What we have learned from 100 surgical reviews

Tim Rockall profile picture

01 April 2019

Tim Rockall
Chair of The Invited Review Mechanism
Royal College of Surgeons


One of my responsibilities as a member of council for the Royal College of Surgeons (RCS) is as chair of the Invited Review Mechanism (IRM). The IRM provides hospitals with an independent, external and professional review of an individual surgeon or surgical service. This typically involves surgeons and lay people being invited into a hospital to talk to staff on a confidential basis and examine information to determine whether there is cause for concern and make recommendations for improvement.

In many areas of surgery, patient outcomes are of a consistently high standard and surgeons are leading the way in delivering major improvements to the quality of people’s lives. Various clinical audits published by the Royal College of Surgeons and NHS England show the UK has surgical outcomes among the best in the world.  The most recent Care Quality Commission annual State of care report demonstrated that the vast majority of surgery in hospitals is either good or outstanding. However, in a small number of surgical departments, more needs to be done to improve the quality, and to reduce the variability, of surgical outcomes and the standards of patient care provided. The IRM can help to address these issues.

In many areas of surgery, patient outcomes are of a consistently high standard and surgeons are leading the way in delivering major improvements to the quality of people’s lives.

Tim Rockall    Chair of The Invited Review Mechanism

Between 2008 and 2017, we carried out a total of 240 IRM reviews and have spent time over the last year analysing the trends within a sequential sample of 100 review reports with regards to 18 key themes. Discussions of what it means to provide good and safe surgery often focus exclusively on the technical aspects of how operations are performed. Technical proficiency is, of course, an absolutely essential pre-requisite for any surgeon, but our findings show that many other factors also play a part when problems arise and should therefore also receive attention.

Technical proficiency is, of course, an absolutely essential pre-requisite for any surgeon, but our findings show that many other factors also play a part when problems arise and should therefore also receive attention.

Tim Rockall    Chair of The Invited Review Mechanism

One of the most significant findings of this analysis was that in over three quarters (76%) of the reviews examined, poor team working had contributed to problems in the delivery of surgical care. This is something I recognise from the specific reviews I have participated in and the many other review reports I have read in my role as the IRM’s chair. It is always disheartening to see a situation in which interpersonal issues have developed over time and have become a barrier to a team achieving its fullest potential.

One of the most significant findings of this analysis was that in over three quarters (76%) of the reviews examined, poor team working had contributed to problems in the delivery of surgical care.

Tim Rockall    Chair of The Invited Review Mechanism

Each individual situation is different but there are a number of common factors, prevalent in many of our reviews. One notable factor is isolated consultant surgeon working. We found that, if individuals do not meet regularly and effectively as a consultant surgical team, they may miss opportunities to identify and tackle, at an early stage, ways of working that could lead to problems. We also found that isolated working increases the risk of poor quality care through a lack of discussion of complex cases or a lack of collaboration to learn from problems and deliver service improvements.

The RCS has developed a simple, interactive web resource to help hospital teams improve the quality of discussions about surgical practice. This web page leads the reader through the 18 key themes and encourages them to think about the strengths and weaknesses of their own services. We hope that those involved in the delivery of surgical care will read our report on the learning from invited reviews, learn from some of the issues other departments have experienced and use this to improve the care they provide to patients.

About the author

Tim Rockall profile picture

Tim Rockall
Chair of The Invited Review Mechanism

Tim Rockall specialises in laparoscopic gastrointestinal surgery and has a particular interest and expertise in laparoscopic colorectal surgery. He has held the position of director of the minimal access therapy unit (mattu) in Guildford since 2003 and also has an active research programme within the fields of minimally invasive surgery, new technology and enhanced recovery after surgery. He is a past president of The Association of Laparoscopic Surgeons of Great Britain and Ireland. Tim Rockall was elected to the RCS’ Council in 2015 and appointed as chair of the Invited Review Mechanism in January 2018.

We use cookies to ensure you have the best possible experience on our website. By continuing we’ll assume that you are happy to receive them. Read our updated privacy and cookie policy. Close