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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.

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.