Keith Willett:
IT’S a familiar story: patients sitting waiting to go home, bags packed but they can’t leave because their care package isn’t ready.
It’s Monday morning and the surgical team are ready to operate, patients are ready in admissions or waiting at home, but no one can start because there are no beds for them after surgery.
The intensive care unit is full. The system has ground to a halt and the first patient isn’t even through the anaesthetic room doors.
To have highly skilled surgeons, anaesthetists and nurses sitting around waiting for patients is clearly a ridiculous waste of resource.
It happens somewhere every day, and in some hospitals every day throughout the winter; so as a surgical community what are we going to do?
We have two choices: we can do nothing and continue with our daily heightening frustration, or as surgeons responsible for the whole pathway of care and our teams, we can use that thwarted energy and become part of the solution.
From April, the first parts of the country formally began to work as single integrated care systems (ICS) with the NHS hand in glove with local authorities; England is making the biggest move to integrate care of any major western country. It’s about our patients and how they receive treatments and personal care.
As some of the most senior, highest paid and experienced consultant leaders in the NHS, we know the problems, we know what good feels like.
With this radical shift to ICS, and their precursor sustainability and transformation partnerships, we need to take the initiative.
Surgeons can play a crucial role in exerting influence both before and during admission to optimise care and access to surgical beds.
Not my job, some of you will say, but given those patients are sat in our surgical beds – 4 per cent of admitted patients stay over 21 days and occupy 19 per cent of hospital beds on any day – it is our problem. Do you walk past them on a ward round and look forlornly for the multi-disciplinary team representative?
It’s likely this patient getting stuck was predicable at your pre-admission clinic or on admission.
I’m certain you ensured the pre-op checklist, investigations and consenting from anaesthetic to skin closure happened just as you planned. So how can we make the problematic part of the pathway happen better?
As surgeons, we must set aside time to understand this problem, look at where and why our patients are getting stuck, and the possible solutions.
I say we do have time while fuming and delayed in the theatre coffee room.
Go and find out from the ward nurses, occupational therapists and physios and set about sorting it with your team and directorate manager.
They will really appreciate your interest and understanding – it’s their frustration too.
The NHS’S patients have changed beyond recognition since 1948 but the hospital system has remained largely the same.
As a trauma surgeon what I used to do in resuscitation area is now done by the paramedic at scene. We have nurses with advanced skills; new technologies and equipment have changed every speciality profoundly.
Fifteen to 20 years ago, most patients had a single system illness or injury; now most are elderly, often with several comorbidities and many frail or with dementia.
Ten days of hospitalisation in an 80-year-old leaves them 10 years older in muscle strength and needing much more support to help them home – this means more occupied beds.
We often think our job is done once the patient is in the recovery ward after the operation but that is so wrong.
There is a lot of capability in the community and a rich tapestry of staff, but there needs to be dialogue with surgical staff about the kind of care needed following surgery and how or where that is best planned and delivered.
Failure to recognise those needs will in future bring us more blocked beds, dormitories full of our elders and empty theatres. What could we do to support the patient who is clinically well enough to go back to the care home but who needs, say, a feeding tube? Patients who need simple
‘Don’t try and make plans in the middle of the battlefield – make them before the battle starts’
after-care, such as a bladder washout, or re-catheterisation, can end up re-attending because their care home can’t provide the follow-up nursing needed.
The best problem solving happens when senior clinicians and managers come together because we start to understand the reasons for blockages and where they could, with some leadership, common sense thinking, access to advice and a rearrangement of resources, be solved.
In winter in particular, many surgical beds are occupied by “medical outliers” – patients admitted from other departments such as A&E
– quelle surprise.
Every year respiratory emergency admissions double from 1,000 to 2,000 admissions a day in England between November and February, and beds have to be found.
As surgeons, rather than bemoan “lost beds” we could be far more involved in better seasonal planning of our activity.
We need space to solve these problems. Don’t try to make plans in the middle of the battlefield – make them before the battle starts.
That means now, as the memories of the winter struggles are fresh and there is time to change things before next winter.
Better relationships are needed across many boundaries into the community if we are to transform the system, and these do not forge overnight. It will take a rearrangement of time and resource but nothing extra – except the willingness and time to think it through with colleagues.
Hopefully, I’ve provided some food for thought.
We have much more control over the wider determinants of outcomes from surgery than we think and can improve our own lot, reduce frustration, use our time better and get back to operating.
By taking time to consider the issues we may begin to see a much bigger picture. By making ourselves more available to general practice and community colleagues we can influence some of those specifics and understand the wider system solutions for us all. After all, we are the leaders of our teams and responsible for all the care our patients receive.