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The publication of this best practice document represents an important step towards strengthening governance and collaborative working in paediatric spinal surgery across the United Kingdom.

Following concerns raised about aspects of paediatric orthopaedic and spinal surgical practice, NHS England and the British Orthopaedic Association (BOA) have engaged with specialist societies to consider how existing governance arrangements might be strengthened, particularly for low-volume, high-complexity surgery.

Working closely with colleagues from the British Scoliosis Society (BSS), we have sought to develop a pragmatic framework that recognises the considerable variation in complexity encountered in paediatric spinal surgery. Complexity is not determined by the diagnosis or magnitude of deformity alone, but also by patient factors, technical demands, surgeon experience and the resources available within the treating institution.

An important principle is recognising that technical ability alone does not define surgical competence. Equally important is the ability to recognise the limits of one's expertise, seek appropriate advice and work collaboratively when the circumstances demand it.

The guidance therefore emphasises the role of structured multidisciplinary discussion, peer review, mentorship and dual-consultant operating in selected complex cases. It also recognises that, in rare circumstances, wider regional or national expert discussion may be beneficial.

We must also recognise that governance extends beyond the decision to operate. Regular review of complications, meaningful outcome measurement and participation in the British Spine Registry are important components of maintaining standards and improving patient care.

Importantly, this document is intended to provide best practice guidance rather than impose rigid rules. Clinical judgement remains central, and the application of these principles must be proportionate to the complexity of the individual case.

Implementing some of these recommendations will require additional resources, protected time within consultant job plans and appropriate administrative and technical support. It is essential that NHS England and healthcare providers recognise these requirements if the proposed improvements are to be delivered consistently and sustainably.

I am grateful to Lee Breakwell and colleagues from BASS,  BSS, BOA and the wider working group for their contributions. I hope this document will provide a foundation for continued collaboration, constructive peer review and a culture in which seeking advice and sharing expertise are regarded as strengths rather than weaknesses.

Ultimately, our shared objective is straightforward: to ensure that every child requiring spinal surgery has access to the appropriate expertise, resources and support to achieve the best possible outcome.

Rajat Verma
President - president@spinesurgeons.ac.uk
British Association of Spine Surgeons