Vascular Surgery The 10th Surgical Specialty Michael J Gough Head of School, Yorkshire & Humber Past-President VSGBI

Why? Armageddon a final war between good and evil at the end of the world, as described in the Bible, or, more generally, any event of great destruction Scalpel or stent?

Vascular Surgery Interventional Radiology Imaging US, MR, CT Intervention 1972 angioplasty 1990 AAA stent graft 1993 Carotid stents 2005 branched grafts Other influences Secondary prevention Smoking cessation The Heyday 1904 Sutured anastomosis 1927 Angiography 1948 Fem-pop vein graft 1952 AAA repair 1953 Aortic reconstruction 1954 Carotid reconstruction Synthetic grafts Critical care Complex aneurysms Late 1980’s

Is the Workload Diminishing? Aging population prevalence expectations: QOL Diabetes 2.3 million  2.5 million 15%  “vascular” problems Aneurysm screening screening programme 5% of 65yr old men Stroke & TIA initiative early presentation early diagnosis early intervention (CEA superior to CAS)

The balance has changed Surgery Intervention

Delivery of Modern Vascular Therapy Problems & Solutions Separate Vascular Specialty Recruitment (radiology) EWTD Demise of General Surgery Curriculum as Subspecialty

Specialty Status = Centralisation Fewer, larger units 7-10 surgeons Interventional radiology Reduction in AAA mortality Delivery of stroke targets Diabetes National Framework Manpower Concentration of trainees Non Training grades Flexible trainees

Why We Need Centralisation & Specialty Status Elective workload Emergency Workload 30-40% of total workload –High risk, cost –Immediate availability Specialty requirements –Endovascular rAAA –Out of hours imaging –Diabetic foot complications Training in resourced units Specialist AES Specialist team including radiologists High volume Audit and Research Curriculum responsive to need Evaluation of new treatments Better manpower planning

The Route to Specialty Status Joint Working Party: VSGBI, RCR, RCS 3 Drivers Workload, Rotas, Recruitment, EWTD, NHS requirements Separate specialty in Europe (The World) 2008: Agreement by RCS 2008: Agreement by VSGBI membership 2009: Application to DoH & Consultation 2010: ???

Department of Health Response by April 2010 General Election – new priorities “Responses generally supportive of the application going through to the next stage” Formal submission of curriculum Exit exam

Anticipated Training Schemes CCT Vascular Surgery ST4-8: Modular Training Vascular Surgery/Intervention ST3 Core Competencies in Gen Surg Core Surgical Training FY1-2

Modular Training Radiology for Surgeons 24 months (? learn quicker) Components: Diploma in medical ultrasound Modules: angiography & angioplasty ultrasound cross-sectional imaging intra-operative procedures “non-vascular” intervention

A Partnership Still need interventional radiologists Large centralised units

The Consultant Job Plan? All day theatre list (intra-op intervention) 0.5 day minimally invasive venous Rx 1-2 OPD 0.5 day ultrasound 0.5 day “intervention”