Recently, NHS England and NHS Improvement published planning guidance for the year ahead, outlining six priorities for the NHS as it emerges from the pandemic. The guidance strikes a balance between prioritising covid response and recovery efforts and advancing the broader service transformation objectives of the NHS Long Term Plan.
With NHS surgical waiting lists now standing at a record 4.6 million, it is not surprising that accelerating the restoration of elective care is one of the priorities. This is before we even consider the millions of “hidden patients” deterred by covid from coming forward for routine treatment for issues such as hip and knee osteoarthritis or cataracts.
The impact of paused screenings, missed appointments, and delayed or cancelled surgery has been devastating for many patients. The Institute for Public Policy Research (IPPR) estimates that there has been a decline of between 29% – 40% in cancer surgery, with the most deprived areas bearing the brunt of the cancellations.
The elective backlog challenge is not a new one for the NHS, but addressing it has acquired a new urgency and scope. Clearing the backlog sustainably and equitably will require the NHS, as the guidance states, “to do things differently.”
We think “doing things differently” must include changing the narrative of the waiting period. We must get better at supporting patients who are waiting for their surgery to be ready for the NHS when the NHS is ready for them. And, in turn, we need to support healthcare teams to be ready for the patient. Or as colleagues have put it, we need to turn “waiting lists” into “preparation lists.”
Why do we need to do this and what should we be doing?
Firstly, through turning waiting lists into preparation lists we should be able to improve postoperative clinician and patient reported outcomes. Around 15% of all patients (250,000 people) who undergo elective surgery every year in the UK are at a high risk of postoperative complications and these patients account for 80% of postoperative deaths, with an even greater proportion suffering significant complications that impact on their quality of life.
Patients most at risk of adverse outcomes are older, multimorbid, and frail, or smoke, drink excess alcohol or have low or high body mass index and lead sedentary lives. This is a growing population and it makes sense to use the waiting period proactively to address these risk factors: optimise underlying health conditions, and encourage and provide exercise and psychological interventions, address smoking and alcohol use, and work towards a healthy weight.
Various approaches to “prehabilitation” encompassing some or all of these factors have been shown to reduce postoperative complications by between 30%-80% and reduce hospital stays by one-two days on average. A number of studies have also shown there to be a reduction in postoperative mortality rates. Additionally, prehabilitation provides an opportunity to support and embed behaviour change which should provide long term health benefit.
There are already excellent prehabilitation programmes running across the NHS. Take the example of WesFit—a prehab programme for cancer patients across Wessex. This initiative provides structured exercise and counselling programmes for cancer patients waiting for surgery. This approach reduced postoperative length of stay, readmissions, and variation in care, and provided care closer to people’s homes. Similarly, perioperative medicine for older people undergoing surgery (POPS) services, employing medical and multidisciplinary optimisation and shared decision making, have shown improved clinical outcomes, cost effectiveness, and are now being scaled nationally.
Second, the waiting list should be used as an opportunity to ensure informed shared decision making and reduce “surgical regret”—experienced by, on average, one in seven surgical patients. Thorough preoperative assessment including paying more attention to patient’s needs, preferences, and priorities will improve mutual understanding, trust, and communication and about the benefits and risks of surgery and alternative options, including options for non-surgical management. Better assessments and joint decision making should reduce surgical regret, harm, and waste.
Third, we should use the waiting time to prepare as healthcare professional teams. We are well aware of variations in outcomes between countries and NHS organisations performing the same procedures. This unwarranted variation is often due to non-surgical elements of perioperative care—meaning they are avoidable.
With a planned approach, working across specialties, we can increase day surgery rates, reduce late cancellations of surgery, improve theatre productivity, utilise enhanced care and critical care more effectively, and reduce length of stay and hospital-wide readmissions. These process-related issues are not only wasteful for NHS and social care, but have significant psychological, financial, and social costs for patients and their families.
Changing waiting lists to preparation lists will improve patient outcomes and quality of care, while also helping to achieve NHS Long Term Plan efficiency and transformation aspirations.
While we have gathered evidence about “what works” in perioperative care, it is clear we haven’t sufficiently focused on systematic implementation of these interventions into routine clinical practice across the NHS.
To address these gaps, the Centre for Perioperative Care (CPOC) is working with a wide range of organisations to provide resources and support for clinicians and managers in the design, development and implementation of innovative approaches to deliver quality perioperative care.
Further details and resources are available on www.cpoc.org.uk
Jugdeep Dhesi, Deputy Director, Centre for Perioperative Care and Consultant Physician in geriatrics and general internal medicine
Lisa Plotkin, Policy Manager, Royal College of Anaesthetists.
Competing interests: none declared.