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Main role

The anaesthetist's major role lies in providing anaesthesia during surgery, but this role is ever widening. For example anaesthetists are leading the development of preoperative assessment of surgical patients and the quantification of risk. They are leading the development of acute pain teams for the relief of post-operative pain, and providing anaesthesia and pain relief in obstetric units.

Anaesthetists often lead the clinical management of intensive care units alongside other specialties, and work closely with Emergency Physicians to treat emergency patients. They provide care for patients in chronic pain clinics, provide anaesthesia in psychiatric units for patients receiving ECT, as well as the provision of sedation and anaesthesia for patients undergoing interventional radiology and radio-therapy.

Trends in perioperative care must mirror those of the wider NHS. Our reliance on care in hospital is unsustainable, inefficient and frequently fails to meet patients’ hopes and expectations.

Communication between primary and secondary care

As we work to ensure patients recover quickly after surgery, the number of days they spend in hospital will steadily decrease. This in turns places demands on the system to communicate more effectively between primary and secondary care, an interface that most agree does not function as well as it should.

As we offer surgery to more older patients, and to those with long-term disease than we ever have before, it is vital that we consider the impact of major surgery in the context of patients’ long-term health. Primary care services need support and excellent communication from a team of experts who understand the impact major surgery has on their individual patients, advising on specific medical problems that have arisen after surgery, coordinating onward referrals if specialist input is needed, and ensuring the GP is fully informed of their patient’s progress in the weeks and months following surgery.

Kidney injury after major surgery

Acute kidney injury (AKI) is a serious clinical problem which has a significant impact on both short and long-term patient outcomes after surgery. As we offer major surgery to more and more patients with risk factors for kidney disease, more patients experience damage to their kidneys as a result of the systemic inflammatory response to surgery. The rising prevalence of risk factors such as older age, chronic kidney disease, diabetes and hypertension indicates that surgery will have a growing impact on the long-term health of patients.

We now recognise that even mild episodes of AKI trigger step-wise deteriorations in renal function, eventually leading to chronic kidney disease. This in turn results in a dramatic increase in cardiovascular risk, reduced survival, and of course increased NHS resource use. For technical reasons, it is very difficult to predict a patient’s risk of kidney disease at the time of hospital discharge. This partly relates to the reliability of routine kidney blood-tests in patients who have major surgery. Local and national collaborations between clinical teams in nephrology, perioperative medicine, intensive care and biochemistry have led to more effective screening systems for AKI and pathways for follow-up.

A major NHS trust in London has taken this a step further by creating an AKI follow up clinic. This is a collaborative venture between several hospital departments, offering patients at risk an expert assessment and screening for the presence or worsening of chronic kidney disease in the months following surgery. This creates key opportunities to improve long-term health by reducing the progression of kidney disease and its cardiovascular consequences. We now realise that many acute illnesses have an important impact on long-term disease. In time, we expect to see routine screening of patients for acute myocardial, kidney and other organ injuries triggered by major surgery. This will allow us to minimise the long-term effects of short-term harm.

High quality training will be required to deliver integrated perioperative care in the NHS. Postgraduate medical training shapes careers that will span 30 years or more and it is essential that this training reflects the organisation and conduct of clinical practice that will provide the best possible care for patients. Much of the infrastructure and mechanisms are already in place, and many of the skills required are already identified in the various medical CCT (Certiificate of Completion of Training) programmes.

Setting standards

Royal Colleges are responsible for defining the curricula for training, and ultimately for setting standards in the provision of perioperative care for patients. These curricula are currently under review and some, like the CCT in Anaesthetics, have already changed to incorporate more perioperative elements.

Training is embedded in the work of all hospitals in the UK, and underpins clinical standards, academic quality and innovation. By developing training in perioperative care, the colleges will support the development of a future consultant workforce that is able to provide the best possible care for patients in the NHS. Trainees themselves recognise this and its importance. Colleges also recognises the importance of training in perioperative care at undergraduate and Foundation level and we hope to work with medical schools and the Foundation Programme to develop this.

Workforce

In terms of workforce training, perioperative care provides both challenges and solutions. The Centre for Workforce Intelligence (CfWI) in-depth review on anaesthesia and intensive care medicine identifies a 25% under supply of anaesthetists and intensivists up to 2033. This projection does not include the need for perioperative positions, which may create further strain on workforce supply.

Conversely, improved patient pathways present an opportunity to use the acute care workforce more effectively. The work of the perioperative care team may reduce demand for anaesthesia and intensive care medicine in the future although this is difficult to model. CPOC will work together with its partner colleges and specialties, and workforce planners in Health Education England (HEE) and the devolved nations, to explore perioperative care solutions to create a better workforce for the future.

The challenges we are currently facing in perioperative care are:

• £16billion is spent on elective surgical care in England each year.
  
   
• 10 million patients have surgery every year, and this number is rising.
  
   
• Long-term conditions: 25% of the population in England have one.
  
   
• An aging population: it is great news that people are living longer, but this does leave us with challenges.
  
   
• Intensive care capacity: less than 1 in 5 non-cardicac surgery patients are admitted to ICU.
  
   
• High-risk patients are a minority, but account for 4 in 5 deaths after surgery.
  
   
• Screening patients for long-term harm: there is currently no system in the UK to screen patients in this manner, for issues such as heart failure or deteriorating kidney function.

There are many steps we can take to create solutions for perioperative care.

• 8 in 10 hospitals offer anaesthesia assessment before surgery.
  
   
• Integrated care for elderly patients happens in several NHS trusts, reducing complications and length of hospital stay.
  
   
• Exercise testing - 2 in 5 hospitals use this to assess risk for patients
  
   
• Participating in perioperative research - there are multiple ongoing research projects and initiatives which you can get involved in to drive perioperative practice.  These include: 
  
  
  
  Perioperative Quality Improvement Programme (PQIP)
  
  National Emergency Laparotomy Audit (NELA)
  
  UK Perioperative Medicine Clinical Trials Network (POMCTN)
  
   
• Over 90% of surgical procedures in the NHS involve the WHO Surgical Checklist. 

Prevention in the NHS operates in different ways, at different times, and at different levels. This makes cross-sector action challenging to operationalise at the scale required to improve population health outcomes and reduce health inequalities.

There is currently no common thread from national to system/organisational level prevention strategies, with accountability mechanisms.

A recent survey of 310 NHS leaders on what they think the NHS’s prevention priorities should be in their local areas has revealed three key priorities:

• delivering a systems approach to prevention (64%)
• embedding prevention into routine practice, eg Make Every Contact Count (45%)
• embedding prevention into clinical and/or patient pathways (43%).2

The NHS can make the most of its existing assets and interactions by building prevention into clinical pathways and working across organisations to ensure services are joined up. Perioperative care offers a means of supporting primary and secondary care organisations to deliver system wide prevention interventions that operate at both individual and population health level.

Perioperative care means reviewing the surgical perioperative pathway, our patient flows and how we prepare our patients for surgery, and how and who decides they are optimised for surgery. It means changing the postoperative course with increased emphasis on enhanced recovery after surgery and re-designing our discharge processes so it is planned and arranged in advance of the surgical event.

And, it means designing care pathways that embed important patient discussions – true shared decision-making where the focus changes from a technically possible surgical procedure, to the delivery of perioperative care designed and wrapped around the patient.

The final decision is therefore one where the patient is at the centre of decision making, and that they, along with the various stakeholders, agree to the appropriate course of action for their condition.

This will ensure patients understand the risks and outcomes and allows clinicians from various specialties to empower patients to get in the best possible physical shape before surgery.

These ‘teachable moments’ provide us an opportunity to ensure that we can really start to address the prevention agenda around smoking, diabetes, obesity and exercise.

Current NHS priorities are largely risk factor and single-issue based. The NHS prevention programme has been shaped by the key risk factors causing premature deaths, eg smoking, diet, blood pressure, obesity, alcohol and drug use. This focus is very welcome.

However, individual interventions alone will not achieve the change we need to deliver at a population level. NHS and public health leaders alike think the NHS should prioritise a systems approach to prevention. The perioperative care pathway, because it is cross-specialty and multi-disciplinary nature, is an ideal approach to deal with the co-morbidities that many of the high risk surgical patients present with.

In this context, with half of all primary and secondary care consultations and admissions for patients with multiple long term conditions, perioperative care is a natural enabler for the treatment of this cohort of patients and CPOC would be keen to see the development of an explicit national strategy to address multimorbidity.

The shift to ICSs and primary care networks will help bring together commissioners, providers and local authorities to make decisions in the interests of the entire health economy, based on clusters of disease profiles across populations.

Cross-sector partnerships with local authorities, community and voluntary organisations

and statutory bodies are enablers of prevention.

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The provision of sedation and anaesthesia for patients undergoing various procedures outside the operating theatre. Examples of this include different endoscopic procedures, interventional radiology and dental surgery (this list is not exclusive).

The anaesthetist's major role lies in providing anaesthesia during surgery, but this role is ever widening. For example anaesthetists are leading the development of preoperative assessment of surgical patients and the quantification of risk. They are leading the development of acute pain teams for the relief of post-operative pain, and providing anaesthesia and pain relief in obstetric units.

Anaesthetists often lead the clinical management of intensive care units alongside other specialties, and work closely with Emergency Physicians to treat emergency patients. They provide care for patients in chronic pain clinics, provide anaesthesia in psychiatric units for patients receiving ECT, as well as the provision of sedation and anaesthesia for patients undergoing interventional radiology and radio-therapy.

The anaesthetist's major role lies in providing anaesthesia during surgery, but this role is ever widening. For example anaesthetists are leading the development of preoperative assessment of surgical patients and the quantification of risk. They are leading the development of acute pain teams for the relief of post-operative pain, and providing anaesthesia and pain relief in obstetric units.

Anaesthetists often lead the clinical management of intensive care units alongside other specialties, and work closely with Emergency Physicians to treat emergency patients. They provide care for patients in chronic pain clinics, provide anaesthesia in psychiatric units for patients receiving ECT, as well as the provision of sedation and anaesthesia for patients undergoing interventional radiology and radio-therapy.

The anaesthetist's major role lies in providing anaesthesia during surgery, but this role is ever widening. For example anaesthetists are leading the development of preoperative assessment of surgical patients and the quantification of risk. They are leading the development of acute pain teams for the relief of post-operative pain, and providing anaesthesia and pain relief in obstetric units.

Anaesthetists often lead the clinical management of intensive care units alongside other specialties, and work closely with Emergency Physicians to treat emergency patients. They provide care for patients in chronic pain clinics, provide anaesthesia in psychiatric units for patients receiving ECT, as well as the provision of sedation and anaesthesia for patients undergoing interventional radiology and radio-therapy.