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Around 10 million patients undergo surgery each year in the NHS

Any healthcare pathway catering for a population of this size must be simple, safe and efficient. However, problems arise when we identify individual patients on this pathway who have complex medical needs. This simple care pathway can then feel inflexible, as we attempt to address different medical problems for each patient we see.

Fortunately, the great majority of patients are well served by existing NHS surgery pathways. However, there is a growing body of evidence that the needs of the high-risk surgical patient are not being met. As a result, patients who are older or have significant medical problems are offered major surgery in a system that cannot adapt to minimise their risk of complications.

Around 250,000 high-risk patients undergo surgery each year in the NHS. This is approximately 15% of all those who need surgery as a hospital inpatient. We believe these patients need extra care to ensure they have the best possible recovery after surgery, but any solution to this problem must function well within the existing high volume NHS surgical service.

Traditionally, the care of patients undergoing major surgery has been tailored to the operation itself and the index disease being treated by the procedure. However, the majority of complications, which occur after surgery are not due to technical errors or failures by the surgical team, but are medical complications such as pneumonia or myocardial infarction. The prevention and treatment of these medical complications requires a broader approach than we currently take to the care of the surgical patient.

Unmet need

The scale of this unmet need is becoming increasingly clear, and with 10 million patients undergoing surgery each year in the NHS, even a low rate of avoidable harm will be associated with many preventable complications and deaths. The long-term impact of this short-term postoperative harm is also increasing.

Some surgical specialties have already made good progress in improving the quality of perioperative care. Cardiac surgery provides an excellent example of an efficient patient-centred care pathway led by a multi-disciplinary team, achieving better outcomes than many other types of major surgery. We need to take a similar approach for patients undergoing all forms of surgery. To achieve this, we need to define an integrated agenda for healthcare policy around the challenge of providing healthcare to patients undergoing major surgery.

We believe that perioperative care provides a solution to the unmet need, using existing skills and expertise within the NHS to reduce variation and improve patient outcomes after surgery.

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. 

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.