Editor,—Arul and Spicer’s recent review1 on this controversial issue failed to address some of the most important points surrounding regionalisation of paediatric surgery. Other papers on the subject are equally unrewarding2 3 and so perhaps there is a need for more debate.

We must balance the need to banish “occasional paediatric practice”4 with the rightful concerns about providing “a child and family centred service in which skilled help is readily available and accessible”.5

The arguments used by the authors on centralisation of paediatric intensive care do not necessarily support the need to regionalise paediatric surgery along the same lines. Paediatric intensive care is a low volume, high risk speciality requiring the skills and equipment justified in only a few UK centres. In contrast the vast majority of surgery on children in the UK is low risk, high volume work very, little of which requires on site specialist paediatric facilities. Paediatric surgery is however attended by significant morbidity if the wrong decisions are made; such morbidity may only be revealed several years later.

Nevertheless we are urged to move towards a model where one paediatric surgical centre serves the specialist surgical needs of a population of 2.5 million and the non-specialist needs of 1.2 million. The remaining 1.3 million children with non-specialist needs in this model would be served by the general surgeon with a paediatric interest (a rare breed according to a recent Senate of Surgery report6). However, according to guidance issued by the British Association of Paediatric Surgeons to purchasers2 such centres might be responsible for cases such as elective repair of congenital inguinal hernia, undescended testis, and circumcision. Arul and Spicer are rightly concerned that the skills required to deal with these problems are considerable if long term morbidity is to be prevented.

In a larger district general hospital such as Norwich, 3000 children under 12 have operations each year. A large proportion of this work is done by two paediatric surgeons. This gives the surgeon, anaesthetist, and more importantly managers the numbers to provide extra facilities and produce a first rate local service for children. As well as medical staff it involves a dedicated, separate provision for children from operating theatre, recovery room, and day care centre to the provision of pain relief, and beyond. Removing our paediatric surgeons would have a significant spin off effect in making the total provision of service less cost effective and more prone to inadequate investment.

If we all believe that children’s surgery should be done by paediatric surgeons (as happens in most developed countries) it is nonsense to make plans of which the main side effect is so much surgery being done by a dying breed of general surgeons with a paediatric interest.