Doug’s story - The perioperative solution to integrated care
During Integrated Care in Action Week (9-15 March 2020) Dr David Selwyn, Director of the Centre for Perioperative Care and Medical Director for Sherwood Forest Hospitals Foundation Trust, explains how perioperative care pathways can unlock integrated care for surgical patients.
Around 10 million patients in the UK undergo surgery every year. For the vast majority surgery will be a success and they will be able to return to their normal lives shortly after leaving hospital.
However, around 250,000 surgical patients with complex medical needs may encounter considerable risk of complications and challenges, but, as we will see, also opportunities.
Meet Doug, a patient who has just been diagnosed with bowel cancer.
Doug has been referred for surgery for the removal of a tumour in his bowel. Doug overall feels well but he has some issues with his lungs and kidneys, which his GP is aware of.
Doug’s anaesthetist only finds out about these underlying conditions on the morning of the surgery, but it’s too late to do anything about it and the surgery goes ahead.
The surgery itself is successful and the tumour is removed, but Doug develops a chest infection or pneumonia in the days immediately after the operation. He has to spend five days in intensive care, followed by another stay on a normal ward, before finally going home.
In the months that follow Doug’s kidney function increasingly deteriorates to the point that he now requires regular kidney dialysis on the NHS.
Although Doug is cancer free, his health is considerably worse than before he had the surgery. Disjointed care and lack of communication between the healthcare professionals looking after Doug have resulted in poor outcomes and increased overall costs to the NHS.
An alternative pathway for patients like Doug is offered by perioperative care - the practice of patient-centered, multidisciplinary, and integrated medical care of patients before, during and after surgery.
So, where would Doug be now if he followed the alternative pathway under the care of a perioperative care multidisciplinary team?
A comprehensive assessment and a prehabilitation programme prescribed by the perioperative care team would have ensured that Doug’s lung function improved ahead of surgery. Doug would have used the time waiting for the operation to prepare for surgery.
As a result, he would now be fitter and be able to tolerate surgery better. He would also have quit smoking, or hopefully reduced it, on the advice of the perioperative care team. Doug may have chosen to use his surgery as an opportunity to make long-term changes to his lifestyle.
With the preoperative optimisation of existing medical conditions and better communication between primary and secondary care settings, Doug’s kidney function would have been preserved and he would not be on dialysis today.
He would have spent considerably less time in hospital and used fewer NHS resources, freeing up beds for other patients who need them. But more importantly Doug’s hospital experience and overall resultant health would be dramatically different.
You can watch an animation of Doug’s very different surgical care journeys on the Centre for Perioperative Care website here.
Good perioperative care improves patient experience of care and the health of populations, and reduces the per capita cost of health care.
The perioperative care approach is part of the solution to the delivery of the integrated care agenda. It allows commissioners to make the most of the resources available to treat the increasing number of patients with multiple long-term conditions.
The good news is that the skills and key personnel required for good perioperative care already exist in the NHS. They just need to come together and work in a more collaborative way by organising themselves in multidisciplinary perioperative care teams.
Many surgical specialties already operate under the model of perioperative care and there are many excellent examples of effective integrated surgical care.
The Centre for Perioperative Care, launched in June 2019, aims to bring together all the specialties involved in the delivery of perioperative care, with at its core the ambition of extending this approach to all forms of major surgery.
To achieve this the Centre for Perioperative Care has launched three UK-wide projects to support integrated care:
- we’ll make the case for and set out a vision of perioperative care, through CPOC’s ‘State of Perioperative Care’ project
- we’ll develop a blueprint on how perioperative care can support Integrated Care Systems and devolved equivalents
- we’ll develop a blueprint for the multidisciplinary perioperative care team.
I want to encourage anyone who has an interest in perioperative care to get involved with the Centre for Perioperative Care. We want to hear your thoughts, learn from your experiences, share our emerging evidence, and create, together, a strong case for perioperative care. You can join our mailing list here.
We’re planning workshops, surveys, focus groups and discussion papers. If you’d like to get involved, please join our informal ‘sounding board’, to:
- give us your views by taking part in surveys, feeding back on draft reports, testing our messaging, and helping plug evidence gaps
- champion our work on social media using #perioperativecare
- blog for us, sharing your experiences, reflecting on our findings, and promoting our work
- Share your case studies!
- Attend our events (including virtually!).
Dr David Selwyn
David was appointed as the inaugural Director of the Centre for Perioperative Care (CPOC) in May this year and tasked with establishing and developing CPOC as a truly cross-organisational, multidisciplinary initiative led by the Royal College of Anaesthetists, facilitating cross-organisational working on perioperative care for patient benefit. He remains an active clinician, dealing with the competing demands of anaesthesia and adult critical care.
Prior to becoming Director of CPOC, David was the Chairman of the RCoA Clinical Directors’ Network, a national network of medical leaders in anaesthesia, intensive care and pain management. He continues to be a representative on a number of the major College quality, safety and professional standards committees and also lectures locally, regionally and nationally on medical leadership.
David was appointed as Executive Medical Director of Sherwood Forest Hospitals Foundation Trust in November 2019 having moved as Deputy Medical Director in July on a secondment from Nottingham University Hospitals where he was the Deputy Medical Director. He has also been appointed as the SFH’s CCIO.
Before beginning his leadership journey, David was a Regional Advisor for 8 years, an inaugural ICM TPD and a Faculty Tutor.