Sir Ara Darzi: Good surgery for the NHS organism?

Sir Ara Darzi is an interesting appointment in the new Labour Pantheon of Heroes. Alongside people like Hewitt, Blair, Milburn, Dobson, Donaldson et al he at least stands out as someone who might actually know something and do something. The question is will he do the right things?

Classical surgical teaching is that a good surgeon knows how to operate, a great surgeon also knows when to operate. Surgeons by temperament are medicine’s doers. They tend to dive in with both hands (or both laparoscopes nowadays) and get on with things. They literally cut to the chase, and if they are not fast they lose the battle between the quick and the dead. They are decisive, and their cardinal virtues are speed and accuracy. If you think your surgeon is getting bored listening to your lament about your bowel spasms, you’re right. The surgeon is answering two questions: Any pathology here? Can I cut it out? If the answer to either or both is no then the surgeon’s interest will rapidly dissipate. Surgeons are great characters, often colourful and energetic, but they are usually impatient with those who don’t show either energy or willing. If you have a surgical problem they are very helpful. If you have anything else you should avoid the surgeons entirely. Good GPs try to prevent surgeons getting their hands on anything other than surgical cases, both to keep surgeons running efficiently, and to protect patients from the dangers of unnecessary intervention.

The old fashioned general surgeon had a bad habit of opening people up to see what was going on inside. They didn’t have as many scans in those days, and a lot of pathology was discovered and treated at the time of surgery for the first time. The patient had to trust the surgeon to “do the needful.” Often both surgeon and patient were surprised by the results.

Now we tend to have prior information and have scan and biopsy results so that operations are planned more carefully. We also do most surgery laparoscopically so that wounds are smaller and infection risks should be lower. Also patients have less tissue damaged on the way to the diseased organ so that they recover faster afterwards. Gall bladder removal used to be a 10 day stay in hospital after open surgery. Nowadays it usually about 2 days after laparascopic cholecystectomy.

Now Sir Ara Darzi has been one of the pioneers of laparoscopic surgery in this country. And I have no doubt his surgical ability is great, and his position at the Hammersmith well merited.

But I wonder if experience at that great centre of excellence is really the best preparation for the role he is about to play in the deciding the future direction and configuration of NHS primary and secondary care.

In his own surgery he is a precise minimally invasive surgeon, aiming to reduce the collateral damage around the operation site as much as possible. In his work on the whole NHS system is he going to be a minimally invasive, neat surgeon? Or is he going to be as big a butcher as “the last of the great general surgeons”?

We do not know, but on Dr Rant our “internal crap detectors” are ringing. Darzi went to Teeside recently with mixed results, and one closure in his wake, despite his not recommending it. The locals were far from impressed.

A Conservative spokesman summed it up thus,
"Ara Darzi has a poor record of supporting access to services for patients. He has a history of rubber-stamping the demands of the Department of Health." Well at least he’s now snuggled up inside the Department of Health.

So will Londoners be flocking gratefully to well staffed polyclinics? I don’t think we’ll need an ultrasound scanner to hear the chorus of disapproval that will greet these proposals. After all we do so want a healthcare system like that of the old Iron Curtain countries don't we?

Dr Rant wonders whether Sir Ara Darzi is really the man to tackle NHS reconfiguration. The top of the medical profession has long been populated by micro-specialists. The sort of people who think ENT is a large speciality, and that they’ll confine their practice to diseases of the right nostril, and more specifically the inferior turbinate bone.

These people always show that specialists are better than generalists- for specific problems- once they have been defined. They have a bad habit of only seeing the numerator of any problem (the cases) and no knowledge of the denominator (the number of patients with all sorts of problems that may or may not belong in their speciality) These micro-specialists obey the classic rule of knowing more and more about less and less.

Now the specialist viewpoint has it uses, but it also has its blind spots. That’s why the work of specialists is best used alongside the much broader vision of the generalist. And when it comes to taking a general overview of a case a GP is better placed than most surgeons to do this.

I hope Sir Ara is reading Barbara Starfield and Julian Tudor-Hart’s work. I hope he’s read some of Iona Heath and James Willis’s stuff as well. I hope has some understanding of the difficulties of dealing with “symptom soup” that is GPs staple fare. I hope he has some idea that demand for health care is near infinite and that symptoms are far commoner than serious medical pathology. Above all Dr Rant hopes that Sir Ara has an idea that health is more than the absence of disease, and that healthcare does not, cannot, and will not, correct health inequalities between social classes.

It’ll be interesting to see how Sir Ara Darzi fares at DH. Sadly Dr Rant is not optimistic for him, partly because we think Labour’s NHS is a total disaster zone, and partly because we are not sure Sir Ara has the right background knowledge for the task he is undertaking, although he may learn quickly. He may of course be a fool, rushing in to take on an impossible task, whilst wiser men look on. The difference between courage and foolishness is often very little, and knowable only in retrospect.

Time will only say "You'll know when you've been Darzied!"