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Tackling the surgical backlog requires policymakers to consider more creative solutions

A year on from the launch of the NHS elective recovery plan, Professor Scarlett McNally considers what more can be done to support the delivery of the elective recovery.

As an orthopaedic surgeon for more than twenty years, I have seen first-hand the challenges facing the healthcare service as it looks to recover from the elective care backlog. I am also the Deputy Director of the Centre for Perioperative Care (CPOC), a cross-specialty centre dedicated to the promotion, advancement and development of perioperative care. I was delighted to bring my experience to work with Mölnlycke on their recent Recovering Elective Care white paper, and to contribute to Mölnlycke’s panel discussion at the Future Surgery Show.

Though the NHS is undoubtedly facing serious challenges, I believe that with the right interventions we can successfully reduce the backlog of care. At the core of realising this ambition are three readily implementable policy recommendations from Mölnlycke’s report: Recovering Elective Care.

Workforce training

Professor Scarlett A. McNally, Consultant Orthopaedic Surgeon, East Sussex healthcare NHS Trust
Professor Scarlett A. McNally, Consultant Orthopaedic Surgeon, East Sussex healthcare NHS Trust

The staff working in the NHS are its single biggest asset and developing them should be the top priority of policymakers. In the immediate term, we need to be clear about the skills in our workforce, and ensure that those are valued. We need to be clear on what skills each staff member has, and ensure that these are always developed and utilised. As part of this, secretaries, administrators, and non-registered clinical staff should be employed to help keep doctors, surgeons, nurses, pharmacists and Allied Health Professionals working at the top of their licence. For example, in my Trust, we appointed Doctors’ Assistants to do work delegated by doctors and there is now an apprenticeship for them.1

We also need to keep training key staff, for example by maximising training opportunities for surgeons in postgraduate training. Creating new ways of working and valuing every member of the team has the potential to improve workforce morale.

The Academy of Medical Royal Colleges describes a ‘trans-disciplinary team’ where team members share skills and understand the basics of each step in the pathway, and I believe that this is how we can make each operating list more efficient.2 By developing trans-disciplinary teams, we can break down silos and share knowledge; and these improved ways of working can help to boost staff morale. Working groups should look at their own data and agree pathways, processes, and standardisation to improve efficiency and work through the backlog.

Shared decision-making

We must also empower patients through shared decision-making (SDM). SDM means the patient being a partner in decisions about their care – whether to undergo an operation, or an alternative treatment plan, and how to prepare for it. There is evidence that this can have a positive impact on patient pathways and outcomes. After a shared decision-making consultation with a geriatrician, 15 per cent of surgical patients decided against surgery, 75 per cent had medications adjusted, and 50 per cent were given lifestyle advice.3

Although, this needs to be handled very carefully, if senior clinicians have a SDM consultation with a patient who then decides against surgery, this is excellent patient-focussed care. It is also likely to reduce the requirement for critical care, re-operations and re-admissions, if people more at risk of complications decide against surgery.

Optimising patients and streamlining

As part of empowering patients, we as healthcare professionals should also support our patients to be ready for surgery. Unfortunately, the pandemic has made people sicker and less healthy, and this means that they are more likely to experience complications during surgery. Supporting patients to be healthier can help to reduce their length of stay by 1-2 days and reduce the likelihood of complications by at least 30 per cent.4

A large proportion of this requires stronger public health messaging, encouraging people to eat the right foods and engage in regular exercise, with resources here. As clinicians, we should learn motivational interviewing, as explained here, to give rapid individualised advice. Using risk stratification to identifying the complex patients allows for targeted optimisation. In many cases, better prepared patients can have their stay converted to a far more efficient Day Case event.

Conclusions

Of course, there is no easy fix for reducing the elective care backlog, and many of the suggestions I have outlined here require support from healthcare leaders and policymakers to be successful. In summary, I am quite hopeful. We have excellent staff. We have patients who are an untapped resource – who will work with us if they are supported to do so. Good perioperative care is better for patients, for costs, for outcomes and for staff.

At CPOC, we are working hard to develop and streamline care for every patient from the moment surgery is contemplated until full recovery. I welcome the role that Mölnlycke have played in providing a forum to share ideas for how to support the health service through their Recovering Elective Care White Paper.

Request the full white paper from Mölnlycke here.

References:

1 McNally S, Huber J. Developing a “Doctors’ Assistant” role to ease pressure on doctors and improve patient flow in acute NHS hospitals. BMJ Leader 2021;5:62-4. https://bmjleader.bmj.com/content/5/1/62

2 Academy of Medical Royal Colleges (2022) Developing professional identity in multi-professional teams https://www.aomrc.org.uk/wp-content/uploads/2020/05/Developing_professional_identity_in_multi-professional_teams_0520.pdf

3 Shahab et al (2021) A Description of Interventions Prompted by Preoperative Comprehensive Geriatric Assessment and Optimization in Older Elective Noncardiac Surgical Patients. Journal of the American Medical Directors Association. Volume 23, Issue 12, December 2022, Pages 1948-1954.e4 https://www.sciencedirect.com/science/article/abs/pii/S1525861022006430

4 Centre for Perioperative Care (2020) Impact of perioperative care: https://www.cpoc.org.uk/about-cpoc-cpoc-policy/proving-case-perioperative-care

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