The 1989 report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD)¹ recommended that surgeons and anaesthetists should not undertake occasional paediatric practice and that consultants who take responsibility for the care of children (particularly in district general hospitals (DGHs) and in single surgical specialty hospitals) must keep up to date and competent in the management of children. A relationship between surgeon volume and operative mortality in adult surgery is recognised.² In 1998, Arul and Spicer³ argued persuasively in this journal that paediatric surgery and anaesthesia should be concentrated in specialist centres. They included in this recommendation both specialist (neonatal surgery, complex surgical conditions, straightforward surgical conditions in children with associated disorders, and urology) and non-specialist (such as inguinal hernia, hydrocoele, circumcision, correction of torsion of the testis) paediatric surgery. Whilst there was agreement that neonatal and complex surgery should be centralised, commentators pointed out that most children’s surgery in DGHs is in ear, nose and throat (ENT), orthopaedics and ophthalmology. Centres would be overwhelmed if all this activity transferred to them and families would have to travel further for treatment.

Anaesthetists also responded to the NCEPOD report by recommending that fewer anaesthetists should be involved in paediatric care.⁴ There were reports of an increased rate of complications for infants anaesthetised by non-paediatric anaesthetists and for groups performing fewer than 100 paediatric anaesthetic procedures a year, quoted in Tomlinson.⁵ Lunn⁶ suggested a minimum paediatric anaesthetic workload to maintain competence, which was unattainable by the majority of DGH anaesthetists.

These considerations led to a movement of children’s surgery away from DGHs to paediatric surgical centres, to the extent that the 2003 report of NCEPOD commented that “many consultants, both anaesthetists and …