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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.

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.

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.