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Changing clinical pathways is one of the biggest challenges in moving to a population health approach. It requires not only development of new care models, but clinical roles and adoption of new ways of working.

While the specialty of anaesthesia is seeing an evolution of the anaesthetist into the ‘perioperative care physician’, this new role cannot work in isolation and the ‘prehab to rehab’ model will only be successful with the buy in of ICSs, their leaders and staff across all providers.

We believe that the implementation of this model of care across system providers can provide the tools needed to help ICSs achieve their goal of improving the health of local populations.

A Teachable Moment

The RCoA’s report A Teachable Moment – Delivering Perioperative Medicine in Integrated Care Systems contains a detailed analysis of the first ten ICSs and offers a series of practical solutions for each to embed perioperative best practice to support their identified clinical priorities and develop related pathways.

 CPOC will strive to facilitate greater collaboration between specialties to improve perioperative care pathways, and we look forward to working with Government and arms-length bodies to support them as they play a key role as catalysts of the culture change needed to achieve this.

The time available to patients to prepare for surgery is a ‘teachable moment’, where a patient can be encouraged by their GP, surgeon and perioperative team to make positive and lasting changes to their lifestyle. The ‘Making Every Contact Count’ (MECC) approach recognises that ‘the opportunistic delivery of consistent and concise healthy lifestyle information enables individuals to engage in conversations about their health at scale across organisations and populations’.

Fitter Better Sooner

The RCoA has launched Fitter Better Sooner, a toolkit to help patients make the most of the perioperative care period and to equip them with the information they need to get fitter for surgery, reduce postoperative complications and adopt a healthier lifestyle.

Prehabilitation

Prehabilitation of surgical patients through exercise has been proven to be particularly effective in reducing postoperative complications and helping patients to return to a full functional state quicker. A structured programme of exercise ahead of surgery improves cardiovascular and muscular conditioning and helps the patient better withstand the physiological stresses of surgery.

As well as making the patient more resilient for surgery, this prehabilitation phase offers an opportunity for patients to experience the benefits of exercise and gives them the tools and knowledge they need to stay physically active long after the postoperative period.

The case study below offers an example of the benefits that comprehensive prehabilitation ahead of surgery and discussions with patients about their lifestyles can bring to patients and their long term health. This type of initiatives are effectively ‘prevention in action’.

Patients with cancer

Prehabilitation is also particularly important for cancer patients. Seventy per cent of the 1.8 million people in the UK living with cancer are also living with one or more other long-term health conditions.

The guidance report, Prehabilitation for People With Cancer, a partnership between the RCoA, the National Institute for Health Research and Macmillan Cancer Support, contains evidence that when services are redesigned so that prehabilitation is integrated into the cancer pathway the quality of life and long-term health of patients is considerably improved.

Engaging with patients

The perioperative approach of engaging in conversations with patients about their lifestyle and providing the tools and information they need to make meaningful changes should be embraced across all care settings and healthcare professions.

Lifestyle change can be daunting for patients and complex for healthcare professionals to deliver. It requires a truly multidisciplinary approach and collaboration between specialties. The greatest success is achieved when patients are encouraged to start changing their lifestyle as soon as they are told they will require surgery by their GP, health assistant or specialty consultant.

We know that coming into hospital for surgery can be a worrying time. Talk to your family and friends about going into hospital and tell them how they can help you. Don’t underestimate how tired you may be afterwards.

Give the below checklist some thought well in advance of the operation.

• How will I pass the time? Have some headphones and music, books, tablet computer or puzzles.  Don’t forget chargers.
• What can I do to relax? Learn some breathing techniques, try yoga or listen to relaxing music. Read about mindfulness.
• What do I need to prepare at home? You may find it difficult to move around when you return from hospital – consider sleeping on the ground floor and getting mobility aids.
• Who can look after my elderly relatives? If friends and family cannot help, contact your local council and your local carer service.
• How will I get to and from the hospital? Can someone drive you? If you are eligible for hospital transport, the hospital may be  able to organise transport for you.
• Do I have enough easy-to-cook meals and healthy snacks for when I get home?  Think who might be able to help prepare meals or help with your shopping afterwards.
• Who can look after my children or pets? Don’t underestimate how tired you might feel after the operation. Ask friends and family to help or to be on standby. To help you with childcare, they may need to arrange time off work too. If you have significant difficulties looking after your children following an operation, talk to your local council or your health visitor.
• Do I have enough medication and batteries for my hearing aid to last me in hospital and when I get home? Remember to take your usual medication into hospital with you.
• Do I have some over-the-counter painkillers at home? You may need to take some during your recovery as instructed by the hospital.
• What do I need to pack? If you are staying in hospital overnight you should think about toiletries, nightwear and comfortable clothes and footwear. It is important to get out of bed, get dressed and start to move as soon as your operation allows – those who do this get home sooner and recover quicker. Temperatures in hospital can vary so some layers of clothing can be useful. See CPOC's practical preparedness resources
• What else would be helpful to do? Get your house and garden in order. Get up to date with your general affairs and finances. This will mean you do not have to worry about these whilst you recover.
• Whom should I let know I am going into hospital? Friends and family can usually give you practical support. It is also good to have people to talk with whilst you are at home recovering. Many people will want to help your recovery, so let them know how they can help in plenty of time.
• Make sure I have a shower/bath before going to hospital to minimise the risk of infection.

Members of the perioperative team at the hospital will discuss your anaesthetic, surgery and recovery period. They will discuss any particular risks you have from both your anaesthetic and surgery and any choices you have. They will give you information to read at home. There will be a
contact number to ring if you need to ask more questions.

The better prepared you are, the easier the process is likely to be.

Below are some questions that you might want to ask the perioperative  team.

• What time do I need to stop eating and drinking before surgery?
• What medication should I take on the day of my surgery?
• What do I need to pack for the hospital?
• Do I need to remove nail varnish, gels or piercings?
• Can I have visitors? When are the visiting times?
• Will someone at the hospital shave me if needed before my surgery?
• When can I expect to go home?
• What help can I expect to need at home afterwards?
• How long will it be before I can shower/bathe again?
• Are there any important ‘dos’ and don’ts’ for my recovery?
• Will I have stitches or staples that need to be taken out?
• How much time will I need to arrange off work?
• Who will give me a fit/sick note for my employer?
• Will I have a check up afterwards?
• How long might it be before I can walk/swim/play golf/run again?
• When can I drive afterwards?
• How long will it be before my life is roughly back to normal?

Depending on what surgery you are having, recovery may take many weeks.

Don’t worry if some days go better than others, as this is normal. It can be useful to keep a recovery diary which you can continue after you go home.

Try and get into a routine and get up in the morning at a regular time. A list of daily goals can give structure to your day and help monitor your progress.

Visits and phone calls from family and friends can cheer you up and encourage you to reach your goals. Be careful though that you don’t tire yourself out from too many visitors.