protagonists. Prioritise patients for treatment on the basis of clinical need alone. > Maintain the highest professional standards within the limitations of the circumstances. Ensure that treatment is culturally sensitive and non-discriminatory. > Take personal precautions consistent with providing the highest level of care.

8.2 Developing countries
Those seeking to assist health care professionals in developing countries by providing surgical services should aim to do so in the spirit of mutual partnership based on humanitarian service and avoid any patronising or dominant attitudes. This includes humanitarian deployment following natural or man-made disasters. Surgeons must: > ensure that whatever is done is for the benefit of the individual and for the local population; > retain the highest standards of care, compatible with the local conditions; > ensure that, as written informed consent may not always be obtainable, the patient understands and voluntarily agrees to the planned procedure. This must always be in the interest of the patient; > adhere to local legal requirements; and > never participate in mutilating operations. Research projects should be undertaken with the highest ethical standards and with the full awareness and agreement of the local and national communities and health agencies.

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8.3 Prisons
The duty of care remains the same when treating prisoners. Surgeons should not condone or contribute to inflicting physical or mental suffering, whether deliberately, systematically or wantonly. (See The Surgeon’s Duty of Care, Senate of Surgery of Great Britain and Ireland, pp 28, 29, 1997). Surgeons should report evidence of abuse and deliberate injuries to the appropriate authority. 8.3.1 Further reading Seeking Consent: Working With People in Prison, Department of Health, 2002

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9 Further reading
9.1 Department of Health
All Department of Health documents can be found at http://www.dh.gov.uk/ in the Policy and Guidance section. Trust, Assurance and Safety: the Regulation of Health Professionals, Cm 7013 Gateway Reference 7823, Department of Health, February 2007 Safeguarding Patients, Cm 7015 Gateway Reference 7864, Department of Health, February 2007 Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections, Department of Health, October 2006 Guidelines for the NHS in Support of the Memorandum of Understanding – Investigating Patient Safety Incidents Involving Unexpected Death or Serious Untoward Harm, Department of Health, November 2006 Good Doctors, Safer Patients: Proposals to Strengthen the System and Improve the Performance of Doctors and to Protect the Safety of Patients, Department of Health, July 2006 Seeking Consent: Working With People in Prison, Department of Health, 2002 Guide to Consent for Examination or Treatment with Consent Forms for Adults, Adults Without Capacity and Children and Young People, Department of Health, November 2001 Reference Guide to Consent for Examination or Treatment, Department of Health, April 2001 Supporting Doctors, Protecting Patients, Department of Health, 1999 A First Class Service – Quality in the New NHS, Department of Health, 1998

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9.2 General Medical Council
All documents can be found at http://www.gmc-uk.org/publications/. 0–18 Years: Guidance for all Doctors, GMC, September 2007 Writing References, GMC, August 2007 Personal Beliefs and Medical Practice, a draft for consultation, GMC, 2007 Valuing Diversity – Resource Guides, GMC, 2006 Raising Concerns about Patient Safety, GMC, 2006 Good Practice in Prescribing Medicines, GMC, 2006 Management for Doctors, GMC, 2006 Maintaining Boundaries, GMC, 2006 Good Medical Practice, GMC, November 2006 Good Practice in Prescribing Medicines, GMC, 2006 Withholding and Withdrawing Life Prolonging Treatments: Good Practice in Decision Making, GMC, 2006 GMC & PMETB Principles of Good Medical Education and Training, GMC, 2006 Conflicts of Interest, GMC, 2006 The Meaning of Fitness to Practise, GMC, 2005 Confidentiality FAQs, GMC, 2004 Continuing Professional Development, GMC, 2004 Confidentiality: Protecting and Providing Information, GMC, 2004 Research: The Role and Responsibilities of Doctors, GMC, 2002 Making and using Visual and Audio Recordings of Patients, GMC, 2002 The Doctor as a Teacher, GMC, September 1999 Seeking Patients’ Consent: The Ethical Considerations, GMC, 1998 (Note: A new document entitled Consent: Patients and Doctors Making Decisions Together is due to be published in 2008. The new guidance will replace the 1998 publication. It is broader in scope than its predecessor, placing greater emphasis on how doctors and patients work together to make good decisions, and providing a framework that will apply to the range of situations that doctors face in practice. It also reflects changes in the law, including the new mental capacity legislation and case law that requires doctors to explain the range of risks associated with a proposed intervention.)

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Serious Communicable Diseases, GMC, October 1997 (Note: update to serious communicable diseases guidance, non-consensual testing following injuries to health care workers. The GMC’s guidance on consent for testing for HIV or other communicable diseases following a needlestick injury or other occupational exposure to patients’ blood or bodily fluids has been superseded by various changes to the law. This means that paragraphs 8–11 of Serious Communicable Diseases are out of date. In England, Wales and Northern Ireland, this area is now governed by the Human Tissue Act 2004, which came into force on 1 September 2006. The Mental Capacity Act 2005, which came into force in April 2007, also affects this area of law. How or whether the Mental Capacity Act will apply in Northern Ireland is still to be determined. In Scotland, this area is governed by the Adults with Incapacity (Scotland) Act 2000, which came into force in April 2001 and the Human Tissue (Scotland) Act 2006, which came into force on 1 September 2006. The GMC advises that you must comply with the requirements set out in the legislation and any statutory regulations and codes of practice issued by the relevant authority or ministers. For information and advice on the law, contact your defence body or professional association or seek legal advice. The GMC will update this statement when they have further information about the effect of the operation and interaction of the human tissue and mental capacity legislation across the UK. For more information on the GMC’s guidance and this statement, contact the GMC’s standards and ethics team on 020 7189 5404.) Guidance for Doctors who are asked to Circumcise Male Children, GMC, 1997 Transplantation of Organs from Live Donors, GMC, 1992 (Note: The GMC is currently drafting Guidance on Expert Witnesses.)

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9.3 The Royal College of Surgeons of England
All documents can be found at http://www.rsc.eng.ac.uk/publications/docs/. Surgery for Children: Delivering a First Class Service, RCS, July 2007 Children in Hospital: Rights and Responsibilities of Children and Parents, RCS Patient Liaison Group, June 2007 The Leadership and Management of Surgical Teams, RCS, June 2007 Continuing Professional Development: Advice to All Surgeons from the Senate of Surgery of Great Britain and Ireland, Senate of Surgery of Great Britain and Ireland, January 2006 The Surgical Workforce Interim Report and Policy Update, RCS, October 2006 Delivering High-quality Surgical Services for the Future. A consultation document from the Royal College of Surgeons Reconfiguration Working Party, RCS, March 2006 Management of Waiting Lists: What is Important to Patients, RCS Bulletin, RCS Patient Liaison Group, 2005 Developing a Modern Surgical Workforce, RCS, January 2005 Equality and Diversity Policy, RCS, 2004 Maintaining your Performance – Dossier of Guidance on Continuing Professional Development for Surgeons, Senate of Surgery of Great Britain and Ireland, 2004 Patient Rights and Responsibilities, RCS Patient Liaison Group, 2002 Better Care for the Severely Injured, RCS and British Orthopaedic Association, July 2000 Code of Practice for the Surgical Management of Jehovah’s Witnesses, RCS, 1996; see also Personal Beliefs and Medical Practice, a draft for consultation, GMC, 2007 The Surgeon’s Duty of Care: Guidance for Surgeons on Ethical and Legal Issues, Senate of Surgery of Great Britain and Ireland, October 1997 Guidelines for Clinicians on Medical Records and Notes, RCS, 1994 (revised from 1990)

9.4 Other bodies
Good Medical Practice – Guidance from the Disability Rights Commission, DRC, 2007 Gynaecological Examinations. Guidelines for Specialist Practice, Royal College of Obstetricians and Gynaecologists, September 2002 Towards Standards for Organ and Tissue Transplantation in the UK, British Transplantation Society, 1998

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10 Useful contacts
10.1 Surgical royal colleges in Great Britain and Ireland
The Royal College of Physicians and Surgeons of Glasgow 232–242 St Vincent Street, Glasgow G2 5RJ Tel: 0141 221 6072 Fax: 0141 221 1804 www.rcpsg.ac.uk The Royal College of Surgeons of Edinburgh Nicolson Street, Edinburgh EH8 9DW Tel: 0131 527 1600 Fax: 0131 557 6406 Email: [email protected] www.rcsed.ac.uk The Royal College of Surgeons of England 35–43 Lincoln’s Inn Fields, London WC2A 3PE Tel: 020 7405 3474 Fax: 020 7831 9438 www.rcseng.ac.uk The Royal College of Surgeons in Ireland 123 St Stephens Green, Dublin 2, Ireland Tel: 00 353 1 402 2100 Email: [email protected] www.rcsi.ie

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10.2 Surgical specialist associations and societies
All the associations and societies are based at The Royal College of Surgeons of England, 35–43 Lincoln’s Inn Fields, London WC2A 3PE. Association of Surgeons of Great Britain and Ireland Tel: 020 7973 0300 Fax: 020 7430 9235 Email: [email protected] www.asgbi.org.uk British Association of Oral and Maxillofacial Surgeons Tel: 020 7405 8074 Fax: 020 7430 9997 Email: [email protected] www.baoms.org.uk British Association of Otorhinolaryngologists – Head and Neck Surgeons Tel: 020 7404 8373 Fax: 020 7404 4200 Email: [email protected] www.entuk.org British Association of Paediatric Surgeons Tel: 020 7869 6915 Fax: 020 7869 6919 Email: [email protected] www.baps.org.uk British Association of Plastic, Reconstructive and Aesthetic Surgeons Tel: 020 7831 5161 Fax: 020 7831 4041 Email: [email protected] www.bapras.org.uk British Association of Urological Surgeons Tel: 020 7869 6950 Fax: 020 7404 5048 Email: [email protected] www.baus.org.uk British Orthopaedic Association Tel: 020 7405 6507 Fax: 020 7831 2676 Email: [email protected] www.boa.ac.uk

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Society of British Neurological Surgeons Tel: 020 7869 6892 Fax: 020 7869 6890 Email: [email protected] www.sbns.org.uk Society for Cardiothoracic Surgery in Great Britain and Ireland Tel: 020 7869 6893 Fax: 020 7869 6890 Email: [email protected] www.scts.org

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10.3 Other contacts
Academy of Medical Royal Colleges 70 Wimpole Street, London W1G 8AX Tel: 020 7486 0067 Fax: 020 7935 9214 Email: [email protected] www.aomrc.org.uk Association of Surgeons in Training 35–43 Lincoln’s Inn Fields, London WC2A 3PE Tel: 020 7973 0300 Fax: 020 7430 9235 Email: [email protected] www.asit.org British Association of Medical Managers Petersgate House, St Petersgate, Stockport SK1 1HE Tel: 0161 474 1141 Fax: 0161 474 7167 Email: [email protected] www.bamm.co.uk British Medical Association BMA House, Tavistock Square, London WC1H 9JP Telephone 020 7387 4499 Fax: 020 7383 6400 www.bma.org.uk British Orthopaedic Trainees Association 35–43 Lincoln’s Inn Fields, London WC2A 3PE Tel: 020 7405 6507 www.bota.org.uk British Association of Day Surgery 35–43 Lincoln’s Inn Fields, London WC2A 3PE Tel: 020 7973 0308 Fax: 020 7973 0314 Email: [email protected] British Association for Emergency Medicine Churchill House, 3rd Floor, 35 Red Lion Square, London WC1R 4SG Tel: 020 7404 1999 Fax: 020 7067 1267 Email: [email protected] www.emergencymed.org.uk

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British Transplantation Society Association House, South Park Road, Macclesfield SK11 6SH Tel: 01625 504 060 Fax: 01625 267 879 Email: [email protected] www.bts.org.uk Clinical Governance Support Team 1st Floor, St John’s House, 30 East Street, Leicester LE1 6NB Tel: 0116 295 2000 Email: [email protected] www.cgsupport.nhs.uk Department of Health (England) Richmond House, 79 Whitehall, London SW1A 2NS Tel: 020 7210 4850 Email: [email protected] www.dh.gov.uk Department of Health, Social Services and Public Safety Castle Buildings, Stormont, Belfast BT4 3SJ Tel: 028 9052 0500 Fax: 028 9052 0572 www.dhsspsni.gov.uk Federation of Independent Practitioner Organisations 14 Queen Anne’s Gate, London SW1H 9AA Tel: 020 7222 0975 Fax: 020 7222 4424 www.fipo.org.uk General Medical Council Regent’s Place, 350 Euston Road, London NW1 3JN Tel: 08457 357 8001 Email: [email protected] www.gmc-uk.org GMC Fitness to Practise Directorate 5th Floor St James’s Buildings, 79 Oxford Street, Manchester M1 6FQ Tel: 0845 357 0022 Email: [email protected] Healthcare Commission Finsbury Tower, 103–105 Bunhill Row, London EC1Y 8TG Tel: 020 7448 9200 Email: [email protected] www.healthcarecommission.org.uk

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The Medical Defence Union 230 Blackfriars Road, London SE1 8PJ Tel: 020 7202 1500 Email: [email protected] www.the-mdu.com The Medical and Dental Defence Union of Scotland Mackintosh House, 120 Blythswood Street, Glasgow G2 4EA Tel: 0845 270 2034 Fax: 0141 228 1208 Email: [email protected] www.mddus.com The Medical Protection Society (Leeds) Granary Wharf House, Leeds LS11 5PY Tel: 0113 243 6436; lo-call: 0845 605 4000 Fax: 0113 241 0500 The Medical Protection Society (London) 33 Cavendish Square, London W1G OPS Tel: 020 7399 1300; lo-call: 0845 605 4000 Fax: 020 7399 1301 Email: [email protected] www.mps.org.uk Medical Research Council 20 Park Crescent, London W1B 1AL Tel: 020 7636 5422 Fax: 020 7436 6179 www.mrc.ac.uk Medicines and Healthcare Products Regulatory Agency 10–2 Market Towers, 1 Nine Elms Lane, London SW8 5NQ Tel: 020 7048 2000 (weekdays 9.00–17.00) or 020 7210 3000 (out of hours) Fax: 020 7084 2353 Email: [email protected] www.mhra.gov.uk National Clinical Assessment Service (England Office) 1st Floor, Market Towers, 1 Nine Elms Lane, London SW8 5NQ Tel: 020 7084 3850; advice line: 020 7062 1655 Fax: 020 7084 3851 Email (general): [email protected] Email (advice): [email protected] www.ncas.npsa.nhs.uk

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National Clinical Assessment Service (Wales Office) Sophia House, 28 Cathedral Road, Cardiff CF11 9LF Tel: 029 2066 0280 Fax: 029 2066 0279 National Clinical Assessment Service (Northern Ireland Office) Lisburn Square House, Office Suite 2, Haslem’s Lane, Lisburn BT28 1TW Tel: 028 9266 3241 Fax: 028 9267 7273 National Confidential Enquiry into Patient Outcome and Death 4–8 Maple Street, London W1T 5HD Tel: 020 7631 3444 Fax: 020 7631 4443 Email: [email protected] www.ncepod.org.uk National Coordinating Centre for Health Technology Assessment Mailpoint 728, Boldrewood, University of Southampton, Southampton SO16 7PX Tel: 023 8059 5586 Fax: 023 8059 5639 Email: [email protected] National Counselling Service for Sick Doctors Tel: 0870 241 0535 National Institute for Health and Clinical Excellence MidCity Place, 71 High Holborn, London WC1V 6NA Tel: 020 7067 5800 Fax: 020 7067 5801 Email: [email protected] www.nice.org.uk National Library for Health Specialist Library for Surgery, Theatres & Anaesthesia www.library.nhs.uk/theatres National Patient Safety Agency 4–8 Maple Street, London W1T 5HD Tel: 020 7927 9500 Fax: 020 7927 9501 Email: [email protected] www.npsa.nhs.uk

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Patient Liaison Group of The Royal College of Surgeons of England 35–43 Lincoln’s Inn Fields, London WC2A 3PE Tel: 020 7869 6045 Fax: 020 7869 6044 Email: [email protected] www.rcseng.ac.uk/patient_information Public Liaison Group of the Royal College of Surgeons of Edinburgh Nicolson Street, Edinburgh EH8 9DW www.rcsed.ac.uk Scottish Government Health Directorate St Andrew’s House, Regent Road, Edinburgh EH1 3DG Tel: 0131 556 8400 Fax: 0131 244 2162 Email: [email protected] www.scotland.gov.uk Scottish Audit of Surgical Mortality 2nd Floor, Cirrus, Marchburn Drive, Paisley PA3 2SJ Tel: 0141 282 2280 Email: [email protected] www.sasm.org.uk Welsh Assembly Government Cardiff Bay, Cardiff CF99 1NA Tel: 029 20 825111 www.wales.gov.uk

53 Good Surgical Practice | 2008

Acknowledgements
The revision and updating of this version of Good Surgical Practice and associated documentation was undertaken, on behalf of the Professional Standards Committee of The Royal College of Surgeons of England, by Maggy Wallace MA BA RN DipEd FHEA.

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The Royal College of Surgeons of England 35–43 Lincoln’s Inn Fields London WC2A 3PE T: 020 7405 3474 www.rcseng.ac.uk
Registered charity number 212808