Surgical questions

May 4, 2002 The Times (London)
Successful surgery is commonly thought to be a matter of cool scientific judgment and extraordinary dexterity. Our report today of the introduction and withdrawal of single-use surgical instruments for tonsil operations shows that far more is involved. There is uncertainty and guesswork, high politics and media management. Sadly the episode also suggests that mistakes made with any of these things can result in tragedy as surely as a slip of the surgeon's knife. The Department of Health and its advisory body, the Spongiform Encephalopathy Advisory Committee (SEAC), have been struggling with a number of difficult decisions forced upon them by the uncertainties that exist about vCJD. Without knowing for sure whether a few hundred or several hundred thousand people will eventually develop the human form of BSE and how easy it is to transmit and without the ability to do all that much to help those who are at risk, it is very difficult indeed to decide exactly what price, in financial or human terms, is worth paying to reduce the risk of infection.

The decision to replace traditional instruments for tonsil operations with single-use instruments therefore involved some guesswork, balancing the risks and costs to patients of changing the instruments with the unquantifiable risk of continuing with the existing ones. Tonsils may be a great deal less infectious than brain tissue, but since the patients involved are so frequently children, the choice made by the department was understandable. It would not be surprising if fear of being accused by the media of underestimating the danger of vCJD also played a role, possibly an outsize one.

However, some serious questions need to be asked about the way the decision was implemented. The Department of Health is studying the experience it has had and the deaths that have occurred to learn lessons. It is certain that mistakes were made. It is important to find out what they were.

A Pounds 25 million change was followed so swiftly by its withdrawal that something clearly went badly wrong. An obvious candidate is that insufficient care was taken to determine how well the new instruments would work before they were commissioned. If the problem with the single-use instruments was merely that surgeons were uncomfortable with them because they were new, then it would have been possible to provide testing and training to ensure that this did not endanger the health of patients. It would certainly be worrying to discover that this was not done because officials wanted to prevent a media health scare. Such things, must not drive policy.

Equally worrying is the suggestion that policy might have changed sooner had they been aware of a death in a private hospital that took place five months before the death that forced their hand. The investigation must examine the truth and reassure the public that regulatory changes prevent it from happening again.

The other issue to be resolved is the continued deployment of single-use instruments in Scotland, Northern Ireland and Wales. Residents in those parts of the UK will wish to know if they would be safer travelling to England to have their tonsils removed. Are surgeons in these parts of the UK being asked to dispose of their instruments because their decontamination facilities are so much poorer than in England or have they simply proved more flexible and adept at changing instruments?

Speedy answers are required to these questions and as much information as possible should be made public. No one wishes to add unnecessarily to panic over vCJD, but decisions made in the open are infinitely superior to mistakes made in secret.

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