Lapco  

About The Programme

The National Training Programme in Laparoscopic Colorectal Surgery



INTRODUCTION

The National Training Programme (NTP) in Laparoscopic Colorectal Surgery (LCS) is funded by the Cancer Action Team at the Department of Health to provide LCS training for colorectal consultants in England. 
 
Lapco was devised in 2007 to implement the 2006 NICE guidelines that state that laparoscopic (including laparoscopically assisted) resection is recommended as an alternative to open resection for individuals with colorectal cancer in whom both laparoscopic and open surgery are considered suitable. The guidance was waived in 2006 due to the lack of trained surgeons and this waiver is due for review in September 2009.
 
In January 2008, 10 groups encompassing initially 16 Trusts in England were allocated training centre status by the National Cancer Action Team at the Department of Health. In January 2010, a further North West Group was appointed as the 11th NTP Training Centre, there are a total of 37 Trusts now involved with the delivery of training through 67 appointed NTP Lapco Trainers. Click to view NTP Trainer List

In early 2008, tthe responsibility for National Clinical Lead for the NTP was given to Professor John Monson, Head of the Academic Surgical Unit in Hull. An office for NTP Coordination was opened in Hull and the programme was introduced via a newsletter published on the ACPGBI website in July 2008. At around the same time, Professor Monson resigned having secured a chair in the USA and the post of National Clinical Lead was re-advertised. At the end of September 2008, Mark Coleman, Consultant Surgeon in Plymouth was appointed the new National Clinical Lead. In March 2009 the new National Coordination Office opened in Plymouth with a full time National Programme Manager and Administrator (Coordination office). Educational assessment is carried out by our group at Imperial College run by Professor George Hanna.
 
The programme was intended to run for 2 years with the aim of training enough colorectal surgeons in LCS to a level of independence in routine colonic resections, this  will give all patients diagnosed with colorectal cancer in England have access to a trained surgeon.  The programme has been extended to run until March 2013 to ensure that all our registered trainees are able to complete their training through the Sign Off process.
 
By the end of the programme, Lapco will have funded 51 Courses, providing a total of 102 course days. These include 12 Cadaveric Courses (Newcastle, Nottingham and Bristol), 12 Immersion Courses (Basingstoke and Bradford), Enhanced Recovery Courses (St Marks and Bristol), 10 Lapco TT (Train the Trainer) Courses, 4 Theatre Practitioner Days, and 8 Lapco National Education Masterclasses hosted throughout the Country.

 PROGRAMME ENTRY 
Registrations to the programme were drawn to a close in October 2011 to ensure that all registered trainees were able to complete their training before the programme end in March 2013 

All Colorectal Consultants in substantive posts in England were eligible to apply to Lapco. Registration was carried out through this website, and application was completed through the submission of an Application Form along with explicit written support from the Trainee’s Trust Chief Executive or Medical Director which was required for an application to be considered (link to Mike Richards letter + NHS management notes). Each application was reviewed by the National Coordination Office and the applicant was written to by the National Cinical Lead, and offered a tailored package of pre-clinical and training opportunities. A Training centre was allocated according to trainee preference, training capacity and geographical location. A training centre manager/administrator contact was provided to each trainee in their appointment letter who is the local coordination link for arranging training sessions.
 
TRAINER APPOINTMENT
NTP Trainers were appointed either through the initial appointment of the training centres through the selection process in 2008, or by subsequent trainer appointments after this date which have been made to support the volume of required training activity, and to comply trainers have had to:
1.Be reccommend to the National Clinical Lead by an existing NTP Trainer
2.Be required by a specific named training centre to assist with their training delivery.
3.To have completed 100 Colorectal Resections
4.Be based in a full time substantive post at a Trust in England
Upon confirmation of the above, all trainer appointments have been recorded and formally appointed in writing to the programme by the National Clinical Lead. All NTP appointed trainers are encouraged to attend the two day Lapco TT (Train the LCS Trainer) Courses, a total of 70% of trainers have attended this course to date.
 
TRAINING PORTFOLIO
 
After application, each programme participant had their own web portfolio, accessed by user name and password through the Lapco web site. Information in each portfolio is also accessible by the National Coordination Office, the Educational Assessment Group and the Training Centre responsible for that participant. Information will be held in confidence. NTP participants are able to download their own portfolio in a usable (.csv) format for use in audit and appraisal, and can view their progress through the "Learning Curve".
 
PROGRAMME STRUCTURE
 
The NTP offered a number of pre-clinical and clinical methods of training. The programme recognised that it needed to be flexible to the needs of surgeons and their varying levels of experience. Many will have already attended masterclasses, cadaver courses or wetlabs and will also have extensive experience of laparoscopic procedures such as cholecystectomy, Therefore the programme needed to offer different entry points accounting for level of skill. The NTP places strong emphasis on team training throughout. It is funded to provide equipment for training centres, to fund places on preclinical courses and to enable backfill of trainers’ clinical sessions whilst engaged in NTP activity.

 
 PRE-CLINICAL TRAINING
 
The Pre-Clinical training opportunities and courses for consultants and their teams were made available throughout the Country, including NTP Funded Cadaveric Courses at Newcastle, Nottingham and Bristol, Immersion Courses at Basingstoke (4 Day Courses) and Bradford (3 Day Courses), and Enhanced Recovery Courses at Bristol, and St Marks, London. The NTP has emphasised and encouraged team training as we recognise that this hastens the ascent up the learning curve. Strong emphasis was placed on Enhanced Recovery Courses as data suggests that enhanced recovery programmes help to further reduce hospital stay in patients undergoing bowel resection.
 
Lapco has run also run a programme of one day laparoscopic colorectal education masterclasses throughout the Country for up to 100 delegates per course. These have encompassed morning sessions on surgical presentations, techniques and approaches, and afternoon sessions structured around live theatre on cases lead by NTP Trainers.  These courses have been suitable for the Consultant, and their team to attend. In addition, as the Lapco programme has developed further emphasis has been placed on the support education for the team, and Lapco has run a number of Theatre Practitioner Courses.
 
Wetlab Courses (ESI, Hamburg and Elancourt, Paris) These courses are sponsored and run by Ethicon (Hamburg) and Covidien (Paris). They are of a similar format covering 2 days. Each comprises lectures on the evidence for laparoscopic colorectal surgery, establishing a practice in LCS, theatre set up, and extensive material on how to perform LCS. Each also gives excellent hands on experience in the wet lab. There are also opportunities for theatre teams to accompany surgeons on these trips. Further information can be obtained through your Ethicon Endosurgery and Covidien Territory Managers.
 
CLINICAL TRAINING
 
It is generally envisaged that around a minimum of 20 cases will be required to reach a level of competence. This may vary in either direction depending on the skill and experience of the individual. A form of assessment of competence has been incorporated into the NTP to provide surgeons in the programme a means of objectively determining that their training has been assessed and recorded by their NTP trainer. This information is intended for use by consultants as part of their appraisal and revalidation. (link to education)
 
All training centres offer on going opportunities for live observation of LCS cases, the NTP has encouraged theatre team involvement in such visits which should take place prior to hands on clinical training.
 
Training takes place normally through a combination of both "in reach" and "out reach" training, with a slight variation of "in reach" for trainees registered with Kings`, Guys & St Thomas` and Guildford as detailed below:

1.In Reach
In reach preceptoring involves consultant trainees operating in the trainers hospital with an honorary contract under the direct supervision of the trainer. The trainee attends the trainers hospital to perform a case with a patient from the trainers trust. This model of training is availalable at 10 Training Centres which are Newcastle, Bradford, Hull, Nottingham, Oxford, St Marks/Colchester/Guildford, Portsmouth, Basingstoke/Frimley Park, South West, & North West.  

2.In Reach with Travelling Patient
There are two training centres which are Kings, Guys & St Thomas` and Guildford who require their trainees patient from their hospital to travel to the trainers hospital where they will be operated on. In this case the tariff to fund the patient’s procedure and care will travel with the patient to the Training centre.  Follow up of patients will return to the responsibility of the trainee after discharge.

Approximately 65% of all NTP Training sessions are carried out on an in reach basis. 

3.Out Reach
The trainer attends the trainees hospital base, the trainee performs a case in their own theatre on their own patient. Available at 10 Training Centres which are Newcastle, Bradford, Hull, Nottingham, Oxford, St Marks/Colchester/Guildford, Portsmouth, Basingstoke/Frimley Park, South West, & North West. An Honorary Contract is required to be in place for the visiting Trainer.  Approximately 35% of all NTP Training sessions are carried out on an out reach basis.

Both the trainee and trainer will be required to have respective honorary contracts and occupational health clearance in place for in reach, and out reach sessions.  Trainees/Trainers/Training Centre Managers are required to schedule a timetable of training cases to ensure where possible that there are performed over a short period of time to ensure rapid ascent up the learning curve. The NTP funds the trainers trust for both in reach, and outreach cases including travelling expenses

In addition to indiviudal clinical theatre training sessions, Lapco have supported the delivery of clinical immersion courses, these are particularly useful for trainees in the early stages of training, or as a refresher to provide some intensity of training over a 3 or 4 day period, or as they head towards the sign off submission at the end of the training period.  Lapco have run funded Clinical Immersion training courses for their registered Consultant trainees in two locations during the programme which have been held at:
 
1.Pelican (Frimley Park and North Hampshire Hospitals) - Led by NTP Trainers Tom Cecil and Mark Gudgeon: A 4 day course with 8 Consultant NTP delegates and 2 laparoscopic colorectal procedures per day. Each delegate directly observes each case, holds the camera for one and actually performs one case under supervision.As before, the trainee will obtain an honorary contract and occupational health clearance from the training centre. This process will be administered by the Training centre administrator. 

2. Bradford Royal Infirmary - Led by NTP Trainer John Griffith: A 3 day course with 3 Consultant NTP delegates, this course combines lectures on laparoscopic procedures, establishing a colorectal practice, videos, with live operating relayed via a link to the adjacent seminar room

ASSESSMENT

The process of  assessment has been devised and is managed by our Education Department at Imperial College. Each training case during the clinical phase will be accompanied by the use of an online Global Assessment Score (GAS) Form. The GAS forms contain essential information on each case without the patient's name to protect confidentiality TRAINEE GAS FORM. On completion of the form it submitted via the website to the National Coordination Office, the Education Department and the Training Centre responsible for that trainee. The information is locked out to prevent the scores being changed, but the data is then available for the trainee to download for their own purposes.The Education Department has also devised a research programme to observe unedited videos and to determine if it is possible to define a proficiency gain curve for laparoscopic colorectal surgery. (go to Imperial College for more)  The trainer is also required to complete a TRAINER GAS FORM after each case which once completed can be viewed by the trainee through their on line account.
 
SIGN OFF (NTP EXIT)
 
Successful exit from the NTP will be triggered by agreement between Trainer and Trainee. The number of cases required to reach this point is also determined between the trainer and trainee as it is generally recognized that this figure will vary. The NTP predicts this figure will be around 20 cases. For final assessment, 2 unedited videos will be submitted for examination by 2 different trainers from the NTP. Following successful examination of the videos, the Training Centre and the National Lead Clinician will write to the Trainee to indicate completion of the programme and advice for future practice, please go to the Sign Off page on the Lapco web site for more information.
 
AUDIT AND REFLECTIVE PRACTICE 

Both during and after the NTP, lapco encourages ongoing prospective audit of cases to observe operative and post operative outcomes. Through the online Global Assessment Forms, data can be accumulated and stored for each participant in the NTP to provide a useful archive for personal use, presentation, appraisal and revalidation.Lapco also encourages the creation and subsequent observation of operative videos as a useful means of reflective practice.

POST SIGN OFF
Lapco requires that trainees signed off the programme submit post sign off data for a period of 12 months after the date of sign off which is submitted to to the Education Team at Imperial College. This can be submitted through a Lapco spreadsheet, or through the post sign off forms which can be viewed on line in the Post Sign Off section of the web site.

Richards
Gateway Approval Required: Information/Good Practice
Letter to:         NHS Chief Executives, NHS FD Trust/Trust Medical Directors

Dear Colleague,

Re: National Training Programme (NTP) in Laparoscopic Colorectal Cancer Surgery – Supporting NICE Technology Appraisal (2006) recommendations for laparoscopic resection for colorectal cancer
 
In August 2006, NICE issued a technology appraisal recommending laparoscopic resection as an alternative to open surgery for people with colorectal cancer in whom both procedures were suitable. NICE estimated that the surgery would result in shorter bed stays and significantly improve the patient experience. On 31 October 2006, the Department of Health waived the 3-month funding direction to implement this appraisal as it was recognised that there were insufficient surgeons trained in the procedure. The waiver is due to be reviewed in 2009.
 
As part of the Cancer Reform Strategy implementation plans the Department of Health and the National Cancer Action Team have developed and funded a programme to train colorectal surgeons to a level of competence in laparoscopic surgery to perform such procedures independently and safely.
 
As we now have the mechanism in place to train consultant surgeons we would urge you to support all your colorectal surgeons and their teams already in training or who wish to start training, to enrol in the national programme. The programme offers surgeons a flexible, supportive and tailored package of training accompanied by a means of acknowledging the level of competence achieved.
 
Ten training centres based in 16 hospitals have been appointed to deliver the programme, which will allow the NHS to build up the expertise to ensure that the existing colorectal consultant surgeon workforce is trained to deliver high quality colorectal cancer surgery in line with the NICE appraisal.
 
The attached management note gives further details on the background and suggests actions the NHS will want to undertake. The NICE appraisal was very clear that patients should be able to make an informed choice between open or laparoscopic procedures following discussion with their surgeon.


Implementation of NICE’s Laparoscopic Colorectal Surgery Appraisal
NHS Management Note
 
Issue
 
1)            In August 2006, NICE issued a technology appraisal recommending laparoscopic resection as an alternative to open surgery for people with colorectal cancer in whom both procedures were suitable. On 31 October 2006, the Department of Health waived the 3 month funding direction to implement this appraisal.
 
2)            This note sets out the reasons for this waiver and the action that the NHS will want to take as a result.
 
Background
 
Clinical Need & Practice
 
3)            There are around 30,000 new cases of colorectal cancer (cancer arising in the lining of the colon or rectum) registered in England and Wales each year. Complete surgical excision of the tumour is essentially the only potential cure and suitable in approximately 75% of diagnosed individuals.
 
4)            The current UK standard for the surgical resection of primary colorectal tumours is open surgery which involves open laparotomy (surgical incision into the abdominal wall) and removal of the tumour via the abdominal incision. This procedure is associated with significant postoperative pain. While techniques such as epidural analgesia can effectively control postoperative pain, associated complications may require high-dependency care.
 
5)            Laparoscopic or laparoscopically assisted resection involves inserting laparoscopic instruments through a number of ports (openings) in the abdominal wall to dissect tissues around the tumour – the tumour is then usually removed through an abdominal incision, the length of which depends on the size of the tumour. A patient who has laparoscopic surgery is likely to make a quicker post surgery recovery and NICE estimate that a laparoscopic colorectal procedure (a highly complex procedure) would result in a shorter hospital stay - 1.4 days less than for open surgery. However, the leading experts in this procedure in the country are seeing savings significantly higher than this (in the region of a saving of 4-10 bed days per patient) – whilst it would clearly be unrealistic to expect such savings from less experienced surgeons, NICE’s estimate should be considered as a starting point on which greater savings could be possible as expertise builds.
 
NICE Appraisal
 
6)            In August 2006, NICE issued an updated technology appraisal on the use of laparoscopic surgery for colorectal (bowel) cancer. It recommended that laparoscopic (including laparoscopically assisted) resection was an alternative to open surgery in people with colorectal cancer in whom both laparoscopic and open surgery were considered suitable.
 
7)            The appraisal noted that the decision about which of the procedures (open or laparoscopic) was undertaken should be made after informed discussion between the patient and the surgeon and that the following should be considerations:
 
a)      the suitability of the lesion for laparoscopic resection;
b)      the risks and benefits of the two procedures;
c)      the experience of the surgeon in both procedures.
 
8)            Associated with the recommendation about surgeon experience, NICE recommended that laparoscopic colorectal surgery should be performed only by surgeons who had completed appropriate training in the technique (criteria to be determined by relevant national professional bodies) and who perform the technique often enough to maintain competence. This is crucial as this is a highly complex procedure.
 
9)            NICE made it the responsibility of cancer networks and constituent Trusts to ensure that any local laparoscopic colorectal surgical practice met the recommended criteria as part of their clinical governance arrangements.
 
Implementation of NICE appraisals
 
10)        Positive NICE appraisals are usually covered by a 3 month funding direction – this places an obligation on PCTs to fund the service recommended in the guidance in order to make it "normally available". In the case of the laparoscopic colorectal appraisal, this would have meant that PCTs should have funded full implementation so that laparoscopic colorectal surgery was “normally available” by 23 November 2006.
 
11)        However, a waiver to a funding direction can be issued by the Department of Health if it is felt that it is not feasible to expect the NHS to make a service normally available within 3 months.
 
12)        On 31 October, the Department of Health waived the 3 month funding direction to implement the laparoscopic colorectal cancer appraisal.
 
Reason for Waiver
 
13)        NICE made clear in its appraisal that laparoscopic colorectal resections should be performed only by surgeons who had completed appropriate training in the technique and who performed the procedure often enough to maintain competence. In NICE’s associated costing template & report it notes that it has been suggested that a surgeon perform either a minimum of 2 procedures a month or 12 annually in order to maintain competence.
 
14)        Of the 30,000 new patients diagnosed with colorectal cancer in England and Wales each year about 75%  - around 22,500 cases are likely to be suitable for complete surgical excision. Of these, the proportion performed laparoscopically is unclear but is estimated by NICE to be about 2.4% - around 540 procedures compared to around 22,000 open surgical procedures each year.
 
15)        Although NICE has not recommended that laparoscopic colorectal surgery is better than open surgery it has recommended that it should be seen as an alternative. NICE has assumed that around 25% of patients would be suitable to have this procedure (about 5,600 patients) and have estimated that over 460 surgeons (carrying out at least 12 resections per annum) would be needed to support this caseload in the NHS.
 
16)        It is of course possible that more patients would be suitable for, and choose, laparoscopic colorectal surgery. For example, in prospective analyses undertaken at Yeovil District Hospital (part of East Somerset NHS Trust) and Colchester General Hospital (Part of East Rivers Healthcare NHS Trust) more than 90% of patients undergoing elective resection of their colorectal cancer were considered suitable for laparoscopic resection. This would increase the number of procedures each year and surgeons needed significantly.
 
17)        In 2006 it was estimated that there were approximately 45 surgeons in the United Kingdom, performing laparoscopic colorectal resections with a further 30 being trained annually. Whether the proportion of laparoscopic colorectal procedures is 25 or 90% in the future, it is clear that there are insufficient surgeons adequately trained at the present time to manage this volume of patients.
 
18)        Although the cost of laparoscopic colorectal surgery should not be a barrier to provision (NICE estimate that it only costs about £265 more than open surgery) it is clear that the infrastructure to support this appraisal (in term of adequately trained surgeons and their teams) is not sufficiently in place to ensure that PCTs could commission “normally available” safe and timely service for all suitable patients across the country. If the 3 month funding direction were to have remained in place this could have led to:
 
a)      patients being treated by surgeons not sufficiently expert in the procedure leading to increased risk of complications and poorer long term outcomes for patients;
 
b)      patients having to wait a long time (significantly more than the 31 day cancer treatment target) to see a suitably qualified surgeon – this could have serious implications as a patient’s cancer could potentially progress and become incurable if they have to wait too long for treatment.
 
19)        A waiver to the 3 month funding direction was therefore issued to give the NHS sufficient time to build up the expertise to ensure that the existing colorectal consultant surgeon workforce is trained to deliver high quality laparoscopic colorectal surgery in line with the NICE appraisal.
 
Action the NHS will want to take
 
20)        The NHS needs to ensure that action is taken locally to:
 
a)      identify existing consultant colorectal surgeons who require training in laparoscopic procedures to support this appraisal – In 2006 it was estimated that there were around 700 surgeons delivering elective colorectal surgery on a regular basis in England & Wales and that 400-600 of these would require training in laparoscopic colorectal surgery. The remainder are likely to be 5 or so years from retirement where it may not be appropriate to take up this form of surgery or those who would not be able, for other reasons, to train in or carry out this type of procedure.
 
b)      make arrangements to ensure that suitable surgeons (and their supporting teams) receive training so that laparoscopic colorectal surgery becomes an alternative for all patients that might be suitable as soon as possible – A National Training Programme now exists delivered by a network of 10 centres and a National Clinical Lead, Mark Coleman, is in place. The programme is supported by a national coordinating function based in Plymouth.
 
c)      allow some surgeons to become "laparoscopic colorectal surgery trainers" to support the expansion of the workforce in this specialty across the country – Within the NTP surgeons will be needed to train, mentor and assess trainees and local health economies are asked to look favourably on requests from consultant surgeons wanting to take on this role;
 
d)      ensure that providers have the necessary facilities and equipment in place to provide laparoscopic colorectal surgery for when adequately trained staff are available.
 
21)        The actions referred to in this section are about consultant surgeons and their teams only. The training of new Specialist Registrars coming through the system also need consideration and the Clinical Lead should work with the Royal College of Surgeons, ALS and ACP to review this.
 
Conclusion
 
22)        The waiver for the laparoscopic colorectal surgery appraisal should not be seen as a reason for the NHS to defer the action needed to enable implementation of this appraisal. The need for this waiver will be reviewed at or around the time that the appraisal is reviewed by NICE in 2009. The NHS needs to use this time to ensure that they are ready for full implementation of the appraisal by:
 
a)      training appropriate surgeons and their teams;
b)      ensuring suitable facilities and equipment are in place;
c)      starting to offer the option of laparoscopic colorectal surgery to patients as soon as they have the necessary capacity and expertise in place to do so.
 
In some localities, where they already have the necessary expertise, they should be able to implement this appraisal immediately.
 
23)        Although, in the short term, the introduction of laparoscopic colorectal surgery will be more expensive than open surgery, in the longer term (as surgeons become more expert) it is likely to result in savings in terms of bed days. NICE estimate a reduction of over 6,400 bed days based on 25% use of laparoscopic colorectal cancer surgery. The NHS should therefore regard this as an “invest to save” initiative as well as one that could significantly improve patient experience.
 
24)   If you have any queries about the content of this management note please contact: 
Andy McMeeking, Associate Director, National
Cancer Action Team 
Tel 0208 282 6317 
Email andy.mcmeeking@ncat.nhs.uk