Perioperative practice under the spotlight

This year the AfPP conference programme included a focus on primary care, in recognition that surgery in this sector is becoming increasingly common and more sophisticated, particularly in light of the Government’s policy of delivering surgery closer to home. This was complimented by an examination of day surgery, in partnership with the British Association of Day Surgery, which tackled the management of waiting lists and “how to push the boundaries of short stay surgery”.

Ian Cumming, predicted some significant changes affecting surgery in hospitals – focusing in particular on the future impact of reduced waiting lists and patient choice. A past president of the AfPP, he examined the question: “who are PCTs and how will they affect the perioperative practitioner?”

Ian Cumming spent most of his career in acute Trusts and was an acute Trust chief executive for 12 years before becoming the chief executive of the North Lancashire Teaching Primary Care Trust (PCT).

RADICAL CHANGES

“I decided that the most interesting place to be over the next few years is going to be in commissioning and PCTs. That’s where the majority of drivers for change are going to come from,” he commented. “When I was asked to speak here, I thought about how these changes would have an impact on perioperative care. I believe the changes that face healthcare in the next five years, will be more radical than anything seen over the last 20 years.”

PCTs have a responsibility for improving the health of the population and reducing inequalities, commissioning healthcare and market management and direct provision of healthcare. However, Ian Cumming said that he did not believe the latter will be the role of PCTs in the long term. He explained that there have been some NHS policy shifts that will have a direct impact on all healthcare professionals’ working lives: “Payment by results is starting to bite. There is a national tariff which is intended to allow patients the freedom of choice to go to any hospital they want, anywhere in the UK. This is starting to produce the ability for independent sector and private hospitals to become providers, giving patients another option on the menu of choices. Patients are starting to choose to go to hospitals for their treatment elsewhere other than the one they would traditionally be referred to by their GP,” he pointed out.

He added that MRSA rates and waiting times are some of the reasons for choosing an alternative hospital to the nearest local institution, but the main one is car parking. Hospitals that are starting to think of themselves as being in competition for business with each other are making “swift u-turns” on their parking policies. Controversially, some are looking at moving all staff parking off site and providing free parking for patients, because they know they will gain activity from surrounding hospitals that are charging for parking.

“Drivers for change are not always what you would expect,” Ian Cumming commented, “although quality of care, outcomes and waiting times and cleanliness are influential factors, of course. When choice was first introduced as a pilot in London, for cataract surgery, around half of people chose to go elsewhere instead of the hospital they would normally have been referred to.

“In those days, waiting times were the key. The lengthy waiting lists of 5-6 months in some places meant that patients would choose those hospitals that were able to perform the operation in 3-4 weeks. The next target about to hit is the 18-week target. Assuming the NHS delivers this, it will mean an end to waiting lists. I recall in 1989, we were dealing with waiting lists of 4 years. We have come along way, since then, but we are not there yet.”

He predicted that waiting times will no longer be one of the deciding factors in choosing where to have an operation. This, he believes, will present a threat to hospitals because “waiting lists are like an order book”.

He told the audience: “If you think of your hospital as a business and you have thousands of people on your waiting list, you know you have enough activity to keep going for many months, irrespective of what patients choose in the short term. If the order book for surgery is 3-4 weeks long and suddenly something hits the headlines such as an outbreak of MRSA, and patients don’t want to go to your hospital anymore, this will cause a serious problem.”

Clinical governance is another consideration. This relates to ensuring the quality of what is being procured is adequate, appropriate and meets the latest national standards. This is becoming an increasingly important aspect of the PCT’s commissioning role.

‘SHRINKING’ HOSPITALS

There has already been a primary to secondary care shift, but there is a lot more movement to come. Ian Cumming said: “I can envisage a scenario where there will be very few medical ‘ologists’ employed by hospitals. I can see them being employed in a community setting, with hospitals employing acute physicians. Many areas of medicine will be managed out in the community, with the exception perhaps of gastroenterology and cardiology.”

“Hospitals are going to shrink. Elective surgery will also shrink, as a result of the reduction of waiting lists. Once the backlog is cleared the activity will be less. Orthopaedics will still be a growth speciality over the next few years, but in most other specialties there will be a declining number of patients coming through the doors with a reduction of beds and equipment for medical ‘ologies’.” The NHS has been revolutionised by the threat of the independent and private sector, he believes, and patient involvement has made hospitals “take their blinkers off”. He gave an example from his previous employment within an acute Trust, where the vasectomy list was extended to Friday evenings over several weeks. This proved hugely popular with patients, who could spend the weekend recovering and did not need to take time off work.

PREDICT AND PREVENT

The PCT also has a responsibility for public health and epidemiology is one area of concern that will also affect the perioperative sector. Diabetes for example is the fastest growing disease in the UK growing by 25% year on year, due to lifestyle. He warned: “If we don’t do something about this now, we will be sitting on a time bomb. In years to come, these patients with diabetes will present to the NHS with failing eyesight, vascular problems, and so on. It is going to be a nightmare of huge proportions.”

He also pointed out that due to advances in the treatment of cancers people are living longer with chronic conditions requiring care. In the case of prostate cancer, for example, more men are dying with prostate cancer – not because of it. This will have an impact on the demands placed on the NHS in terms of surgery for other age related conditions such as hip replacements – supporting the view that orthopaedics will continue to be a growing perioperative area. This will be further fuelled by the fact that the UK has an ageing population and people can now expect to live longer than their parents. Other changes associated with public health include a focus on prevention: “The NHS has always been a ‘national sickness service’ but we need to move towards a model of ‘predict and prevent’ from the traditional ‘diagnose and treat’,” Ian Cumming exclaimed.

He also raised the issue of tackling inequalities in life expectancy and patient outcomes depending on geography and background, along with variations in the treatment received from hospital to hospital. One hospital in his ward showed an above average number of hysterectomies being performed. (The PCT is currently talking to the hospital.) The rates of revascularisation also varied greatly between areas depending on the proximity to a cardiac centre. In one area, life expectancy was reduced due to road accidents, prompting the need to work with other agencies to establish transport strategies.

Commissioning is about procuring the best possible health outcomes for the population. It is not about buying hip replacements or hysterectomies – which is subcontracting, he explained. Ian Cumming added that it is about establishing the need, how this can be best addressed, when the intervention should take place and were it is best to do it. This is having an effect on the acute sector. In the past, discussions with the PCT over budget would consist of examining last year’s spend in order to ascertain allocation of the next year’s spend. The actual health “need” of the population was not examined.

“With regards to where it is best to perform interventions, there will be significant changes,” Ian Cumming said. “There will not only be a shift from primary to secondary, but also from tertiary to secondary,” he pointed out. “My PCT is spending £5.5 m on dermatology in our local district hospitals. We won’t be in the next two years. There will be significant changes in ‘what is done where’.”

“Market management is another key area. There is no point in having a shiny new independent sector treatment centre that provides all the elective orthopaedic surgery in the area if you cannot provide a trauma service within the NHS because you haven’t got enough people.”

QUALITY

PCTs also have a responsibility for ensuring clinical quality. “We are supposed to monitor the care given in acute hospitals, investigate adverse incidents, ensure lessons are learnt, and compare hospitals against peers. We also are supposed to procure on the basis of best possible outcome.

“In particular, we should be looking at how hospitals are rewarded as there are perverse incentives. At the moment, if a patient has a hip replacement and all goes well, the PCT pays the hospital. If the patient goes into surgery, something goes wrong with the anaesthetic, they spend a week in intensive care, six weeks in hospital in total and also get a DVT, the hospital gets paid five times as much.” “This situation will change. Hospitals must be paid for the quality of treatment.” He explained that in the North West a scheme is being piloted called “payment for quality”. Effectively, the PCT will pay more if hospitals give a proven higher quality of care. This will be a supplement that will directly affect the perioperative sector which is on top of the national tariff. The strategy will be rolled out across the rest of the UK if proven successful. He also explained that practice based commissioning has had the effect of stopping unnecessary consultant follow up appointments at hospitals. Consultants’ job plans will change significantly, with fewer outpatient clinics.

“This will cause some financial pain for hospitals as these appointments equate to quite a lot of money,” he pointed out. “GPs will be cutting this off and only referring the patient for a consultant follow up appointment if clinically appropriate. They will perform the follow up themselves and the money will be reinvested somewhere else.” Service provision will not be the responsibility of PCTs in the future in his view, because they are commissioning bodies.

“We are about the buying of the best possible outcomes for a patient. If we are also a provider, we have a conflict of interest,” Ian Cumming said. “The Government says that it will be getting rid of many targets but value for money, outcome and patient and staff satisfaction will be key. PCTs will be commissioning for outcomes not treatments. Moreover, PCTs of the future will be more like SHAs of the past,” he concluded.

The AfPP conference covered a diverse range of issues from advancements in recovery care, bariatric surgery and trauma management; to infection control, improving the patient pathway, the NHS IT agenda and much more. Delegates also had the opportunity to view the latest innovations for the perioperative environment at the exhibition – from lanryngeal airways to bougies; laryngscopes to endoscopes; along with operating tables, single use instruments and procedure trays from a variety of leading suppliers. An in depth insight into the many issues raised at the conference can be viewed in the January 2008 issue of The Clinical Services Journal.