Sub-specialization or super-specialization in surgery?

A special centre for prosthetic hip replacement set up 10 years ago has been successful in its primary objectives, producing high quality work at low cost and stimulating research. The project has not yet been successful in achieving a permanent staffing structure, but this is the effect of certain British ideologies in surgical training, with the result that craftsmanship and technology cannot be reconciled with pure intellectual attainment.The success of the project suggests the importance of isolating elective surgery from emergency surgery in the interests of cost-effectiveness. Problems of isolation from teaching hospitals are not insurmountable, but isolation to some degree is essential to achieve the minimum size necessary for efficiency and to ensure unbroken professional team-work among all levels of staff. While maximum efficiency in this field can be achieved only in special centres, too many primary operations will be required every year to insist that total hip replacement should be done only in special centres. A special feature of this field is the need for a permanent staffing structure to hand on technical expertise as an unbroken tradition.