For clarity, I no longer meet the number of surgical procedures required, so that is why I no longer operate.
The royal colleges of surgery, of which there are four—Glasgow, Edinburgh, London and Dublin—are the hosts for that surgical standard. A standard also applies in medicine, across other specialties and in general practice, but it is neatest in surgery, as you have illustrated. It is unusual for there to be an actual number, although it is true that there is one in some areas, such as knee revisions. A second artificial knee replacement is quite a difficult and complex procedure. I cannot remember the number—Tracey Gillies might remember—but I think that a surgeon might have to do 15 knee revisions a year, because the procedure is hugely complex. A person is only going to need a knee revision once in their life, probably—maybe twice, but it would be unusual to have three knees in a lifetime. I do not mean three knees; I mean three consecutive knee revisions on the one knee. A health system—whether Danish, Scottish or Swedish—will make a decision that knee revisions will be done in a knee revision expert centre. Our knee revision expert centres are in the Golden Jubilee national hospital and in Lothian, so people have to travel for a knee revision.
When you ask the public what they think about what happens with knee revisions, or cleft lip and palate surgery, they probably consider it to be reasonable. About 100 babies a year are born with a cleft lip and palate, and it is pretty clear that we are not going to deal with that in five centres, but will deal with it in a very small set of units. However, diabetes is hugely common and affects hundreds of thousands of people, so we are going to have to do that everywhere. There is no choice: GPs will have to see diabetics. We are not suddenly going to say, “You can’t go to your general practitioner if you’re diabetic. You have to go to the Golden Jubilee.”
The two extremes are okay. Every healthcare system in the world is struggling with where the line is in that continuum, particularly those with rural challenges, such as Scotland’s. In Inverness, at some level we will have to continue to provide most surgical specialties at Raigmore, but there are decisions to be made around trauma, cardiothoracic surgery and neurosurgery, where the numbers are not tiny but they are not big enough to be managed at huge centres. There would not be enough cases at Raigmore to provide surgeons with the number of major trauma surgeries that they would require to maintain their skills.
There are both numbers and competencies about how that might be done. The fundamental answer to the question is that the royal colleges decide and can inspect our surgical levels. We then give advice to the ministers about how we should distribute that care around the nation, taking in the views of the public, the clinical teams and the local elected officials at every level in those environments, but at some level somebody has to make a decision about what will be provided in NHS Grampian or NHS Highland, and that will not always be everything.