Domain 1: Knowledge, skills and development

'Domain 1: Knowledge, skills and development' is the first domain of Good Surgical Practice, which sets standards for surgeons and members of the surgical team. Good Surgical Practice uses the same headings that appear in Good Medical Practice and is the surgical companion to these General Medical Council (GMC) standards.

About Good Surgical Practice

1.1. Maintaining competence and developing your knowledge and performance

1.2. Providing good surgical care

1.3. Non-elective admissions (including those requiring surgery)

1.4. Research

1.5. Introduction of new techniques

Surgeons are specialist doctors who offer effective, informed and up-to-date care to patients through surgical intervention. They are responsible for keeping themselves up to date and maintaining their knowledge and competence in all areas of their practice. Surgeons work in teams that include a range of professionals. All team members should learn continuously from each other, further enhancing the quality of care. Surgeons are also expected to be aware of and understand new developments in their field of expertise.

1.1. Maintaining competence and developing your knowledge and performance

1. Keep up to date with current clinical guidelines in your field of practice and comply with ethical and legislative guidance in relation to your practice.
2. Ensure that your skills and knowledge are up to date by committing to continuous learning, and by undertaking continuing professional development (CPD) and educational activities in all aspects of your work including, where relevant, management, teaching and research. The surgical royal colleges and surgical specialty associations recommend a minimum of 50 hours of CPD activity per year, or 250 hours of CPD activity across the 5-year revalidation cycle.
3. Ensure that CPD activities are relevant to your practice and support your current skills, knowledge and career development. CPD should be planned in discussion with your appraiser and included in your job plan and your annual personal development plan.
4. If your job plan does not allow you to keep up to date, you should address this in discussion with your appraiser or medical director.
5. Maintain an accurate portfolio of your clinical activity, including outcomes and complications. Such evidence must encompass your whole practice wherever this is delivered, including private practice.
6. Take part in local quality improvement activities, including quality improvement projects, participation in local audit and measuring validated outcome data. Where available, you should liaise with your hospital to obtain an analysis of routinely collected data for index procedures identified by the relevant surgical specialty association.
7. Submit all your activity data to national audits and databases relevant to your practice and present the results at appraisal for review against the national benchmark.
8. Play an active role in ensuring that your audit returns and outcome results accurately reflect your practice by being routinely involved in checking and quality-assuring the data attributed to you and your team.
9. Take prompt action to investigate and ensure patient safety if audit, peer review or routinely collected data show that your patient outcome results fall outside the accepted norm. Engage in conversation with your appraiser to identify the nature and basis of the concern and cooperate in relevant local investigations. You should follow the audit provider’s policy for managing outliers.
10. Take part in regular morbidity and mortality meetings.
11. Take part in national enquiries; for example, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).
12. Attend and contribute to regular meetings with colleagues in the same and related specialties and attend multidisciplinary meetings.
13. Participate in the annual appraisal process, taking time to reflect critically on your whole practice, including non-clinical roles and private practice. You should have a constructive discussion with your appraiser using evidence gathered throughout the year.
14. Be proactive in seeking information from your patients on their experience of care and respond appropriately. Reflect meaningfully on feedback received from patients and use this information to improve your practice.
15. In each revalidation cycle, undertake at least one patient feedback exercise using a validated tool and present the results for discussion at appraisal, demonstrating actions taken and learning achieved.

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1.2. Providing good surgical care

When providing elective care for patients with non-urgent conditions, you should:

1. Work within the limits of your competence and within the range of your routine practice. Refer where necessary.
2. Ensure that patient treatment is prioritised according to clinical need.
3. Take full responsibility for the management of patients admitted under your name, leading the surgical team to provide best care. Responsibility should encompass preoperative optimisation and postoperative recovery.
4. Ensure that patients are cared for in an appropriate and safe environment that takes into account any specific requirements or reasonable adjustments they may require. You should be satisfied that adequate resources are available for safe patient care and consider postponing planned procedures if they are not. If patient safety may be compromised by a lack of resources, this must be recorded and communicated to the relevant clinical manager.
5. Ensure that patients receive satisfactory postoperative care and that relevant information is promptly recorded and shared with the appropriate team, the patient and their supporter(s).
6. Follow current clinical guidelines in your field of practice and be prepared to justify your actions, where appropriate, when that guidance has not been followed.
7. Make efficient use of the resources available. Any requests to hospital management for the allocation of resources for patient care should be sensible, realistic and proportionate to the needs of the patient.
8. Utilise the skills and knowledge of other clinicians. When the complexity of the procedure is an issue, you should consider shared operating with another expert surgeon. Where appropriate, transfer the patient to another colleague or unit where the required resources are available.
9. Ensure that, when the patient is discharged from hospital, appropriate information is shared with the patient, the patient’s supporters and the extended care team. In addition, unless the patient requests otherwise, all relevant information should be sent to the patient’s general practitioner (GP), where possible in electronic form, within 24 hours.
10. Where appropriate, accept patients on referral by GPs, consultant colleagues or as an emergency through the emergency department. If you agree to see a patient directly without referral, the patient should be informed that their GP will receive a report unless the patient requests otherwise.
11. Ensure that any instruction to withhold or withdraw treatment is taken in consultation with the patient or family and authorised by the appropriate senior clinician, except in circumstances in which this is not possible.

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1.3 Non-elective admissions (including those requiring surgery)

In the context of this section, non-elective admissions requiring surgical intervention are understood in line with the following 2024 NCEPOD classifications: immediate surgery (immediate life-, limb- or organ-saving interventions that are carried out within minutes of the decision to operate); and urgent surgery (interventions for acute onset or clinical deterioration of potentially life-threatening conditions or conditions that may threaten the survival of limb or organ and which are carried out within hours of the decision to operate).

When on call, you should:

1. Accept responsibility for the assessment and continuing care of every patient admitted under your name unless, or until, they are formally transferred to the care of another doctor.
2. Be available either in the hospital or within a reasonable distance of the hospital to give advice throughout the duty period.
3. Ensure you are able to respond promptly to a call to attend an emergency patient.
4. 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.
5. Delegate the management of emergency surgical operations only when you are sure of the competence of the colleagues to whom the patient’s operative care will be delegated.
6. Support local processes for the advance publication of rotas and ensure that any alternative cover arrangements are specifically made and clearly understood. In case of an unexpected absence in a rota, it is a joint responsibility between the surgical team and the unit manager to find suitable cover in the interest of patient safety.
7. Ensure the formal handover of patients to an appropriate colleague following periods on duty.
8. Taking into account the patient’s best interest ensure that, in an emergency, you only perform unfamiliar operative procedures if there is no safe clinical alternative, if there is no colleague available who is more experienced or if after consultation with the nearest specialist unit transfer is considered a greater risk to the patient.
9. If unexpected circumstances require colleagues to act beyond their practised competencies, you should provide support in making the care of the patient the first concern.

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1.4. Research

Surgical research is vital for surgical innovation that leads to the improvement of patient care and effectiveness of surgical interventions. Surgeons should strive to participate in research initiatives related to their practice.

If you undertake research, you should:

1. Acknowledge the wellbeing of the individual patient as the paramount concern, regardless of the value of the research project.
2. Submit full protocols of proposed research and details of intended new technical procedures to your local research/ethics committee before starting.
3. Ensure that all clinical trials you undertake are registered and all trial results are published, including negative results or results where the outcome is different to what was expected.
4. Treat patients participating in research as partners, respecting their dignity and unique clinical circumstances. You should be satisfied that the expected benefits of the research outweigh any anticipated risks.
5. Fulfil the recommendations of the Declaration of Helsinki statement of ethical principles for medical research involving humans, including identifiable human material and data (NB: this is currently under revision by the World Medical Association).
6. Fully inform research participants about your research aims, intentions, values, relevance, methods, risks and discomforts, and record this in their notes.
7. Fully inform patients in randomised trials about the procedures being compared and their risks and benefits, and record this in their notes.
8. Inform participants how their confidentiality will be respected and protected.
9. Accept that a patient may refuse to participate or withdraw during the programme, in which case their treatment must not be adversely affected.
10. 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.
11. Seek permission to remove tissue beyond that excised diagnostically or therapeutically.
12. Acquire explicit permission to use any removed tissue for commercial purposes; for example, to grow cell lines or for genetic research.
13. Discourage the publication of research findings in non-scientific media before reporting them in reputable scientific journals or at meetings.
14. Disclose any personal affiliation or financial and commercial interest in relation to your research and its funding. This includes, for example, private healthcare companies, pharmaceutical companies or instrument manufacturers.
15. Report any fraud that is detected or suspected to the local research/ethics committee.
16. Recognise and be familiar with the Human Tissue Act 2004 regulations and obtain appropriate licences where necessary.
17. Fulfil the strict regulations of the Animals (Scientific Procedures) Act 1986 when obtaining permission to carry out research on animals.

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1.5. Introduction of new techniques

New surgical techniques include a new or personally developed operation, any major modifications to an established procedure (including new equipment) or the introduction of a procedure not previously performed in the hospital. When a new technique is to be used, the patient’s interests should be considered paramount. For robotic-assisted surgery, there is currently no regulation or nationally established protocol for the introduction of such programmes in hospitals, including requirements for training and maintaining competence and quality. We recommend that surgeons and their employers follow professional guidance set out by the surgical royal colleges.

If you are introducing a new technique, you should:

1. Discuss the technique with colleagues who have relevant specialist experience and seek approval through the relevant local approval processes, or from your medical director.
2. Follow local protocols to obtain permission from the local clinical governance committee (or other body with the function of overseeing new intervention procedures and new technologies). Such protocols should include evidence that the new technique is safe and that all clinical staff who plan to use it will undertake relevant training, mentorship and assessment.
3. Contact the Interventional Procedures Programme at the National Institute for Health and Care Excellence (NICE) to learn the status of the procedure and/or to register it. If the new technique involves medical devices or equipment, these should be registered with the Medicines & Healthcare products Regulatory Agency.
4. Liaise with the relevant surgical specialty association.
5. Ensure that patients know when a technique is new or experimental and/or how it has been shown to be effective in clinical trials elsewhere, and explain all established alternatives before seeking consent and recording their agreement to proceed.
6. Be open and transparent regarding sources of funding for the development of any new technique.
7. Record and audit outcomes and review progress with a peer group.
8. Where possible, obtain necessary training in the new technique.
9. Take part in regular educational activities that maintain and further develop competence and performance.
10. Enable the training of other surgeons in this new technique.
11. Ensure that any new device complies with European standards and is certified by the competent body.
12. When it comes to the introduction of robotic-assisted surgery in your scope of practice, work with your relevant local committee to seek approval and follow professional guidance by the surgical colleges for the minimum requirements of robotic skills training, accreditation and mentoring, including considerations around case selection, consent and audit.

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