Good Surgical Practice 2008

The Royal College of Surgeons of England
35–43 Lincoln’s Inn Fields

London WC2A 3PE
T: 020 7405 3474
www.rcseng.ac.uk
Registered charity number 212808
Good Surgical Practice

February 2008
Review date: 2010
Published: February 2008
Review date: 2010
Good Surgical Practice is endorsed by:
The Association of Surgeons of Great Britain and Ireland

The British Association of Oral and Maxillofacial Surgeons
The British Association of Otorhinolaryngologists – Head and Neck Surgeons
The British Association of Paediatric Surgeons
The British Association of Plastic, Reconstructive and Aesthetic Surgeons
The British Association of Urological Surgeons
The British Orthopaedic Association
The Royal College of Physicians and Surgeons of Glasgow
The Royal College of Surgeons in Ireland
The Royal College of Surgeons of Edinburgh
The Society for Cardiothoracic Surgery in Great Britain and Ireland
The Society of British Neurological Surgeons
Published by The Royal College of Surgeons of England
Registered Charity No. 212808
Professional Standards and Regulation

London WC2A 3PE
Tel: 020 7869 6032
Fax: 020 7869 6030
Email: psd@rcseng.ac.uk
www.rcseng.ac.uk
© The Royal College of Surgeons of England 2008
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording or otherwise, without the prior written permission of The Royal
College of Surgeons of England.
While every effort has been made to ensure the accuracy of the information contained
in this publication, no guarantee can be given that all errors and omissions have been
excluded. No responsibility for loss occasioned to any person acting or refraining from
action as a result of the material in this publication can be accepted by The Royal
College of Surgeons of England.
Designed and typeset by Close to Water Ltd, Crayford, Kent

Printed by Latimer Trend & Company Ltd, Plymouth, Devon
Contents
The duties of a doctor registered with the General Medical Council 5

Note on terminology 5
Introduction 6
Clinical governance 7
Appraisal 7
Revalidation, recertification and relicensure 8
1 Good clinical care 9

1.1 Providing a good standard of surgical practice and care 9
1.2 The treatment of emergencies 11
1.3 Working with children 12
1.4 Organ and tissue transplantation 13
1.5 Record keeping 14
1.6 Generic guidance: examples of individual standards 15
1.7 Presenting examples of your evidence 16
2 Maintaining and improving good surgical practice 17

2.1 Maintaining and improving your knowledge and performance 17
2.2 Adverse events 18
2.3 New techniques 19
3 Teaching, training and supervising 21

3.1 Medical students 21
3.2 Surgical trainees 22
3.3 Staff and associate specialist-grade surgeons 23
3.4 Locum surgeons 23
3.5 Responsibilities of surgical trainees 24
4 Relationships with patients 26
4.1 Consent 26
4.2 Consent for transfusion 28
4.3 Maintaining trust 28
4.4 Communication 29
5 Working with colleagues 32

5.1 Working together 32
6 Probity in professional practice 34

6.1 Provision of information 34
6.2 Private practice 35
6.3 Research 36
7 Health 38
7.1 Patient safety 38
8 Additional guidance: armed conflict, developing countries and prisons 40

8.1 Armed conflict 40
8.2 Developing countries 40
8.3 Prisons 41
9 Further reading 42
9.1 Department of Health 42
9.2 General Medical Council 43
9.3 The Royal College of Surgeons of England 45
9.4 Other bodies 45
10 Useful contacts 46
10.1 Surgical royal colleges in Great Britain and Ireland 46
10.2 Surgical specialist associations and societies 47
10.3 Other contacts 49
Acknowledgements 54
The duties of a doctor registered with the General Medical Council
Patients must be able to trust doctors with their lives and health. To justify that trust
you must show respect for human life and you must do the following:
> Make the care of your patient your first concern.

> Protect and promote the health of patients and the public.
> Provide a good standard of practice and care:
> keep your professional knowledge and skills up to date;
> recognise and work within the limits of your competence; and
> work with colleagues in the ways that best serve patients’ interests.
> Treat patients as individuals and respect their dignity:
> treat patients politely and considerately; and
> respect patients’ rights to confidentiality.
> Work in partnership with patients:
> listen to patients and respond to their concerns and preferences;
> give patients the information they want or need in a way they can understand;
> respect patients’ right to reach decisions with you about their treatment and care; and
> support patients in caring for themselves to improve and maintain their health.
> Be honest and open and act with integrity:
> act without delay if you have good reason to believe that you or a
colleague may be putting patients at risk;
> never discriminate unfairly against patients or colleagues; and
> never abuse your patients’ trust in you or the public’s trust in the profession.
You are personally accountable for your professional practice and must always be
prepared to explain and justify your decisions and actions.
Good Medical Practice, GMC, 2006.
Note on terminology
Good Medical Practice came into effect on 13 November 2006. In Good Medical Practice
the terms ‘you must’ and ‘you should’ are used in the following ways:
> ‘you must’ is used for an overriding duty or principle;
> ‘you should’ is used when the General Medical Council (GMC) is providing an
explanation of how that overriding duty is to be met; and
> ‘you should’ is also used where the duty or principle will not apply in all situations or
circumstances, or where there are factors outside your control that affect whether or
how you can comply with the guidance.
The same convention is used in this document.
‘Ensure’ is used where surgeons must do all that is within their control to make sure
that the event takes place.
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Good Surgical Practice | 2008
Introduction
Good Surgical Practice sets standards for surgeons. The first edition of
Good Surgical Practice, published in 2002, followed the publication of the GMC’s
Good Medical Practice in 2001. This new edition follows the revision of Good Medical
Practice published in 2006. The document combines a modified and revised text of
Good Surgical Practice (RCS, 2002) and Criteria, Standards and Evidence (RCS,
2004). A significant range of new references have been added to both the text and the
further reading list.
The standards set are intended to be reasonable, assessable and achievable by all
competent surgeons. They complement those standards required of all doctors by the
GMC as set out in Good Medical Practice (GMC, 2006). Good Surgical Practice uses
the same headings that appear in Good Medical Practice and is the surgical
companion to the GMC document. Details of other useful guidance and information
are also provided.
Good Surgical Practice is written primarily for any surgeon, whether consultant, staff
or associate specialist, or trainee, working within and/or outside NHS practice. It may
be used as a framework for providing evidence for appraisal and revalidation based
on the criteria and standards set out in Good Medical Practice. The standards set out
in this document may be used both by surgeons to confirm their good practice and by
those who may have to make judgments about surgeons’ performance.
Good Surgical Practice is also intended for the use and benefit of patients, to give
them an informed understanding of the standards they can reasonably expect from a
competent surgeon.
It is recognised that good surgical practice depends not only on the personal
attributes of the surgeon but also on effective team-working and adequate resources
and time. All surgeons are responsible for the standards of clinical care that they offer
to patients and should bring to the attention of their employing authority any
deficiencies in resources that impact on the quality of clinical care and patient safety.
Although it is acknowledged that a document of this kind may be seen as being either
too prescriptive or ambiguous, it is for individuals to reflect on their practice and work
to the standards set out in this document.
6
Clinical governance
Clinical governance is a statutory duty across all NHS Trusts.* It can be defined as a
framework through which the NHS organisations are accountable for continuously
improving the quality of their services and safeguarding high standards of care by
creating an environment in which excellence in clinical care will flourish (A First Class
Service – Quality in the New NHS, Department of Health, 1998). Clinically focused
practice depends on the governance of clinicians by clinicians. The process is
supported by the chief executive of the Trust who is required to confirm and facilitate
the process and is individually legally accountable for the service provided in the Trust.
Similar arrangements should exist in the independent sector. Further useful
information can be obtained from:
> the Department of Health;
> the Clinical Governance Support Team (a learning organisation that uses the
knowledge of its staff and its relationships with other NHS organisations to support
those who shape the health care experience for patients, carers and the public); and
> the Healthcare Commission (the independent inspection body for both the NHS and
independent health care in England).
Appraisal
Appraisal is the process that gives surgeons an opportunity to formally discuss their
professional roles and clinical practice (Supporting Doctors, Protecting Patients,
Department of Health, 1999). Its dual role is to improve on good performance and also
to recognise poor performance at an early stage. A national appraisal scheme was
introduced in 2001 and is now a contractual requirement for all consultants working in
the NHS. Consultants who practise in both the NHS and the private sector have the
opportunity to submit their private practice activity as part of their NHS appraisal.
Consultants in independent practice who do not have an NHS contract will need to
make independent arrangements for appraisal. Appraisal is based on the seven core
headings presented in Good Medical Practice (GMC, 2006), which sets out the
standards required of all doctors. They are:
1 good clinical care,

2 maintaining good medical practice,
3 relationships with patients,
4 working with colleagues,
5 teaching and training,
6 health, and
7 probity.
Each of these headings is addressed in this document.
*This document has been written from an English perspective. Different health services operate in other parts of
the UK and in Ireland. Nevertheless, the standards remain relevant.
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Revalidation, recertification and relicensure
Since the publication of the last edition of Good Surgical Practice, there have been
significant changes proposed in relation to revalidation. The white paper,
Trust, Assurance and Safety: the Regulation of Health Professionals in the 21st
Century (Department of Health, 2007), which builds on the responses to Sir Liam
Donaldson’s report, Good Doctors, Safer Patients (Department of Health, 2006),
reaffirms the government’s commitment to the introduction of a system of revalidation.
The white paper is complemented by the government’s response to the recommendations
of the Fifth Report of the Shipman Inquiry and to the recommendations of the Ayling,
Neale and Kerr/Haslam Inquiries, Safeguarding Patients, which sets out a range of
measures to improve and enhance clinical governance in the NHS.
Medical revalidation will have two core components: relicensure and specialist
recertification. All doctors wishing to practise in the UK will require a licence to
practise. The GMC will issue these licences as soon as it is practicable to do so. The
licence will be subject to five-yearly renewal, based on a ‘positive affirmation of the
doctor’s entitlement to practise, not simply on the absence of concerns’ (Trust,
Assurance and Safety, paragraph 2.11, Department of Health, 2007).
Specialist recertification will apply to only those doctors who are on specialist practice
or general practice registers. They will be required to demonstrate that they continue
to meet the particular standards that apply to their medical specialty. Recertification
will be carried out at regular intervals, of no more than five years, where possible
coinciding with relicensure. The medical royal colleges will have specific responsibility
for developing standards and systems for doctors in their particular specialty.
The Department of Health will be asking the GMC ‘to consult with its key constituencies
to translate the recent update of Good Medical Practice (GMC, 2006) into an effective
framework against which individual doctors’ practice can be appraised and objectively
assessed’ (Trust, Assurance and Safety, paragraph 2.21). The Department will be
consulting widely on the ways in which all these proposals will be put into effect in the
future.
As plans for revalidation are developed, information will be available from:
> the Department of Health (http://www.dh.gov.uk/);

> the GMC (http://www.gmc-uk.org/);
> the Academy of Medical Royal Colleges (http://www.aomrc.org.uk/); and
> royal colleges including The Royal College of Surgeons of England

(http://www.rcseng.ac.uk/).
8
1 Good clinical care
Definition
Good surgical care starts at first consultation and diagnosis, with the patient as either
an outpatient or inpatient. It is given in conjunction with other colleagues in the health
care team. It concentrates particularly on the practice of safe, timely and competent
surgical intervention, ensuring that patients are prioritised and treated according to
their clinical need. Surgery should be avoided where the risks outweigh the benefits.
The decision of intervention is assessed on the basis of the surgeon’s ability and
experience, patient need and available resources, taking into account the
requirements of both emergency and elective activity. Surgeons must demonstrate
competence in their own area of practice and a willingness to refer where necessary.
They must demonstrate knowledge and understanding of the necessary ethical and
legal issues relating to their area of surgical practice. They must communicate clearly
with patients and their supporters* and ensure that comprehensive, legible and
contemporaneous records are kept of all their patient interactions.
1.1 Providing a good standard of surgical practice and care
In meeting the standards set out in Good Medical Practice (GMC, 2006), surgeons
must provide good clinical care by:
> ensuring that patients are treated according to the priority of their clinical need;
> communicating compassionately and clearly with patients and, with the patient’s
consent, with their supporters and, in the case of children, with their
parent(s)/responsible adult(s);
> carrying out surgical procedures in a timely, safe and competent manner;
> providing elective care for patients with non-urgent conditions and carrying out
procedures on them that lie within the range of the surgeon’s routine practice;
> ensuring patients are cared for in an appropriate and safe environment that takes
into account any special needs they may have, ensuring that adequate resources
are available for safe patient care and postponing planned procedures if they are
not. If patient safety may be compromised by a lack of resources, this must be
recorded by the surgeon and communicated to the chief executive and medical director;
> ensuring patients receive satisfactory postoperative care and that relevant information
is promptly recorded and shared with the appropriate team, the patient and their
supporter(s);
*The term ‘supporter’ is used throughout this document to refer to the relative, carer or friend who has been
identified by the patient as someone with whom they wish to share information about their treatment/operation.
Information should only be shared with the supporter with the patient’s consent. (See section 4.1.) The name of the
supporter should be recorded clearly in the patient’s notes.
9
> ensuring that, on the discharge of a patient from hospital care, appropriate
information is shared with the patient and/or their carer(s);
> making good use of the resources available;
> ensuring that any instruction to withhold or withdraw treatment (for example,
resuscitation categorisation) is normally taken in consultation with the patient or
family and authorised by the appropriate senior clinician (see Withholding and
Withdrawing Life Prolonging Treatments: Good Practice in Decision Making, GMC 2006);
> accepting patients on referral from GPs, consultant colleagues or as an emergency

through the accident and emergency department. If a surgeon agrees to see a
patient directly without referral, the patient should be informed that the GP will
normally receive a report;
> utilising the knowledge and skills of other clinicians and transferring the patient,
when appropriate, to another colleague or unit where the required resources and
skills are available;
> being aware of current clinical guidelines in their field of practice and the advice they
contain. Surgeons should explain to patients the reasons for not following such
guidance if an alternative course of clinical management is undertaken; and
> discussing with patients and their supporters alternative forms of treatment,
Including non-operative care and recording the reasons for their decisions.
1.1.1 Further reading
Improving Your Elective Patient’s Journey, RCS Patient Liaison Group, 2007
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1.2 The treatment of emergencies
Emergency care is a major component of surgical practice. When on call, surgeons must:
> accept responsibility for the assessment and continuing care of every emergency
patient admitted under their name unless, or until, they are formally transferred to
the care of another doctor;
> be available either within the hospital or within a reasonable distance of the hospital
to give advice throughout the duty period;
> ensure they are able to respond promptly to a call to attend an emergency patient;
> be aware of protocols for the safe transfer to another unit of emergency patients
when the complexity of the patient’s condition is beyond the experience of the
admitting surgeon or the resources available for their proper care;
> delegate assessment or emergency surgical operations only when they are sure of
the competence of those trainees and staff and associate specialist grades to whom
the patient’s operative care will be delegated;
> ensure that rotas are published in advance and that any alternative cover
arrangements are specifically made and clearly understood;
> ensure the formal handover of patients to an appropriate colleague following periods
on duty; and
> ensure appropriate handover by junior staff and be available for a ward round
between shifts.
In an emergency, unfamiliar operative procedures should be performed only if there is
no clinical alternative, if there is no colleague who is more experienced available or if
transfer to a specialist unit is considered a greater risk.
Guidance on safe handovers can be found at:

http://www.rcseng.ac.uk/service_delivery/wtd/docs/Safe%20handovers.pdf
Advice on designing safe rotas is available at:

http://www.rcseng.ac.uk/service_delivery/wtd/rotas
11
1.3 Working with children
Surgeons must:
> when communicating with a child or young person:

> treat them with respect and listen to their views,
> answer their questions to the best of your ability, and
> provide information in a way they can understand;
> be aware of the needs and welfare of children and young people when seeing
patients who are parents and carers, as well as any patients who may represent a
danger to young children (Good Medical Practice, GMC, 2006);
> communicate effectively with parent(s)/responsible adult(s);
> protect the child’s privacy; and
> treat children only if they have the appropriate training and ongoing experience in
the clinical care of children in their specialty, except in the case of an emergency.
Getting the Right Start: National Service Framework for Children, Young People and
Maternity Services: Standards for Hospital Services, Department of Health, 2003
Surgery for Children: Delivering a First Class Service, RCS, July 2007
Children in Hospital: Rights and Responsibilities of Children and Parents, RCS Patient
Liaison Group, June 2007
0–18 Years: Guidance for all Doctors, GMC, September 2007
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1.4 Organ and tissue transplantation
Surgeons undertaking organ or tissue transplantation must:
> comply with current laws and ethics (see The Surgeon’s Duty of Care, Senate of
Surgery of Great Britain and Ireland, 1997, pp. 23–25) and follow the guidance set
out in Towards Standards for Organ and Tissue Transplantation in the UK (British
Transplantation Society, 1998);
> choose recipients solely on the basis of medical suitability;
> fully inform recipients of hazards and likely outcome when gaining informed consent;
> fully inform living donors of risks and outcome to themselves and of the benefits and
risks for the recipient. Living organ donation must never be acquired by coercion or
for profit; and
> when using cadaver donors or other tissue, conform to current regulations regarding,
for example, prior agreement, assent of relatives and certification of brain death.
Information regarding removal, storage and use of human organs can be found at the
website of the Human Tissue Authority (http://www.hta.gov.uk/).
13
1.5 Record keeping
Surgeons must do the following:
> Ensure all medical records are legible, complete and contemporaneous, and have
the patient’s identification details on them.
> Ensure that when members of the surgical team make case-note entries they are
legibly signed and show the date, and, in cases where the clinical condition is
changing, the correct time.
> Ensure that a record is made of the name of the most senior surgeon seeing the
patient at each postoperative visit.
> Ensure that a record is made by a member of the surgical team of important events
and communications with the patient or supporter (for example, prognosis or potential
complication). Any change in the treatment plan should be recorded.
> Ensure that there are legible operative notes (typed if possible) for every operative
procedure. The notes should accompany the patient into recovery and to the ward
and should be in sufficient detail to enable continuity of care by another doctor. The
notes should include:
> date and time;

> elective/emergency procedure;
> the names of the operating surgeon and assistant;
> the operative procedure carried out;
> the incision;
> the operative diagnosis;
> the operative findings;
> any problems/complications;
> any extra procedure performed and the reason why it was performed;
> details of tissue removed, added or altered;
> identification of any prosthesis used, including the serial numbers of
prostheses and other implanted materials;
> details of closure technique;
> postoperative care instructions; and
> a signature.
> Ensure that follow-up notes are sufficiently detailed to allow another doctor to
assess the care of the patient at any time.
14
1.6 Generic guidance: examples of individual standards
> A surgeon must communicate clearly with patients and their supporters, checking
concerns and ensuring understanding by asking questions to test knowledge.
> A surgeon should ensure that the patient knows the name of the person responsible
for their care.
> Whenever possible, a surgeon should ensure that only one team is responsible for
the patient’s care at any one time.
> A surgeon must carry out emergency or elective surgical procedures in a timely, safe
and competent manner, delegating or referring to colleagues where appropriate; for
example, when treating children or complex cancer.
> A surgeon will be aware of and follow current guidance in their field of practice and
will be able to justify their actions, where appropriate, when that guidance has not
been followed.
> A surgeon should demonstrate that patients are treated according to the priority of
their clinical need.
> In their absence, the surgeon must arrange safe and effective cover and handover
for the assessment, treatment and continuing care of emergency and elective
patients for whom they are responsible.
> A surgeon must comply fully with current ethical and legislative guidance in relation
to their area of expertise.
> A surgeon must maintain legible, comprehensive and contemporaneous records.
> A surgeon will bring to the attention of those responsible any resource shortfalls that
might jeopardise safe and effective patient care.
15
1.7 Presenting examples of your evidence
Sources of evidence might include:
> job plan/work programme;

> information regarding annual caseload;
> examples of resource shortfalls that may have compromised patient care;
> record of examples of cancellations or deferment, for example, on account of

patient safety;
> demonstration of knowledge of best practice as advised by College and associations;
> results of clinical outcomes as compared with relevant College/association

recommendations or national or international benchmarks where available;
> record of attendance at audit meetings, of clinical audits and of implementation of

audit recommendations;
> records of attendance of morbidity and mortality meetings and compliance with
audits of the National Confidential Enquiry into Patient Outcome and Death
(NCEPOD). Surgeons should be present at, or receive minutes of, mortality
meetings, where patients who died under their care were discussed;
> on-call rotas;
> results of random audit of medical records/minutes of meetings where records and
notes have been audited against agreed standards. Sample audit of clinical notes
should also include an audit of operation notes; and
> contribution of relevant data to national audit programmes and national registries.
16
2 Maintaining and improving good surgical practice
Definition
Surgeons are specialist doctors who offer effective, informed and up-to-date care to
patients through surgical intervention. They ensure that their knowledge of surgical
procedures is maintained on a regular basis by a variety of measures, including
regular evaluation of patient safety incidents. Surgeons work within teams, which include
a range of professionals. All team members should learn continuously from each other,
further enhancing the quality of care. They are committed to learning in many ways,
including learning from mistakes. They recognise that good surgical practice requires
constant review and regular continuing professional development (CPD) activities as
an essential part of their professional practice. They must record the progress of their
career and CPD in a portfolio that reflects their professional practice.
2.1 Maintaining and improving your knowledge and performance
All surgeons must:

> keep up to date with the relevant literature;
> attend and contribute to regular meetings with colleagues in the same and related
specialties;
> attend multidisciplinary meetings with, for example, pathologists, radiologists,

oncologists and other physicians;
> establish and maintain an up-to-date and valid portfolio of all procedures and clinical
activity, which includes an accurate log book;
> include CPD and the need to maintain knowledge base in job plans;
> take part in annual appraisal;
> take part in quality-assurance and -improvement systems;
> take part in national enquiries and audits, for example, the National Confidential
Enquiry into Patient Outcome and Death (NCEPOD) and the Scottish Audit of
Surgical Mortality (SASM); and
> take part in regular morbidity/mortality and audit meetings.
17
All surgeons should:
> be aware of the immediate results of operations and participate in the audit of the
long-term outcomes;
> be aware of the results obtained by peer groups and seek advice from colleagues if
there is a major discrepancy;
> share their results through the audit process;
> keep an accessible record of their surgical activity complying with the Data
Protection Act 1998;
> contribute to ongoing clinical trials wherever possible; and
> recognise when they are unfit to work through fatigue, illness or the influence of
alcohol or drugs.
2.2 Adverse events*
Surgeons should inform patients of any adverse events that occur during their care,
report the event to the responsible officer of the Trust and, if considered necessary, to:
> a local audit meeting; then

> the National Patient Safety Agency.
All surgeons must be aware of the ‘alert’ and ‘hazard’ notices issued by the Medicines
and Healthcare Products Regulatory Agency (MHRA; previously the Medical Devices
Agency, or MDA). Adverse incidents arising from the failure of medical devices must
be reported to the MHRA (http://www.mhra.gov.uk/). The Committee on Safety of
Devices has been set up to advise ministers and complement the work of the MHRA
(Devices sector).
*National Patient Safety Agency guidance defines the term ‘patient safety incident’ as ‘any unintended or
unexpected incident that could have or did lead to harm for one or more patients receiving NHS funded healthcare’.
Seven Steps to Patient Safety, NPSA, February 2004.
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2.3 New techniques
New techniques include:
> a new or personally developed operation;

> any major modifications to an established procedure; and
> the introduction of a procedure not previously performed in the Trust/organisation.
When a new technique is to be used, the patient’s interests should be considered

paramount. Therefore, surgeons must:
> first discuss the technique with colleagues who have relevant specialist experience
and the medical/clinical director;
> follow local protocols with regard to local ethics committee approval;
> contact the National Coordinating Centre for Health Technology Assessment
(NCCHTA) to learn the status of the procedure and/or to register it;
> liaise with the relevant specialist association;
> ensure that patients and their supporters know when a technique is new before
seeking consent and that all the established alternatives are fully explained prior to
recording their agreement to proceed;
> be open and transparent regarding the sources of funding for the development of
any new technique;
> audit outcomes and review progress with a peer group;
> where possible, obtain necessary training in the new technique;
> take part in regular educational activities that maintain and further develop
competence and performance;
> enable the training of other surgeons in this new technique; and
> ensure that any new device complies with European standards and is certified by
the competent body.
19
> A surgeon must keep up to date with the literature and developments in their own
and associated fields of practice.
> A surgeon should take part in annual appraisal.
> A surgeon must keep an accessible record of their surgical practice complying with
the Data Protection Act 1998.
> A surgeon must ensure that they have undergone a period of appropriate training
before undertaking a significantly new procedure (for the individual concerned) on a
patient (where that procedure has been shown to be of value).
> A surgeon undertaking a new procedure should ensure that appropriate ethical
approval has been sought and confirmed by the medical director and should also
contribute to the evaluation of that new procedure, complying with NCCHTA
guidelines or similar standards.

> a detailed summary of annual CPD activity, and how practice has been altered;
> record of attendance at multidisciplinary meetings, for example minutes/register of

the meeting and certificates of attendance at courses;
> use of journals and other educational and evidence-based tools;
> authorship of publications, authored guidelines, etc;
> record of last appraisal, personal development plan (PDP) and subsequent changes
in practice;
> record of all surgical procedures and clinical activity, which will be required for recertification;
> record of any patient safety incidents and their outcomes, and how they have
influenced practice; and
> when employing a new technique or new technology, proof that there is a good
evidence base for its use, that it is registered with or has been reported to the
NCCHTA or that it is being tested formally by research. Surgeons often have
new ideas or employ modifications of an older technique.
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3 Teaching, training and supervising
Definition
Surgeons should be willing, as part of their professional practice, to engage in the

training and supervision of students, trainees and other members of the surgical
and health care team. They have responsibilities for creating a learning environment
suitable for teaching, training and supervising students, trainees and others. They
should contribute to the theoretical and clinical training of students while ensuring that
patients have the right to refuse to be seen by students if they so wish. They must
ensure that effective supervision arrangements are in place for all grades of trainee,
allowing for the acquisition of the necessary experience while ensuring that patient
safety is paramount. Individuals with whom trainees can legitimately share concerns
should be identified. Surgeons should understand and demonstrate effective skills of
delegation, assuring themselves at all times of the competence of those to whom they
delegate across the health care team.
3.1 Medical students
Surgeons should:
> encourage and support medical students;

> involve themselves actively in teaching if students are attached to their team;
> be aware of the professional competencies to be achieved by students;
> explain to patients that they have the right to refuse to participate in student teaching
and reassure patients that such a refusal will not prejudice their treatment in any way;
> ensure that students are introduced to patients;
> ensure that privacy and confidentiality are maintained and that students understand
and respect this requirement; and
> ensure that when a student is involved in specific examinations or procedures on

patients under general anaesthesia, written consent has been obtained giving the
full extent of the student’s involvement.
The Doctor as a Teacher, GMC, 1999

Generic professional competencies are set out on the Intercollegiate Surgical
Curriculum Programme (ISCP) website.
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3.2 Surgical trainees
Consultant surgeons must accept overall responsibility for any duties that are delegated
to a trainee or other doctor.
Surgeons must:
> delegate duties and responsibilities only to those specialist trainees and foundation
doctors or other doctors whom they know to be competent in the relevant area
of practice;
> indicate to trainees when more senior advice and assistance should be sought;
> be present throughout an operation until they are satisfied that the trainee is
competent to carry out the procedure without immediate supervision;
> when on duty, be available to advise/assist the trainee at all times unless specific
arrangements have been made for someone else to deputise;
> ensure that the trainee maintains an up-to-date portfolio that complies with the Data
Protection Act 1998 that is accurate, legible and frequently updated;
> attend a Training the Trainers course, or equivalent, and an approved course in
appraisal skills if undertaking the role of supervisor or trainer of any junior doctor;
> take reasonable steps to ensure that the trainee is fit to undertake their responsibilities,
particularly with reference to fatigue, ill health or the influence of alcohol or drugs;
> ensure that assessment and appraisal of trainees is carried out regularly, thoroughly,
honestly, openly and with courtesy; and
> not assign as competent someone who has not reached or maintained a satisfactory
standard of practice.
22
3.3 Staff and associate specialist-grade surgeons
Surgeons must:
> ensure that staff and associate specialists are only appointed to standard,
recognised grades.
Staff and associate specialist surgeons must:
> perform to the standards detailed in this document;

> be accountable for their activities to a named consultant;
> identify and agree the extent of their delegated responsibilities with a named
consultant, including the level of independent activity expected; and
> undertake CPD.
3.4 Locum surgeons
Consultant surgeons practising in the same specialty, or the specialty nearest to that
of the locum concerned, must ensure that the locum is:
> fully conversant with the routines and practices of the surgical team;
> familiar with, and takes part in, the audit processes of the unit;
> not isolated and knows from whom to seek advice on clinical or managerial matters; and
> not required or expected to work outside their field of expertise.
A locum consultant, not on the GMC Specialist Register, must be under the
supervision of a named substantive consultant in the same specialty. Locum surgeons
must perform to the standards detailed in this document.
23
3.5 Responsibilities of surgical trainees
(Foundation Year 1; Foundation Year 2; Specialist Trainees 1–6)
In addition to the requirements of all surgeons set out in this document, trainees must:
> ensure continuity of care for patients for whom they are responsible by formally
handing over the patient’s care to a responsible colleague at the end of their period
of duty;
> know which consultant is on call and seek advice or assistance when appropriate;
> understand the importance of seeking advice from someone with more experience;
> recognise the circumstances in which they are expected to seek advice and
assistance from a more senior member of the team;
> be available according to a rota published in advance;
> maintain all records relating to their training;
> maintain legible and up-to-date clinical records;
> support and assist their colleagues, in particular those junior to them;
> be prepared to share concerns about possible shortcomings in patient care that
they perceive in those with whom they work, whether senior or junior to them;
> inform the responsible consultant before a patient is taken to theatre for a major
surgical procedure; and
> recognise when they are unfit to work through fatigue, illness or the influence of
alcohol or drugs.
24
> A surgeon must maintain the privacy, dignity and confidentiality of patients while
working with all members of the surgical team, including undergraduates.
> A surgeon should contribute to the provision of a learning environment suitable for
teaching, training and supervising students, trainees and others.
> A surgeon must only delegate duties and responsibilities that are appropriate to
the level of competence of those with whom they are working and check that the
delegated duty has been performed.
> If involved in teaching, a surgeon should ensure that they have the necessary skills
and have taken part in training.
> A surgeon must be honest and open when assessing and appraising.
> A surgeon should be courteous when working with all members of the surgical team.
> evidence of attendance at an appropriate teaching course, for example Training the
Trainers or equivalent. This could include a piece of self-reflective work on teaching
style or peer review for a teaching session;
> for surgeons responsible for undertaking the assessment of trainees, evidence of
attendance at an appropriate course;
> a summary of formal teaching/lecturing activities and supervision/mentoring duties; and
> results of formal and informal feedback from trainees on the effectiveness of
postgraduate and undergraduate teaching and training.
25
4 Relationships with patients
Definition
Surgeons must make every effort to establish and maintain the trust of their patients
at all times. Surgeons must establish and maintain effective relationships with patients
and, where appropriate, their supporters, in a number of ways. They must allow
sufficient time to explain surgical procedures, risk and alternative treatment options;
they must ensure understanding of the surgical and associated processes involved;
and they must ascertain and respect patients’ wishes. Surgeons must understand that
seeking informed consent for surgical intervention is a process, not merely the signing
of a form, and one that requires time, clarity of explanation and patience. Surgeons
must take every opportunity to demonstrate to patients that their safety is paramount
and treat complaints with courtesy and respect, responding promptly, openly and
honestly.
The following principles are laid out in Good Medical Practice (GMC, 2006) but are of
particular relevance to surgeons.
4.1 Consent
The Department of Health has published a Reference Guide to Consent for Examination
or Treatment (Department of Health, 2001). All surgeons must be familiar with the
processes and details in this document before seeking agreement to proceed with
any intervention. Obtaining consent involves a dialogue between surgeon and patient,
which leads to the signing of the consent form.
In addition, surgeons must:
> establish whether a patient has a supporter as early as possible in the relationship
and mark this clearly on their notes;
> meet with the patient prior to surgery to discuss operation and implications;
> ensure that patients, including children, are given information about the treatment
proposed, any alternatives and the main risks, side effects and complications when
the decision to operate is made. The consequences of non-operative alternatives
should also be explained;
> provide time for patients and their supporters to discuss the proposed procedure and
provide an opportunity for the patient to make a fully informed and unharassed decision
to agree to the treatment suggested and to indicate by signature their willingness to proceed;
> carefully consider any ‘advance decision’ (living will) that the patient may have
written under the Mental Capacity Act 2005 (c. 9);
26
> give the patient the opportunity to indicate any procedure they do not wish to be
carried out;
> make sure that the patient understands, and is agreeable to, the participation of
students and other professionals in their operation;
> gain agreement from the patient if video, photographic or audio records are to be
made for purposes other than the patient’s records (for example, teaching, research
or public transmission);
> follow appropriate guidance for the retention of tissue;
> clearly mark the site to be operated on with the patient’s agreement while they are
awake and prior to premedication;
> verify the operation to be undertaken by checking the records, including images and
consent form and, where possible, with the patient, rather than relying solely on the
printed operating list for the procedure being performed;
> ensure that the written consent and the notes include, when appropriate, the side to
be operated on using the words ‘left’ or ‘right’ in full;
> ensure that digits on the hand are named and on the foot numbered and similarly
marked with the patient’s agreement while they are awake and prior to
premedication; and
> record all discussions about consent in the patient’s records.
Seeking Patients’ Consent: The Ethical Considerations, GMC, 1999

Confidentiality: Protecting and Providing Information, GMC, 2004
Confidentiality FAQs, GMC, 2004
Patient Rights and Responsibilities, RCS Patient Liaison Group, 2002
Improving Your Elective Patient’s Journey, RCS Patient Liaison Group, 2007
Explaining the Risks and Benefits of Treatment Options: Suggestions for Hospital
Doctors, Royal College of Physicians, 2006
27
4.2 Consent for transfusion
Surgeons must establish the views held by individual patients regarding their position
in relation to transfusion as certain forms of transfusion may be unacceptable.
Code of Practice for the Surgical Management of Jehovah’s Witnesses, RCS, 2002
4.3 Maintaining trust
In addition to abiding by the recommendations of Good Medical Practice (GMC, 2006),

surgeons must:
> ensure their working arrangements allow adequate time to listen and properly
communicate with patients and their supporters. The chief executive and medical
director must be informed if there are inadequacies;
> fully inform patients and their supporters of the plans and procedures for their
treatment, the risks and anticipated outcomes and any untoward developments as
they occur, or as soon as possible afterwards;
> support any request for a second opinion and give assistance in making the
appropriate arrangements;
> obtain the patient’s verbal consent before carrying out any clinical examination;
> support a request by a patient for a third person to be present while they are
undergoing a clinical examination;
> explain the purpose and nature of any examination of the breast, genitalia or rectum
and observe GMC guidance on intimate examinations;
> be aware of cultural differences and sensitivities and respect them; and
> contribute to patient surveys and respond to their findings.
Maintaining Boundaries, GMC, 2006
28
4.4 Communication
All surgeons must:
> listen to and respect the views of patients and their supporters;
> listen to and respect the views of other members of the team involved in the
patient’s care;
> recognise and respect the varying needs of patients for information and explanation;
> insist that time is available for a detailed explanation of the clinical problem and the
treatment options;
> encourage patients to discuss the proposed treatment with their supporter(s);
> fully inform the patient and their supporter of progress during treatment;
> explain any complications of treatment as they occur and explain the possible
solutions; and
> act immediately when patients have suffered harm and apologise when appropriate.
Personal Beliefs and Medical Practice: A Draft for Consultation, GMC, 2007
29
> A surgeon should ensure that, as part of the ongoing process of obtaining consent,
they give patients and, where appropriate, their supporters, relevant and adequate
information, including benefits and risks, in a timely manner.
> A surgeon should observe the relevant legislation and guidance in respect of
honouring the wishes of a patient in their care.
> A surgeon should ensure that details of all proposed surgical procedures are, where
possible, checked with the patient, as well as with the written record.
> A surgeon should ensure that patients and, where appropriate, their supporters are
aware of their rights with respect to appropriate national and local guidance on the
retention of tissue and that patients and their supporters are aware of their part in
the processes involved.
> A surgeon should gain agreement from the patient, in accordance with the policy of
the relevant Trust, when video, photographic or audio records are to be made for
any purpose.
> A surgeon should contribute to appropriate means of testing patient satisfaction.
> A surgeon should ensure that a patient’s dignity is respected at all times, for
example with unconscious patients and in clinical demonstrations.
> A surgeon should respond appropriately and professionally to any comments or

complaints from patients or their supporters about the service they have received
and cooperate fully with any complaints procedures, offering an apology
where appropriate.
30
> examples of participation in validated patient surveys and other methods of patient
involvement;
> applying/implementing results from participation in random audit of patient consent forms;
> examples of approach to handling informed consent;
> examples of plaudits from patients and colleagues; unsolicited expressions of

satisfaction and gratitude and compliments on management; and
> a summary of complaints made against the surgeon, the process by which they are
handled and details of the outcomes and, where appropriate, evidence of changes
to practice.
31
5 Working with colleagues
Definition
Surgeons work in partnership with others in the health care team – which includes other
professionals, technicians, support staff and management – in order to offer safe and
effective care to patients. They must work to develop effective relationships, respecting
the professionalism of all colleagues. Knowledge and understanding of, and respect for,
the roles and views of others are essential to achieving good patient outcomes.
Surgeons must ensure continuity of patient care by arranging effective cover for their
own patients where possible and be prepared to cover for colleagues in emergencies.
5.1 Working together
Apart from in exceptional circumstances, surgeons must always make formal

arrangements for cover. However, in such exceptional circumstances, surgeons must
take responsibility for patients under the care of an absent colleague even if formal
arrangements have not been made.
Ineffective team working must not be allowed to compromise patient care.
Surgeons must:
> work effectively and amicably with colleagues in multidisciplinary teams, attend
multidisciplinary team meetings, share decision making, develop common
management protocols where possible and discuss problems with colleagues;
> continue to participate in the care of, and decisions concerning, their patients when
they are in the intensive care unit or the high-dependency unit;
> willingly and openly participate in regular appraisal of both themselves and trainee
surgeons and other staff;
> always respond to calls for help from trainees and others in the operating theatre
and elsewhere as a matter of priority;
> ensure there is a formal handover of continuing care of patients to another colleague
at the commencement of leave; and
> ensure that, when acting as manager or director, their practice and appraisal
processes are subject to the same scrutiny as others.
The Leadership and Management of Surgical Teams, RCS, 2007

Management of Healthcare: the Role of Doctors, paragraphs 19–21, GMC, 1999
32
> A surgeon should willingly and openly participate in regular appraisal of both
themselves and trainee surgeons and other staff, where appropriate.
> A surgeon should always respond to calls for emergency help from trainees,
colleagues and other members of the surgical team in the operating theatre and
elsewhere as a matter of priority.
> A surgeon should ensure that there is a formal and explicit handover/cover of continuing
care of patients to another named colleague when unavailable for any reason.
> A surgeon should recognise their own technical and professional limitations and
refer to colleagues where necessary or appropriate.
> A surgeon should share their concerns about the physical or psychological health or
well-being of any members of the health care team, through appropriate channels.
> A surgeon should work together with other members of the health care team in a
professional and supportive manner to maintain continuity of patient care, regardless
of patient location.
> description of the setting within which you work and the structure within which
you practice;
> evidence of multi-/interdisciplinary relationships, for example minutes of

multidisciplinary team meetings;
> details of additional responsibilities within the team, for example clinical director or
surgical tutor; and
> evidence of attendance at team development events and compliance with agreed
procedures and behaviours, including 360-degree appraisal/multi-source feedback.
33
6 Probity in professional practice
Definition
Surgeons must understand the need to demonstrate probity in all aspects of their
professional practice and adhere to the principles set out in Good Medical Practice
(GMC, 2006), regardless of where they may be working (for example, the NHS or private
sector). They must demonstrate honesty, objectivity and courtesy in their dealings with
others. They must declare any commercial involvement, which may give rise to actual or
potential conflict of interest and ensure that neither their name nor practice is used
inappropriately in the promotion of personal commercial advantage. Surgeons working
in the private sector must ensure transparency in their dealing with patients in respect of
costs for services and any actual or potential limitations of clinical care.
6.1 Provision of information
Surgeons should adhere to all the principles set out in Good Medical Practice
(GMC, 2006). In particular, when providing information surgeons must:
> avoid any material that could be interpreted as designed to promote their own
expertise, either in general or in a particular procedure;
> declare any commercial involvement that might cause a conflict of interest;
> avoid denigrating others;
> ensure that the literature provided by the institution where they work and any
interview they give to the media does not make unreasonable claims; and
> demonstrate honesty and objectivity when providing references for colleagues and
team members.
34
6.2 Private practice
All surgeons working in the private sector, including independent sector treatment
centres (ISTCs), must:
> make arrangements for the continuity of care of any inpatients;
> maintain the standard of record keeping as listed in section 1.5 and audit all surgical
activity;
> be honest in financial and commercial matters relating to work and in particular:
> ensure that patients are made aware of the fees for their services and
cost of any treatment by quoting, where possible, their professional fees
in advance,
> inform patients if any part of the fee goes to any other doctor, and
> not allow commercial incentives to influence treatment given to a patient;
> make clear to patients the limits of care available in any independent hospital used;
for example, the level of critical care provision provided and the qualifications of the
resident medical cover; and
> if working solely in private practice, enable peer review of their surgical activities and
participate in meaningful audit, CPD and appraisal.
Doctors working in England and Wales who are wholly engaged in private practice in
premises that are otherwise unregistered must register under the Care Standards
Act 2000.
Surgeons who work in both the NHS and the independent sector should:
> undertake similar types of procedures in both;
> fulfil their NHS contracted duties; and
> not use NHS staff or resources to aid their private practice unless specific
arrangements have been agreed in advance.
35
6.3 Research
Surgeons who undertake research must:
> submit full protocols of proposed research and details of intended new technical
procedures to the research/ethics committee before starting;
> treat patients participating in research as partners;
> fulfil the regulations of the World Medical Association Declaration of Helsinki 1964
(http://www.wma.net/);
> fully inform research participants about aims, intentions, values, relevance,
methods, hazards and discomforts and record this in their notes;
> fully inform patients in randomised trials about the procedures being compared and
their risks and benefits and record this in their notes;
> inform participants how their confidentiality will be respected and protected;
> accept that a patient may refuse to participate or withdraw during the programme, in
which case their treatment must not be adversely influenced;
> seek guidance from the ethics committee concerning the need for consent for the
use of tissue removed during an operation for research purposes in addition to
routine histopathology;
> seek permission to remove tissue beyond that excised diagnostically or therapeutically;
> acquire specific permission to use any removed tissue for commercial purposes; for
example, to grow cell lines or for genetic research;
> fulfil the strict regulations of the Animals (Scientific Procedures) Act 1986 when
obtaining permission to carry out research on animals;
> discourage the publication of research findings in non-scientific media before

reporting them in reputable scientific journals or at meetings;
> disclose any financial interest in, for example, pharmaceutical companies or
instrument manufacturers;
> ensure that anything regarding the project that may be published on the internet or
elsewhere follows ethical principles;
> report any fraud that is detected or suspected to the local research/ethics
committee; and
36
> recognise and be familiar with the Human Tissue Act 2004 regulations and obtain
appropriate licenses where necessary.
Further information on research governance can be found at http://www.dh.gov.uk/

and on the Scottish Executive website at http://www.show.scot.nhs.uk/cso/.
Research: The Role and Responsibilities of Doctors, GMC, 2002
> A surgeon should declare any actual or potential conflict of interest in line with
national guidelines and local policy.
> A surgeon must demonstrate honesty and objectivity when providing references for
colleagues and other team members.
> A surgeon who works in the NHS and the private sector must maintain identical
standards and performance in both sectors.
> A surgeon must ensure that their professional practice is based on best clinical
evidence, and not influenced by commercial considerations.
> A surgeon undertaking research should ensure that there is an audit trail of
documentation and that research is carried out under appropriate ethical standards
and complies with research governance, including the careful recording and storage
of data.
> details of actual or potential conflicts of interest, which must be declared; and
> evidence of meeting local policy on probity.
37
7 Health
Definition
Surgeons have a duty of care to maintain patient safety at all times and not to work
in any health state that might impair judgement and/or jeopardise patient safety. They
must take particular precautions against the transmission of blood-borne diseases, in
both their own and their patients’ best interests. They must understand and honour the
importance of reporting serious communicable disease in the public interest, in either
themselves or their colleagues.
7.1 Patient safety
Surgeons must not compromise patient safety because of ill health, fatigue or the
effects of drugs or alcohol.
Surgical operations place surgeons at particular risk of acquiring and transmitting

blood-borne viruses that can cause serious communicable diseases, such as hepatitis
and HIV. (See Serious Communicable Diseases, GMC, 1997 and related note in
section 9.2).
In the event of a needlestick injury, surgeons must follow established Trust/

organisation guidelines.
Surgeons must take precautions and follow established guidelines when operating on
high-risk patients.
All surgeons have a duty of care to their patients and must seek advice from an
appropriately qualified doctor if they believe they have a serious communicable
disease. Surgeons also have a duty of care to inform the appropriate authority if they
know of a colleague who may have a serious communicable disease or any illness
that is liable to put patients at risk. They must ensure that health risks are addressed
and that patients are not put at unnecessary risk due to transfer of blood or
tissue infection.
38
> A surgeon must not work when their health state is adversely influenced by fatigue,
disease, drugs or alcohol.
> A surgeon must exercise a duty of care in terms of reporting serious communicable
disease or health states that might jeopardise safe patient care, in either themselves
or colleagues.
> A surgeon must be aware of health and safety regulations in respect of their practise
and follow Trust guidelines and relevant legislation.
> a signed declaration by the surgeon of evidence of adherence to local practice; for
example, that health issues have not and do not affect their fitness to practise;
> hepatitis status; and
> record of absence through sickness.
39
8 Additional guidance: armed conflict, developing countries
and prisons
Additional guidance is given for surgeons working in the following circumstances.
8.1 Armed conflict
> In armed conflict, standards of surgical practice should be, as far as practically
possible, as laid out in Good Surgical Practice, given the conditions and
environment in which one is practising.
> Only operate at the request and with the consent of the patient. If the patient is
incapable of giving consent, then act only in the patient’s best interests.
> Do not discriminate between the protagonists. Prioritise patients for treatment on the
basis of clinical need alone.
> Maintain the highest professional standards within the limitations of the
circumstances. Ensure that treatment is culturally sensitive and non-discriminatory.
> Take personal precautions consistent with providing the highest level of care.
8.2 Developing countries
Those seeking to assist health care professionals in developing countries by

providing surgical services should aim to do so in the spirit of mutual partnership
based on humanitarian service and avoid any patronising or dominant attitudes. This
includes humanitarian deployment following natural or man-made disasters.
Surgeons must:
> ensure that whatever is done is for the benefit of the individual and for the local population;
> retain the highest standards of care, compatible with the local conditions;
> ensure that, as written informed consent may not always be obtainable, the patient
understands and voluntarily agrees to the planned procedure. This must always be
in the interest of the patient;
> adhere to local legal requirements; and
> never participate in mutilating operations.
Research projects should be undertaken with the highest ethical standards and with the
full awareness and agreement of the local and national communities and health agencies.
40
8.3 Prisons
The duty of care remains the same when treating prisoners. Surgeons should not
condone or contribute to inflicting physical or mental suffering, whether deliberately,
systematically or wantonly. (See The Surgeon’s Duty of Care, Senate of Surgery of
Great Britain and Ireland, pp 28, 29, 1997).
Surgeons should report evidence of abuse and deliberate injuries to the appropriate
authority.
Seeking Consent: Working With People in Prison, Department of Health, 2002
41
9 Further reading
9.1 Department of Health
All Department of Health documents can be found at http://www.dh.gov.uk/ in the

Policy and Guidance section.
Trust, Assurance and Safety: the Regulation of Health Professionals, Cm 7013
Gateway Reference 7823, Department of Health, February 2007
Safeguarding Patients, Cm 7015 Gateway Reference 7864, Department of Health,
February 2007
Health Act 2006: Code of Practice for the Prevention and Control of Healthcare
Associated Infections, Department of Health, October 2006
Guidelines for the NHS in Support of the Memorandum of Understanding –
Investigating Patient Safety Incidents Involving Unexpected Death or Serious
Untoward Harm, Department of Health, November 2006
Good Doctors, Safer Patients: Proposals to Strengthen the System and Improve the
Performance of Doctors and to Protect the Safety of Patients, Department of Health,
July 2006
Seeking Consent: Working With People in Prison, Department of Health, 2002
Guide to Consent for Examination or Treatment with Consent Forms for Adults, Adults
Without Capacity and Children and Young People, Department of Health, November
2001
Reference Guide to Consent for Examination or Treatment, Department of Health,
April 2001
Supporting Doctors, Protecting Patients, Department of Health, 1999
A First Class Service – Quality in the New NHS, Department of Health, 1998
42
9.2 General Medical Council
All documents can be found at http://www.gmc-uk.org/publications/.
0–18 Years: Guidance for all Doctors, GMC, September 2007

Writing References, GMC, August 2007
Personal Beliefs and Medical Practice, a draft for consultation, GMC, 2007
Valuing Diversity – Resource Guides, GMC, 2006
Raising Concerns about Patient Safety, GMC, 2006
Good Practice in Prescribing Medicines, GMC, 2006
Management for Doctors, GMC, 2006
Maintaining Boundaries, GMC, 2006
Good Medical Practice, GMC, November 2006
Good Practice in Prescribing Medicines, GMC, 2006
Withholding and Withdrawing Life Prolonging Treatments: Good Practice in Decision
Making, GMC, 2006
GMC & PMETB Principles of Good Medical Education and Training, GMC, 2006
Conflicts of Interest, GMC, 2006
The Meaning of Fitness to Practise, GMC, 2005
Confidentiality FAQs, GMC, 2004
Continuing Professional Development, GMC, 2004
Confidentiality: Protecting and Providing Information, GMC, 2004
Research: The Role and Responsibilities of Doctors, GMC, 2002
Making and using Visual and Audio Recordings of Patients, GMC, 2002
The Doctor as a Teacher, GMC, September 1999
Seeking Patients’ Consent: The Ethical Considerations, GMC, 1998
(Note: A new document entitled Consent: Patients and Doctors Making Decisions
Together is due to be published in 2008. The new guidance will replace the 1998
publication. It is broader in scope than its predecessor, placing greater emphasis
on how doctors and patients work together to make good decisions, and providing
a framework that will apply to the range of situations that doctors face in practice. It
also reflects changes in the law, including the new mental capacity legislation and
case law that requires doctors to explain the range of risks associated with a
proposed intervention.)
43
Serious Communicable Diseases, GMC, October 1997
(Note: update to serious communicable diseases guidance, non-consensual testing
following injuries to health care workers.
The GMC’s guidance on consent for testing for HIV or other communicable diseases
following a needlestick injury or other occupational exposure to patients’ blood or
bodily fluids has been superseded by various changes to the law. This means that
paragraphs 8–11 of Serious Communicable Diseases are out of date.
In England, Wales and Northern Ireland, this area is now governed by the Human
Tissue Act 2004, which came into force on 1 September 2006. The Mental
Capacity Act 2005, which came into force in April 2007, also affects this area of law.
How or whether the Mental Capacity Act will apply in Northern Ireland is still to be
determined. In Scotland, this area is governed by the Adults with Incapacity
(Scotland) Act 2000, which came into force in April 2001 and the Human Tissue
(Scotland) Act 2006, which came into force on 1 September 2006.
The GMC advises that you must comply with the requirements set out in the
legislation and any statutory regulations and codes of practice issued by the
relevant authority or ministers. For information and advice on the law, contact your
defence body or professional association or seek legal advice.
The GMC will update this statement when they have further information about the
effect of the operation and interaction of the human tissue and mental capacity
legislation across the UK. For more information on the GMC’s guidance and this
statement, contact the GMC’s standards and ethics team on 020 7189 5404.)
Guidance for Doctors who are asked to Circumcise Male Children, GMC, 1997
Transplantation of Organs from Live Donors, GMC, 1992

(Note: The GMC is currently drafting Guidance on Expert Witnesses.)
44
9.3 The Royal College of Surgeons of England
All documents can be found at http://www.rsc.eng.ac.uk/publications/docs/.
Surgery for Children: Delivering a First Class Service, RCS, July 2007
Children in Hospital: Rights and Responsibilities of Children and Parents, RCS Patient
Liaison Group, June 2007
The Leadership and Management of Surgical Teams, RCS, June 2007
Continuing Professional Development: Advice to All Surgeons from the Senate of Surgery
of Great Britain and Ireland, Senate of Surgery of Great Britain and Ireland, January 2006
The Surgical Workforce Interim Report and Policy Update, RCS, October 2006
Delivering High-quality Surgical Services for the Future. A consultation document from
the Royal College of Surgeons Reconfiguration Working Party, RCS, March 2006
Management of Waiting Lists: What is Important to Patients, RCS Bulletin, RCS

Patient Liaison Group, 2005
Developing a Modern Surgical Workforce, RCS, January 2005
Equality and Diversity Policy, RCS, 2004
Maintaining your Performance – Dossier of Guidance on Continuing Professional

Development for Surgeons, Senate of Surgery of Great Britain and Ireland, 2004
Patient Rights and Responsibilities, RCS Patient Liaison Group, 2002
Better Care for the Severely Injured, RCS and British Orthopaedic Association, July 2000
Code of Practice for the Surgical Management of Jehovah’s Witnesses, RCS, 1996;
see also Personal Beliefs and Medical Practice, a draft for consultation, GMC, 2007
The Surgeon’s Duty of Care: Guidance for Surgeons on Ethical and Legal Issues,
Senate of Surgery of Great Britain and Ireland, October 1997
Guidelines for Clinicians on Medical Records and Notes, RCS, 1994 (revised from 1990)
9.4 Other bodies
Good Medical Practice – Guidance from the Disability Rights Commission, DRC, 2007
Gynaecological Examinations. Guidelines for Specialist Practice, Royal College of

Obstetricians and Gynaecologists, September 2002
Towards Standards for Organ and Tissue Transplantation in the UK, British
Transplantation Society, 1998
45
10 Useful contacts
10.1 Surgical royal colleges in Great Britain and Ireland
The Royal College of Physicians and Surgeons of Glasgow

232–242 St Vincent Street, Glasgow G2 5RJ
Tel: 0141 221 6072
Fax: 0141 221 1804
www.rcpsg.ac.uk
The Royal College of Surgeons of Edinburgh

Nicolson Street, Edinburgh EH8 9DW
Tel: 0131 527 1600
Fax: 0131 557 6406
Email: information@rcsed.ac.uk
www.rcsed.ac.uk

35–43 Lincoln’s Inn Fields, London WC2A 3PE
Tel: 020 7405 3474
Fax: 020 7831 9438
www.rcseng.ac.uk
The Royal College of Surgeons in Ireland

123 St Stephens Green, Dublin 2, Ireland
Tel: 00 353 1 402 2100
Email: info@rcsi.ie
www.rcsi.ie
46
10.2 Surgical specialist associations and societies
All the associations and societies are based at The Royal College of Surgeons of
England, 35–43 Lincoln’s Inn Fields, London WC2A 3PE.
Association of Surgeons of Great Britain and Ireland

Tel: 020 7973 0300
Fax: 020 7430 9235
Email: admin@asgbi.org.uk
www.asgbi.org.uk
British Association of Oral and Maxillofacial Surgeons

Tel: 020 7405 8074
Fax: 020 7430 9997
Email: office@baoms.org.uk
www.baoms.org.uk
British Association of Otorhinolaryngologists – Head and Neck Surgeons

Tel: 020 7404 8373
Fax: 020 7404 4200
Email: admin@entuk.org
www.entuk.org
British Association of Paediatric Surgeons

Tel: 020 7869 6915
Fax: 020 7869 6919
Email: adminsec@baps.org.uk
www.baps.org.uk
British Association of Plastic, Reconstructive and Aesthetic Surgeons

Tel: 020 7831 5161
Fax: 020 7831 4041
Email: secretariat@bapras.org.uk
www.bapras.org.uk
British Association of Urological Surgeons

Tel: 020 7869 6950
Fax: 020 7404 5048
Email: admin@baus.org.uk
www.baus.org.uk
British Orthopaedic Association

Tel: 020 7405 6507
Fax: 020 7831 2676
Email: secretary@boa.ac.uk
www.boa.ac.uk
47
Society of British Neurological Surgeons
Tel: 020 7869 6892
Fax: 020 7869 6890
Email: admin@sbns.org.uk
www.sbns.org.uk
Society for Cardiothoracic Surgery in Great Britain and Ireland

Tel: 020 7869 6893
Fax: 020 7869 6890
Email: sctsadmin@scts.org
www.scts.org
48
10.3 Other contacts
Academy of Medical Royal Colleges

70 Wimpole Street, London W1G 8AX
Tel: 020 7486 0067
Fax: 020 7935 9214
Email: academy@aomrc.org.uk
www.aomrc.org.uk
Association of Surgeons in Training

Tel: 020 7973 0300
Fax: 020 7430 9235
Email: info@asit.org
www.asit.org
British Association of Medical Managers

Petersgate House, St Petersgate, Stockport SK1 1HE
Tel: 0161 474 1141
Fax: 0161 474 7167
Email: bamm@bamm.co.uk
www.bamm.co.uk
British Medical Association

BMA House, Tavistock Square, London WC1H 9JP
Telephone 020 7387 4499
Fax: 020 7383 6400
www.bma.org.uk
British Orthopaedic Trainees Association

Tel: 020 7405 6507
www.bota.org.uk
British Association of Day Surgery

Tel: 020 7973 0308
Fax: 020 7973 0314
Email: bads@bads.co.uk
British Association for Emergency Medicine

Churchill House, 3rd Floor, 35 Red Lion Square, London WC1R 4SG
Tel: 020 7404 1999
Fax: 020 7067 1267
Email: baem@emergencymedicine.uk.net
www.emergencymed.org.uk
49
British Transplantation Society
Association House, South Park Road, Macclesfield SK11 6SH
Tel: 01625 504 060
Fax: 01625 267 879
Email: secretariat@bts.org.uk
www.bts.org.uk
Clinical Governance Support Team

1st Floor, St John’s House, 30 East Street, Leicester LE1 6NB
Tel: 0116 295 2000
Email: support@ncgst.nhs.uk
www.cgsupport.nhs.uk
Department of Health (England)

Richmond House, 79 Whitehall, London SW1A 2NS
Tel: 020 7210 4850
Email: dhmail@dh.gsi.gov.uk
www.dh.gov.uk
Department of Health, Social Services and Public Safety

Castle Buildings, Stormont, Belfast BT4 3SJ
Tel: 028 9052 0500
Fax: 028 9052 0572
www.dhsspsni.gov.uk
Federation of Independent Practitioner Organisations

14 Queen Anne’s Gate, London SW1H 9AA
Tel: 020 7222 0975
Fax: 020 7222 4424
www.fipo.org.uk
General Medical Council

Regent’s Place, 350 Euston Road, London NW1 3JN
Tel: 08457 357 8001
Email: gmc@gmc-uk.org
www.gmc-uk.org
GMC Fitness to Practise Directorate

5th Floor St James’s Buildings, 79 Oxford Street, Manchester M1 6FQ
Tel: 0845 357 0022
Email: practise@gmc-uk.org
Healthcare Commission
Finsbury Tower, 103–105 Bunhill Row, London EC1Y 8TG
Tel: 020 7448 9200
Email: feedback@healthcarecommission.org.uk
www.healthcarecommission.org.uk
50
The Medical Defence Union
230 Blackfriars Road, London SE1 8PJ
Tel: 020 7202 1500
Email: mdu@the-mdu.com
www.the-mdu.com
The Medical and Dental Defence Union of Scotland

Mackintosh House, 120 Blythswood Street, Glasgow G2 4EA
Tel: 0845 270 2034
Fax: 0141 228 1208
Email: info@mddus.com
www.mddus.com
The Medical Protection Society (Leeds)

Granary Wharf House, Leeds LS11 5PY
Tel: 0113 243 6436; lo-call: 0845 605 4000
Fax: 0113 241 0500
The Medical Protection Society (London)

33 Cavendish Square, London W1G OPS
Tel: 020 7399 1300; lo-call: 0845 605 4000
Fax: 020 7399 1301
Email: info@mps.org.uk
www.mps.org.uk
Medical Research Council

20 Park Crescent, London W1B 1AL
Tel: 020 7636 5422
Fax: 020 7436 6179
www.mrc.ac.uk
Medicines and Healthcare Products Regulatory Agency

10–2 Market Towers, 1 Nine Elms Lane, London SW8 5NQ
Tel: 020 7048 2000 (weekdays 9.00–17.00) or 020 7210 3000 (out of hours)
Fax: 020 7084 2353
Email: info@mhra.gsi.gov.uk
www.mhra.gov.uk
National Clinical Assessment Service (England Office)

1st Floor, Market Towers, 1 Nine Elms Lane, London SW8 5NQ
Tel: 020 7084 3850; advice line: 020 7062 1655
Fax: 020 7084 3851
Email (general): ncas@ncas.npsa.nhs.uk
Email (advice): advice.service@ncas.npsa.nhs.uk
www.ncas.npsa.nhs.uk
51
National Clinical Assessment Service (Wales Office)
Sophia House, 28 Cathedral Road, Cardiff CF11 9LF
Tel: 029 2066 0280
Fax: 029 2066 0279
National Clinical Assessment Service (Northern Ireland Office)

Lisburn Square House, Office Suite 2, Haslem’s Lane, Lisburn BT28 1TW
Tel: 028 9266 3241
Fax: 028 9267 7273
National Confidential Enquiry into Patient Outcome and Death

4–8 Maple Street, London W1T 5HD
Tel: 020 7631 3444
Fax: 020 7631 4443
Email: info@ncepod.org.uk
www.ncepod.org.uk
National Coordinating Centre for Health Technology Assessment

Mailpoint 728, Boldrewood, University of Southampton, Southampton SO16 7PX
Tel: 023 8059 5586
Fax: 023 8059 5639
Email: hta@hta.ac.uk
National Counselling Service for Sick Doctors

Tel: 0870 241 0535
National Institute for Health and Clinical Excellence

MidCity Place, 71 High Holborn, London WC1V 6NA
Tel: 020 7067 5800
Fax: 020 7067 5801
Email: nice@nice.org.uk
www.nice.org.uk
National Library for Health

Specialist Library for Surgery, Theatres & Anaesthesia
www.library.nhs.uk/theatres
National Patient Safety Agency

4–8 Maple Street, London W1T 5HD
Tel: 020 7927 9500
Fax: 020 7927 9501
Email: enquiries@npsa.nhs.uk
www.npsa.nhs.uk
52
Patient Liaison Group of The Royal College of Surgeons of England
Tel: 020 7869 6045
Fax: 020 7869 6044
Email: communications@rcseng.ac.uk
www.rcseng.ac.uk/patient_information
Public Liaison Group of the Royal College of Surgeons of Edinburgh

Nicolson Street, Edinburgh EH8 9DW
www.rcsed.ac.uk
Scottish Government Health Directorate

St Andrew’s House, Regent Road, Edinburgh EH1 3DG
Tel: 0131 556 8400
Fax: 0131 244 2162
Email: ceu@scotland.gov.uk
www.scotland.gov.uk

Scottish Audit of Surgical Mortality
2nd Floor, Cirrus, Marchburn Drive, Paisley PA3 2SJ
Tel: 0141 282 2280
Email: sasm@isd.csa.scot.nhs.uk
www.sasm.org.uk
Welsh Assembly Government

Cardiff Bay, Cardiff CF99 1NA
Tel: 029 20 825111
www.wales.gov.uk
53
Acknowledgements
The revision and updating of this version of Good Surgical Practice and associated
documentation was undertaken, on behalf of the Professional Standards Committee of
The Royal College of Surgeons of England, by Maggy Wallace MA BA RN DipEd FHEA.
54
London WC2A 3PE
T: 020 7405 3474
www.rcseng.ac.uk
Registered charity number 212808

February 2008
Review date: 2010

Good Surgical Practice 2008

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The Royal College of Surgeons of England

35–43 Lincoln’s Inn Fields

Good Surgical Practice

Good Surgical Practice is endorsed by:

The Association of Surgeons of Great Britain and Ireland

Registered Charity No. 212808

Professional Standards and Regulation

© The Royal College of Surgeons of England 2008

Designed and typeset by Close to Water Ltd, Crayford, Kent

The duties of a doctor registered with the General Medical Council 5

1 Good clinical care 9

2 Maintaining and improving good surgical practice 17

3 Teaching, training and supervising 21

5 Working with colleagues 32

6 Probity in professional practice 34

8 Additional guidance: armed conflict, developing countries and prisons 40

> Make the care of your patient your first concern.

1 good clinical care,

Each of these headings is addressed in this document.

As plans for revalidation are developed, information will be available from:

> the Department of Health (http://www.dh.gov.uk/);

> royal colleges including The Royal College of Surgeons of England

1.1 Providing a good standard of surgical practice and care

> accepting patients on referral from GPs, consultant colleagues or as an emergency

1.1.1 Further reading

1.2.1 Further reading

Guidance on safe handovers can be found at:

Advice on designing safe rotas is available at:

> when communicating with a child or young person:

1.3.1 Further reading

Surgeons undertaking organ or tissue transplantation must:

Surgeons must do the following:

> date and time;

Sources of evidence might include:

> job plan/work programme;

> record of examples of cancellations or deferment, for example, on account of

> results of clinical outcomes as compared with relevant College/association

> record of attendance at audit meetings, of clinical audits and of implementation of

2.1 Maintaining and improving your knowledge and performance

All surgeons must:

> attend multidisciplinary meetings with, for example, pathologists, radiologists,

2.2 Adverse events*

> a local audit meeting; then

New techniques include:

> a new or personally developed operation;

When a new technique is to be used, the patient’s interests should be considered

2.5 Presenting examples of your evidence

Sources of evidence might include:

> record of attendance at multidisciplinary meetings, for example minutes/register of

Surgeons should be willing, as part of their professional practice, to engage in the

3.1 Medical students

> encourage and support medical students;

> ensure that when a student is involved in specific examinations or procedures on

3.1.1 Further reading

The Doctor as a Teacher, GMC, 1999

Staff and associate specialist surgeons must:

> perform to the standards detailed in this document;

3.4 Locum surgeons

(Foundation Year 1; Foundation Year 2; Specialist Trainees 1–6)

> be available according to a rota published in advance;

> maintain all records relating to their training;

> maintain legible and up-to-date clinical records;

3.7 Presenting examples of your evidence