Case Studies: Preoperative Optimisation
Identified area for improvement
Lack of specialist perioperative cardiological opinion in context of preparedness for surgery when referring patients from perioperative care to general cardiology services.
How did you know there was a problem?
Patients would be referred to general cardiology for assessment in the peri-operative period. In some instances the question asked may not be detailed enough or clear enough to obtain meaningful information about how to manage the issue perioperatively. Patients were then potentially ‘cleared by Cardiology’ in terms of no further Cardiology action required to optimise. These patients may then proceed to surgery, but still be cancelled on the day because the question or answer was not specific or interpreted correctly. Common issues might be, Cardiology response would be focussed on whether the cardiology pathology was appropriately treated. There was no consistent advice about ability to tolerate major surgery and recovery, treatment options if cardiac deterioration perioperatively or risk assessment.
Since the inception of the High risk Anaesthetic meeting roughly 500 patients have been discussed in the weekly meeting. A communication channel grew organically between the perioperative Anaesthetists and a Cardiologist with particular expertise and interest. Patients were initially discussed on an ad-hoc basis. Similar questions were being asked of this cardiologist and It became clear that a regular meeting for discussion of high risk patients would be useful. It would give a chance for a group of anaesthetists, intensivists, surgeons and cardiologists to review imaging, suggest further investigations and share learning about perioperative decision making.
The meeting was initially face to face, it allowed discussion and debate in real time. However, the covid pandemic necessitated a move to a digital platform. This was beneficial, as more people can now attend. Imaging can be shared easily and the meeting can be widened to allow the learning to be spread more efficiently. To date 100 different clinicians have attended over 18 months including hospital clinicians, community cardiology GPs, academics and medical students. Initially meeting face to face was difficult. We are a large multi-site trust with people working remotely from each other and so if someone was on another site they would miss the meeting.
Ironically, moving to virtual meetings during the covid pandemic has helped.
The cardiologists involved have been extremely supportive and have taken a lead in the clinic. It has led to a decrease in their workload in spread over the week and clinicans feel decision making has improved.
The ICU/Anaesthetic department here has a strong tradition of advanced Echocardiography skill. The perioperative clinic has access to regular ICU/Anaesthetist led echo clinics. This means investigations are done by clinicans with experience in and understanding of the issues posed perioperatively. These images can then be reviewed at the meeting and further management plans agreed upon by the MDT. It is predominantly Cardiology, Anaesthetics and Intensive care. A number of the Intensive care team are also medically specialised, with both Respiratory and Renal involvement. Attenders also include perioperative medicine, community cardiology GPs, academic anaesthetic staff.
- Impact has been qualitative.
- Workload for cardiology has reduced.
- Pressure on on call cardiology services has been markedly reduced.
- Feedback from surgeons and anaesthetists has been very positive when patients have been through this pathway.
- Community GPs, trainees and medical students have commented on the educational quality of the meeting.
The provision of procedure specific information is essential when preparing patients for elective surgery. This information should be ‘presented in a format that can be easily understood’ and should start ‘when listed for surgery, then whenever needed throughout their care’ (prehabilitation to rehabilitation) (NICE:NG157).
At the same time Enhanced Recovery Programmes (ERP) have become increasingly widespread within orthopaedic surgery. They are based upon the following key principles (Enhanced Recovery Partnership, 2012):
• The patient is in the best possible condition for surgery
• The patient has the best possible management during and after their operation
• The patient experiences the best post-operative rehabilitation
Central to this is the education, advice and support delivered to the patient both pre-operatively and post-operatively. When designing patient education and support programmes it is therefore essential to focus not only on the content of these programmes but also the timing, format and accessibility of information regarding a range of topics important to the patient to maximise their impact.
To address some of the requirements of information giving / patient education and ERP it has become standard care for many orthopaedic services to run a one-stop ‘joint school’. The ‘joint school’ is usually delivered in the weeks before surgery and provides a condensed overview of the expect care, rehabilitation, and surgical recovery. However, this approach has a number of disadvantages as it is a one off event, delivered face to face, and is uncoupled from peri-operative care and post-operative rehabilitation. Further limitations of this approach have been starkly highlighted during the Covid-19 pandemic, with hospitals limiting opportunities for face-to-face contact with patients in a bid to reduce footfall and implement new ways of working.
In 2017 we needed to redesign our surgical preparation pathway and patient facing educational materials. We wanted to extend the joint school approach using a digital platform that could support decision making and provide education and support across the entirety of the care pathway. This led us to develop a bespoke digital patient and education support program to cover all aspects of care, starting at surgical listing and continuing beyond discharge from the orthopaedic service.
Work done locally at South Tees Hospitals NHS Foundation Trust showed that there was significant variation in the type, quantity and detail of information requested by and delivered to patients during their perioperative care episode (Norman 2015 MSc thesis). Some patients wanted minimal information about the processes of care whereas other request detailed information about a range of clinical issues. A ‘one size fits all’ approach to information content and delivery was failing to address the needs of all patients.
Furthermore, a review of the orthopaedic care pathway for hip and knee replacement patients demonstrated a number of issues in the way patients received education and support.
1. There was a wide variety of staff involved in the delivery of patient education and support including physiotherapists, occupational therapists, nurses, nurse practitioners. The variation in team members had resulted in delivery of patient education material that differed in its content and often lacked key information.
2. The timing of the delivery of patient education and support was inconsistent. Sometimes this happened only a few days before surgery giving patients little time to prepare themselves and their home environment.
3. Rapid turnover over of trainee doctors on the ward, many of whom had no prior orthopaedic experience, meant that many felt uncomfortable delivering advice and support to arthroplasty patients during their stay. This led to inconsistent information at the point of discharge from hospital.
4. There was significant duplication of work between team members and a limited access to key information as they maintained their own paper records which weren’t always available in the patients medical records.
5. There was pressure on clinic space leading to our pre-admission service being relocated to a local community hospital. While this had some advantages, it led to a lack of oversight of the process for individual patients by their treating Conusultants.
6. This approach led to a large number of patients contacting the ward and secretarial services with queries about upcoming operations. This was a significant burden of work for the ward and secretarial teams.
Having identified the aforementioned problems the Trust looked for solutions. It was felt a ‘digital joint school’ approach might provide the most appropriate way forward. We therefore developed a solution in collaboration with GoWellHealth (GWH) (https://gowellhealth.co.uk/about-us) who had a web-based healthcare platform that allowed creation of bespoke patient education and support programs.
In developing a solution alongside GWH, a list of desirable requirements were drawn up:
• Clear and consistent delivery of patient information that can be delivered in a variety of formats (written, video, email, interactive forms etc).
• Ability to track patient engagement and monitor patient use.
• To have the capability to collect information from patients including the collection of Patient Reported Outcome Measures (PROMs) and health and social care information
• It should be clinician driven and controlled, the hospital orthopaedic team should be in charge of what their patients see and the information they receive.
• Transparent information delivery – creation of a program of information that is visible to all members of the hospital orthopaedic team with information about individual patients being available to all registered healthcare team members at all times.
• Adaptability – Ability to change and update programs and information in response to patient demand and need.
• Ability to include all members of the hospital orthopaedic team to increase engagement and buy-in with the process.
• 2-way communication with patients (patient can contact surgical team and surgical team can contact patient)
• Secure portal for patient communication and electronic correspondence (safe mechanism to send patient letters out negating the need for postage and its associated cost).
• Ability to contact a cohort of patients in one action. For example a blanket email or document broadcasted to all patients simultaneously which means administrative staff do not need to contact patients individually
• Data ownership – South Tees Hospitals NHS Foundation Trust own the data about their patients and have confidence that this information will not be sold to a third party
• Ability to use in all orthopaedic sub-specialities (i.e. not limited to elective hip and knee replacement) and to be able to expand across the organisation to other speciailities (e.g. thoracics) if desired.
GWH is a web-based platform, this means that patients are not limited to an app-based program and the information can be accessed using a variety of devices such as phones, tablets and laptops.
Patients are registered to GWH via their care provider at the point of listing for surgery to a bespoke digital clinic (e.g. our orthopaedic patients were registered to the Orthopaedic clinic). This allows multiple ‘clinics’ to be set up within the same platform to support the management of patients in other specialities.
Patient education resources and support mechanisms (e.g. prompting emails, interactive forms monitoring progress and recovery) were created within the GWH platform using a variety of digital formats (PDF documents, videos, interactive forms, email etc.). Each piece of individual content is uploaded and stored in a library of content. The content within the library can then be combined to create a targeted ‘carepack’ of structured information over a particular period of time. For example 10 pieces of individual content including PDF documents, videos and interactive forms can be combined to create a ‘carepack’ delivered over a 3 week period to target leg conditioning and exercises prior to surgery; or a more comprehensive carepack involving >100 pieces of content developed by the wider hospital orthopaedic team can be combined and structured in the months before surgery to provide a pre-operative ‘digital joint school’ covering all aspects of care. Our patients receive multiple carepacks targeted to their needs and timed to key events within their care pathway (listing for surgery, pre-assessment, hospital inpatient stay, post-operative rehabilitation)
The advantage of being able to structure the content within the carepac is that the care team have control over the timing the content is delivered to the patient and the way in which this is delivered. Additionally, it does not overwhelm the patient by delivering the information all at once, instead allowing for chunking and repetition of information, all of which are proven techniques to help increase patient engagement and emphasising key information. Content can easily be created, uploaded, edited or deactivated, allowing for adaptability in the Trust’s response to patient demand and need.
Additional features created within GWH included:
• Interactive forms – allowing data collection from patients e.g. PROMs and health screening questionnaires that allow potential health problems to be recognised early in the patient pathway.
• Communication module – 2 way client communication, allowing patient to contact their care team within the secure platform via a central route. This allowed central co-ordination of patient queries and ensured they could be triaged and directed effectively. For example using the GWH platform our team acknowledged 93.3% of communications received through the platform within 24 hours, with 66.3% of these also being resolved by the orthopaedic care team within this timeframe. Over half (56.9%) of communications were resolved via the GWH communication module and another 29.5% by an additional orthopaedic telephone consultation
• Broadcast – This allows pieces of content to be selected and sent out to groups of individuals in one action.
• Reports – Detailed reports of patient engagement and activity on the platform can be pulled. Using this information, bespoke reports can be created for individual patients.
• Health Professional access – All healthcare team members (surgeons, nurses, physiotherapists etc.) can have access to the platform via their own login, viewing the content and information provided to each and every patient within the clinic.
The following barriers were encountered:
1) Information governance (IG): We required each patient’s personal details and email to register them on GWH. This initially required us to take written consent to use this data for this purpose to satisfy local IG requirement. Through the COVID pandemic written consent became inpratical and we moved to a verbal consent process supported by an email explanation of data use and handling with an option to opt out should patients request their data not be used.
2) Staff engagement: We encountered early issues with clinic staff not offering and encouraging uptake following listing for surgery. This required repeated staff education and training.
3) Funding: It was initially difficult to secure funding for a digital approach. This required close collaboration with the GWH team to demonstrate benefits and create a business case for the technology.
4) Cultural change: Moving from an analogue to digital approach was met with resistance by some team members
5) Inequalities: Some people are not digitally enabled (lack of internet and no email). The program is designed so that a patient can be registered to a family member or carers email address. It encourages families and carers to become involve in the patients care. Despite this a small percentage of people (approximately 10-20%) could not be registered on the GWH platform.
The following enablers were encountered:
1) There was a ‘need for change’ rather than change for changes sake. There was recognition within the team of the benefits of a digital approach
2) The team had the support of colleagues to do something different. A number of colleagues were strong advocates and early adopters of the approach and helped to bring others along with them.
3) We had strong support from the GWH team. This included help developing our pathway and the content within it and suggesting improvements based on their experience in other healthcare settings.
4) After the initial phase of work we were able to gain funding for administrative support for the program. This enabled more timely registration for patients, more responsive communications and frequent review of the content of our pathways.
5) Interest from other clinical teams in the Trust helped to ‘raise the profile’ of our work and enabled the creation of an interrgrated digital solution to a number of clinical pathways within the GWH platform. This has lead to the development of a prehabilitation program for orthopaedic patients housed within the platform that can be seamlessly offered to all patients within our digital joint school.
The pieces of content have been designed by a range of team members involved in elective hip and knee joint replacements, including:
• Surgical care practitioners
• Occupational therapists
• Ward teams
The digital joint school was developed by the lower limb arthroplasty team within the orthopaedic department at South Tees Hospitals NHS Foundation Trust.
To evidence the value of our ‘digital joint school’ approach we aimed to demonstrate:
(1) high levels of patient engagement
(2) high levels of patient experience
(3) impact on patient flow and functional recovery
To assess these aims, we performed 3 discrete analyses:
(1) An evaluation of patient engagement focussing on the impact of patient demographics on when, how and the duration of engagement in the first 1195 patients registered on to the platform between 21/09/2017 and 28/05/2020.
(2) Qualitative semi-structured interviews with a subset of patients who had complete the program and were at least 90 days post- primary hip or knee replacement. These interviews were transcribed and analysed using thematic analysis.
(3) Comparison of outcomes (length of stay, 6-month EQ5D index and Oxford Hip/Knee Score) for patients receiving our digital joint school program (n=595) and a cohort that overlapped the introduction of the program that did not receive it (n=1811). The data for these analyses was extracted from the Trusts routinely collected Hospital Episodes Statistics(HES) data, National Joint Registry (NJR) data and DoH Patient Reported Outcome Measures (PROMs) data. Statistical comparisons were modelled and adjusted for differences in age, gender, Charlson comorbidity score and relevant pre-operative outcome score.
(1) Overall, 832 of the 1195 patients (70%) actively engaged with the DJS (logged on an viewed at least 1 item of the DJS content). Each patient accessed it a median of 15 times and spent a mean of 83 minutes browsing content. There was no difference in the level of engagement or time spent on the platform dependent on age (p=0.19;p=0.34) or gender (p=0.75;p=0.08). Older patients favoured computers to access the DJS whereas younger patients favoured phones (p<0.001).
(2) Three key themes were identified in relation to the DJS: (1) Impact on health behaviours; (2) Contribution to recovery; (3) Delivery of information. Patients reported that the DJS improved understanding and preparedness as well as supporting rehabilitation and recovery after surgery.
(3) In the adjusted statistical models patients registered within the DJS demonstrated significant improvements in their EQ5D index (hips p=0.002;knees p=0.04), Oxford Hip/Knee scores (hips =0.009; knees 0.002) and a reduction in length of stay (hips only p<0.001) compared to the groups that did not receive the DJS. The unadjusted differences for these outcomes were a) LOS = 2.6 days shorter LOS for hips in the DJS group; 2) EQ5D index = 0.03 better improvement in the EQ5D score in the DJS group; 3) Oxford Hip/Knee scores between 1.6 and 2.3 points better improvement in the DJS group.
This evidence demonstrates that a ‘digital joint school’ approach providing procedure specific education and support spanning the entire patient pathway is deliverable and demonstrates high levels of patient engagement and a positive patient experience. This method of care delivery is also associated with improvements in patient flow, health utility and functional outcome. Moving to a digital model also reduces the requirement for face-to-face interaction, reduces cost and standardises information giving, leading to a more consistent approach to care.
We regularly engage with our patients to improve the design and content of the program. We have done this in a number of ways:
- Patient interviews
- Patient satisfaction surveys
- Patient experience surveys
- Assessment of patients confidence with digital technology
- Analysis of patient communications within the program
- Patients rate all content using a ‘smiley face tool. This provides real time feedback about the usefulness of content and acts as a driver for change within the program
Work is also ongoing with the ‘Arthroplasty 4 lower Limb’ PPI group to develop research questions reated to this work.
Our program links to the NHS long term plan. With the digital transformation plan the NHS describes the need to ‘improve how the NHS delivers its services in a new and modern way; providing faster, safer and more convenient care.’ Our program aligns with this approach.
The DoH Five Year Forward View has encouraged efforts to deliver more healthcare out of acute hospitals and closer to home, with the aim of providing better care for patients. Our program provides high quality care and support in the home, reducing the requirement for patients to travel to face to face appointments.
Our program is also aligned with NICE clinical guidelines for the patient population (NG157) and the principles of the GIRFT (Getting It Right First Time) initiative.
We have worked with other clinical teams within secondary care to develop complimentary care pathways. The intention is to create a number of interrelated care pathways that can be delivered seamlessly in one digital platform. This will maximise patient care and experience and can be individulaised to the patients care needs, providing truly bespoke care. We are currently working alongside our anaesthetic and Public Health (South Tees) colleagues to integrate their community based prehabilitation service (PREPWELL - https://www.southtees.nhs.uk/services/prepwell-project/) within the GWH platform.
We have also expanded our approach to other clinical areas within orthopaedics e.g. Hand surgery, Foot and Ankle Surgery, Trauma; and to other surgical specialities e.g. Thoracic surgery.
To ensure robust evaluation of our outcome measures, and future scalability, we have also partnered with the Health Economics team from Northumbria University.
Historically patients requiring colorectal resection for cancer were not referred to the perioperative medicine team until the cancer MDT had taken place and the patient had returned to clinic to discuss results and treatment. Surgery would then be scheduled with the next 2 weeks leaving little or no time for prehabilitation
Our perioperative medicine team worked with the surgeons and clinical nurse specialists to identify an earlier point in the pathway that patients could be referred. It was agreed to start referring patients to the prehabiliiation service following identification of a likely cancer in endoscopy. Although patients did not have a confirmed diagnosis at this point they were aware they were being investigated for a probably cancer and that if this was confirmed surgery was likely to be the first line treatment.
For those patients who required surgery and did not come via endoscopy it was agreed that members of the prehab team would attend the colorectal cancer MDT and take direct referrals from the meeting.
What was the impact?
Early referral of patients to the prehab service via from endoscopy and MDT allowed patients to have an extra 2 weeks of prehab time in their pathway prior to surgery. It was initially thought that patients may find it difficult physically preparing for surgery prior to having a definite diagnosis however none of the patients have reported this to be an issue.
Initially the colorectal team were concerned that patients could potentially have it confirmed they had cancer by someone other than the surgeon or clinical nurse specialist, however this has now been overcome by the prehab nurses working closely with the colorectal cancer nurses regarding communication with patients. This change in practice has worked because the teams have worked together to challenge the traditional order of events in the perioperative period
A preoperative “Fit 4 Surgery” school was established at University Hospital Southampton in May 2016. The school consists of a two-hour classroom based session covering the benefits of exercise, nutrition, the Enhanced Recovery approach, and lifestyle modification advice regarding smoking and alcohol intake. All patients undergoing elective major colorectal, urological and upper GI resections are invited to attend. The aim of the school is to provide patients with advice and tools to enable behaviour modification and improve fitness prior to major elective surgery.
We have collected feedback from the patients attending school since inception. This has been done using a Likert style satisfaction questionnaire, which patients are asked to complete anonymously at the end of the session. We also asked patients to complete a short lifestyle self-reported questionnaire post-surgery to help identify if they had made any changes to their lifestyle as a result of attending. The responses to the lifestyle questionnaire were compared with those of a similar control group of patients who had not attended school.
We also used the school with the presence of a dietitian, as a screening opportunity for malnutrition. The attending dietitian was able to offer one to one advice to patients identified as at risk while the attended the school.
What was the impact?
During the 2 year data collection period 848 patients were invited to the surgery school with 450 patients attending. 63% of school patients stated they intended to make a lifestyle change as a result of attending. 8% stated that they would recommend the school to a friend having surgery.
The free text aspect of the evaluation form has also been useful in ascertaining acceptability and patient experience of surgery school.
Sessions were regularly described as “useful”, “interesting”, “insightful”, “relevant”, “reassuring”, “above expectation” and “well worth the time”. The staff delivering the presentations were frequently described as “caring”, “supportive”, “friendly”, “approachable” and “welcoming”.
Patients’ described themselves as feeling more confident, inspired to change behaviour, better prepared and less fearful of surgery having attended the session.
Other useful feedback was that patients found it a useful forum to talk to others going through a similar experience, they liked the frequent opportunity to ask questions either openly or on a 1:1 basis, and they felt valued and invested in as service users.
Of those who completed a lifestyle questionnaire postoperatively, 232 had attended school and 182 had not. Improvements in physical activity were higher in school attenders, 46% of patients attending school reported becoming more active compared with 25% who had not attended school. A particularly marked increase in reported activity was seen in those who were not physically active prior to school attendance. There were similar numbers of patients who smoked and drank alcohol in the school and non-school attenders. The proportion of smokers who reduced tobacco consumption was similarly high in both groups (88% and 81%). Similarly reduction of alcohol intake prior to surgery was also seen to be high in both groups (71% vs 67%).
With regard to diet modification, 42% of school patients made positive changes to their diet, compared with 36% of patients who did not attend school.
With regard to the nutrition screening. 27% of the patients screened at surgery school were identified to be at risk of malnutrition. These were offered advice with the dietitian and followed up as necessary. These patients would otherwise have had their malnutrition undetected until preassessment which would have allowed little time for intervention and optimisation.
Barriers / Enablers/ Sustainability
The attendance rate of those who are invited to surgery school remains around 60% of those invited. We currently have no way of reaching out to those who are unable to attend school for whatever reasons. 10% of patients are also referred to late in their surgical pathway to attend the school, due to surgery being within a week of referral date.
This project has been relatively resource intensive as if requires the time of the health professionals involved including a physio, nurse, dietitian and psychologist to deliver the sessions and collect the data.
The positive role for exercise in oncology is now well recognised and increasingly evidenced in the literature. Inspired by this, Dr. Thomas Collyer, a consultant in anaesthesia, intensive care and perioperative medicine at Harrogate and District NHS Foundation Trust, began a journey to incorporate physical activity into cancer care in Harrogate. Over 18 months Dr. Collyer and a small perioperative team developed a business case for a fully integrated exercise and wellbeing service. In December 2018 they successfully secured an award for approximately £720,000 from Yorkshire Cancer Research, to run a two year pilot service. The Active Against Cancer service, run by Harrogate and District NHS Foundation Trust and funded by Yorkshire Cancer Research, launched 6 months later on 15th July 2019.
Active Against Cancer has grown to consist of a service manager, lead physiotherapist, lead physical trainer and cancer care coordinator. There is also a team of 10 level 4 trained, cancer specialist physical trainers delivering exercise classes, including Pilates and Yoga. The team are highly skilled and experienced in providing safe and effective fitness programmes, specifically for patients with cancer.
Active Against Cancer is open to patients at all stages of the cancer journey, irrespective of cancer site, prognosis or fitness level. This includes patients who have been recently diagnosed and are awaiting treatment (prehabilitation), those who are currently receiving treatment (maintenance) and those who have completed their treatment (rehabilitation). There is a well-established referral pathway with the majority made by the cancer nurse specialists; within the first 7 months of opening Active Against Cancer has had over 550 referrals. Patients are informed that exercise forms an important part of their cancer care; in essence, activity and wellbeing is being prescribed to the patients.
Initially patients are invited for a 1-1 assessment which aims to assess the patient’s current activity levels, highlighting any limitations and setting goals to address these. The assessment information is then used to inform an individualised exercise programme. The exercise programmes are delivered at Harrogate Sports and Fitness Centre, away from the hospital setting, by the dedicated team. Classes are specific to an individual’s fitness level and stage of treatment. They can vary from high intensity interval training to chair based low intensity classes. Nordic walking, dancing, yoga and pilates are also on offer.
In addition to the physical benefits of exercise, Active Against Cancer also aims to improve the mental and emotional wellbeing of patients. Classes are designed to be fun and group based, providing a platform for peer-to-peer support. Twice weekly walk and talk sessions, coffee mornings and regular patient led social events are also open to the friends, family and careers of patients. Dr Emma Radcliffe, Active Against Cancer Service Manager has said ‘We are already seeing patients grow in confidence, create new friendships and develop support networks. Ultimately we hope to promote long term behavioural change, so that our patients, their friends and their families all enjoy the benefits of exercise and being physically active for years to come.’
The successful integration of Active Against Cancer into the cancer care pathways, and the overwhelming popularity of the service, has meant that the service has had to expand rapidly. Active Against Cancer has employed and trained an increasing number of physical trainers and increased studio hours in order to deliver an expanded timetable of classes. Another challenge has been ensuring the site is accessible to all patients. The service is currently working with local voluntary driver schemes and exploring the possibility of implementing satellite classes at different venues across the Harrogate District to improve accessibility.
Although in its infancy, Active Against Cancer has been a huge success with patients. The service has been rated 4.9 / 5 for overall patient experience, with 96% ‘strongly agreeing’ that they feel safe and well supported whilst exercising. Debbie, a regular service user has said ‘This is more than an exercise group; it’s a whole community that helps patients to recover both physically and psychologically from the diagnosis, through treatment and beyond.’
In summary Active Against Cancer is a novel exercise referral service for patients living with and beyond cancer in Harrogate. It is hoped that the service will not only improve the health and wellbeing of patients but also pave the way for others to develop similar services.
Dr Tom Knapp, Anaesthetic and Perioperative Fellow at Harrogate and District NHS Foundation Trust