The perioperative solution to integrated care

In early 2020, the Royal College of Anaesthetists (RCoA) asked 2,500 members across the UK to predict the future of surgical care. Almost two-thirds (63%) told us that over the next two decades, by 2040, the surgical team will look and work very differently. [1]

Driving this transformation are 250,000 high-risk surgical patients with increasingly complex needs—patients needing extra care each year to give them the best chance of recovery. Yet, today, their care is often designed around a specific operation or disease, not their individual or unique need. In some ways, it’s easy to understand why. 

Yet this approach is associated with substantial, and avoidable, increases in length of hospital stay and postoperative complications; and avoidable demand for primary and outpatient care, hospital readmissions, prolonged ill health, delayed return to work, reduced quality of life and shortened life expectancy. Not the best outcome for the patient or the NHS.

Ensuring a patient is in the best or optimal condition for their operation, receives high-quality care during surgery, and is supported to full recovery shouldn’t be three separate aims. Every patient’s journey should be along a coordinated pathway delivering the right services in a co-ordinated and logical way with primary, secondary and community care staff are all involved—providing patient focussed, high-quality care with better outcomes, better experiences, and more efficient use of resources.

This is the perioperative approach—patients empowered through shared decision-making and personalised care, with clinicians and professionals across the system working together. It’s an approach that starts with getting fit for the stress of surgery or “rehabilitation,” a “teachable moment” set in a framework of screening, assessment, and promoting healthy behaviours through prescribing exercise, nutrition, and psychological interventions. And, it’s an approach already cutting post-operative complications and mortality by 50%, reducing length of stay, enhancing postoperative recovery, and increasing capacity for current and predicted demand.  

High quality perioperative care is dependent on seamless communication and collaboration across primary and secondary care and the social care sector, to identify the needs of communities and adapt services—improving population health while reducing costs. Getting it right offers a solution to the integration challenge. Steve Powis, NHS England’s National Medical Director, has encouraged “all system leaders within an Integrated Care System…to consider how a perioperative care approach could improve patient care in their area”.

Integrated care means breaking traditional barriers between hospitals, GP practices, community services and social care. It means working effectively with local government, private and voluntary-sector organisations on the determinants of health. It means supporting primary, secondary and community services to build multidisciplinary teams. It means developing clear local population data to help reduce inequalities in health

Encouragingly, 40% of our members feel we’re now already moving towards effective person-centred care for people with complex needs, based on multidisciplinary working. In fact, nearly a quarter are telling us that they’re already working as part of multidisciplinary perioperative care teams across primary, secondary and community care settings. Yet, while the NHS long term plan aims to deliver coordinated care to improve outcomes and the patient experience, it doesn’t once mention perioperative care. 

In turn, few models of integrated care have seized the potential of perioperative care to reshape services to transform the lives of surgical patients—and to build the vital bridge between secondary, surgical, care, and primary, community and social care. Getting it Right First Time reviews are demonstrating wide variation in the establishment of services. Perioperative care isn’t about re-inventing the wheel. It’s about using the skills and resources that already exist and working differently to provide an optimised, integrated, pathway for surgical patients. 

If we can shift the dial even just a fraction in the right direction over the lifetime of the NHS long term plan, and those of newly forming Integrated Care Systems, towards a perioperative approach, we could have a hugely positive impact on the lives of our patients. We can transform short and long term quality of patient care and outcomes to improve safety, clinical effectiveness, patient focus and efficiency. We can reduce demand on the NHS, ‘level up’ the public’s health and elevate the productivity of the UK economy. 

Our 2040 vision is of an integrated care pathway fully embedding perioperative care.

To coincide with NHS England’s Integrated Care in Action Week, the Centre for Perioperative Care, a cross-specialty initiative led by the RCoA, has launched a new programme to address the integration challenge. Find out more, and get involved, here.

David Selwyn, Director of the Centre for Perioperative Care and Medical Director for Sherwood Forest Hospitals NHS Foundation Trust

Mark Weiss, Head of Policy and Public Affairs, Royal College of Anaesthetists

Competing interests: None declared

[1] RCoA Workforce Survey, March 2020