Waiting times, standards, and a new way of delivering safe, effective healthcare for patients
Ravi Mahajan, President
| Royal College of Anaesthetists
Waiting times set a patients’ expectation for when they should begin treatment, but they do nothing to inform a comprehensive treatment programme. President of the Royal College of Anaesthetists, Professor Ravi Mahajan, says the quality of care should not be measured by time based targets alone, but also include post-operative outcomes and the quality of life after surgery.
The Long Term Plan for the NHS published at the start of the year has plotted an ambitious course for the health service in England over the next decade. If last year, the NHS’s 70th, was defined by planning for the future, it is this year, in ‘NHS 71’, that we must begin the task implementing the ideas and changes that are needed to provide for a sustainable health system.
Anaesthetists are the largest single specialty of doctors in NHS hospitals. Collectively, we offer care and treatment for two in three of all hospital inpatients.
This puts anaesthetists in a unique place and the Royal College of Anaesthetists is committed to ensuring that anaesthetic doctors are ensuring the care that they provide patients reflects not only the safest and most effective clinical practice, but also the outcomes that they – the patient – want.
For the College, we see our most significant contribution being the development of perioperative care, and see ‘NHS 71’ as a critical juncture in implementing this evolution on the way patient care is provided.
What is perioperative care?
Delivering patient care along a comprehensive perioperative pathway is about providing more personalised and coordinated patient care for those that might require a surgical procedure. On a perioperative pathway, care is coordinated from the moment an operation is contemplated through to a patient’s full recovery and beyond.
In February, the College published a report that looked at how the new care models being established across the NHS in England were able to incorporate a perioperative approach to patient care. The report highlighted a number of perioperative approaches already being used across England that are improving patient outcomes and saving the NHS money.
Can we have perioperative care pathways with current waiting times standards?
It is the College’s view that there should be no ‘default’ option for any patient. For example, as anaesthetists, we know that often surgery is not the only option and should not be the automatic choice when other lifestyle changes could improve long-term health more appropriately. Research led by the Health Services Research Centre at the Royal College of Anaesthetists found that one in seven operations were cancelled on the day they were due to take place. Though a number of factors were to blame, including bed and staff shortages, around one third of these cancellations occurred for clinical reasons – including where a patient was not in a fit enough condition for their surgery.
In a comparison with 10 other systems in high-income countries, a 2017 Commonwealth Fund report ranked the NHS as the best health care system overall. However, in health care outcomes, the UK was just one place from bottom.
Waiting times set a patients’ expectation for when they should begin treatment, but they do nothing to inform a comprehensive treatment programme. Instead of waiting times targets why do we not focus on target outcomes? Shared decision making between a patient (their carer if they have one) and the healthcare professionals responsible for delivering care and treatment should consider a range of factors – timeliness of care is absolutely one of them.
Decisions taken in 18 weeks could define quality of life for 18 years, or 30 or 50. Would it not be better to ensure that services are commissioned, staff are available and the focus of management is placed on excellent patient care – not prioritising resources to stop the clock from ticking.
Having the staff to deliver care is the most important thing for patients
Patient expectation and satisfaction with the NHS is closely linked to the proper provision of staff across every part of the NHS. The British Social Attitudes survey for 2015 found that 55% of people who were dissatisfied with the NHS cited waiting times – making it the most frequently cited reason.
However, curiously, despite sustained breaches of waiting times standards, this figure has fallen over a sustained period, to 52% in 2017. This change has coupled an increase in the percentage of dissatisfied respondents citing a lack of NHS staff as a reason for their dissatisfaction, rising from 44% to 52% of respondents from 2015 to 2017.
What drives satisfaction with the NHS is the quality of care being provided. More than two-thirds (68%) of respondents who were satisfied with the NHS cited this reason, compared to a figure of 61% in 2015.
Quality of care is the main determinant of satisfaction with the NHS and this relationship is getting stronger.
Of those dissatisfied with the NHS, waiting times remain one of two key issues, but they were once the single most important factor.
Looking at it in another way, in 2015, 55% of people who were dissatisfied with the NHS overall cited waiting times, while 61% of people who were satisfied with the NHS cited the quality of care (a 6% gap). That gap has now more than doubled (to 13%).
What next?
NHS England has been carrying out a clinical review of standards across the NHS, to see whether patients would be well served by updating and supplementing some of the older targets currently in use. In an interim report, published on 11 March 2019, NHS England announced pilots of new NHS targets and measures for Trusts to report back on, which will inform final recommendations later in the year.
As a College, we support NHS England’s plans to pilot new NHS targets and measures across services for mental health, cancer care, elective care and urgent and emergency care.
It is important the pilots and new standards support new ways of delivering healthcare, such as perioperative care pathways. The period between referral for surgery and the day of operation presents a golden opportunity for prehabilitation, which, facilitated by hospitals’ perioperative teams, ensures that the patient is in the best physical and mental condition ahead of surgery.
Fitter patients recover from surgery quicker and experience fewer complications than those who do not receive a comprehensive preoperative assessment in hospital. Shared decision-making should be a fundamental element of discussions with patients regarding their surgery. The quality of care should not be measured by time based targets alone, but also include post-operative outcomes and the quality of life after surgery.
Our next big step in that endeavour will be the upcoming launch of a Centre for Perioperative Care, or CPOC, that will bring together representatives in a pathway-based approach to develop the standards for perioperative care. CPOC will launch in May 2019 with a remit to take an open-minded, multi-disciplinary look at how we improve patient care.
Professor Ravi Mahajan is President of the Royal College of Anaesthetists and Professor of Anaesthesia and Intensive Care at Nottingham University Hospital NHS Trust. If you would like to learn more about perioperative care or CPOC please contact perioperative medicine@rcoa.ac.uk
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