Improving emergency surgery. Professor Mike Horrocks September 2014

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1 Improving emergency surgery Professor Mike Horrocks September

2 Emergency surgery 1.2m people require emergency surgical assessment or treatment per year Approximately 25% of all surgical admissions in were emergencies General surgery (40%) followed by trauma & orthopaedics (32%) account for majority of emergency surgical treatment 2

3 What are the challenges facing emergency surgery? Variable mortality Approx. 80% of all surgical mortality arises from unplanned surgical intervention Mortality rate following emergency laparotomy varies 12-fold across UK hospitals Organisation of care Diagnostic and support services not always available 24/7 Pressure on A&E leads to delays in triage and treatment DGH model no longer appropriate 30% marginal tariff forces hospitals to cross-subsidise emergency work with payment for elective care Lack of outcomes data, standards and commissioning guidance Poor co-ordination and information sharing with primary, community & social care Unsatisfactory readmission processes in some hospitals 3

4 What are the challenges facing emergency surgery? Pressure on emergency services A&E departments are experiencing a 3% annual increase in attendances Increasing numbers of admissions Leads to delays in assessment, diagnosis and treatment Workforce Focus on specialist surgical care means there are fewer general surgeons able to take part in on-call rotas Increased pressure on trainees, working under less supervision European Working Time Directive Insufficient access to diagnostic and support services seven days-a-week Changing needs Increasing numbers of older patients, who are more likely to have additional personal or clinical needs Insufficient community and social care support impact on the timely discharge of older patients from hospital 4

5 RCS member survey: emergency surgery over the winter Key concerns: Coordination of care 73.4% believe co-ordination with primary and social care was inadequate or poor Discharge 60.5% said efficiency of discharge was inadequate or poor Separation of emergency and elective surgical care 31% considered this inadequate or poor Less than half (46.2%) were always free from elective surgery commitments when scheduled to provide emergency surgical care over the winter 16.3% were rarely or never free from elective commitments 5

6 RCS member survey: emergency surgery over the winter Key concerns: Availability of operating theatres 44% said the availability of operating theatres was inadequate or poor Availability of support services 31.5% considered the availability of services such as radiology and diagnostics inadequate or poor What would have the greatest impact on improving emergency surgery services? 1. Having support services available seven days a week, 24 hours a day (65%) 2. Separating emergency and elective surgical pathways (54%) 3. Geriatric physicians working alongside surgical specialty teams (47%) 6

7 RCS emergency surgery policy briefing (September 2014) Recommendations: System design NHS England should encourage the separation of elective and emergency surgery work as far as possible Specialist centres should work in operational networks to support collaboration and operate transfer arrangements NHS England must develop a broader strategy about how to improve primary and community care Better outpatient facilities can relieve some of the pressure on A&E and can be a more clinically appropriate pathway than admission to hospital Monitor and NHS England should accelerate their review of the tariff and abolish the 30% marginal rate 7

8 RCS emergency surgery policy briefing (September 2014) Recommendations: Workforce HEE and the royal colleges must consider how to create an attractive career structure for emergency medicine and emergency surgery A&E training for all trainee surgeons should be reintroduced The recommendations of the Taskforce on EWTD must be implemented All political parties should commit to pursuing seven day services in the NHS Data, standards and guidance NHS England and the surgical community should publish further audit data for emergency surgical procedures More clinical (NICE) and commissioning standards for emergency surgery are needed. 8

9 RCS emergency surgery policy briefing (September 2014) Recommendations: Delivering patient-centred, coordinated care Every patient should know which consultant is responsible for their care and how they can be contacted On discharge, all patients should receive a copy of their discharge summary and rehabilitation prescription and know how to contact the treating team if problems arise Patients who need to be readmitted should be able to return to the surgical unit where they were treated, without going through emergency services Enhanced recovery programmes should be rolled out through financial incentives such as CQUINS Communication between surgical specialists and GPs must improve Comprehensive Geriatric Assessments should be carried out by MDTs to ensure older people s additional needs are fed into their discharge plans. Joint care pathways should be shared between surgical teams care of the elderly physicians 9

10 RCS Major Trauma project This project aims to support the sustainability of Major Trauma Centres by ensuring there is a clear, recognised and respected training programme for surgeons working in such centres. Two working groups will consider: Development of role profile(s); competency requirements; training and education provision Stakeholder identification and engagement to ensure recognition and adoption of the training and education programmes We are also exploring how to take forward our work to improve the outcomes for emergency surgery patients. 10

11 The broader picture: Building a sustainable and resilient emergency care system In March 2014 the RCS co-organised a summit with the College of Emergency Medicine, Royal College of Paediatrics and Child Health, Royal College of Physicians, and NHS Confederation The summit was followed by a report, Acute and emergency care: prescribing the remedy (July 2014) Recommendations Every emergency department should have a co-located primary care outof-hours facility Senior decision-makers at the front door of the hospital, and in surgical, medical or paediatric assessment units, should be normal practice, not the exception The funding and target systems for emergency department attendances and acute admissions are unfit for purpose and require urgent change Emergency services should be delivered 24/7, with full diagnostic support available 24 hours a day, including access to specialist services. Emergency departments should have the appropriate skill mix to deliver safe, effective and efficient care robust networks of care and emergency referral pathways must be in place where back-up is not available on-site 11

12 NHS England s urgent and emergency care review Proposals 1. Support self care Provide more accessible information about self-treatment options and accelerate the development of comprehensive and standardised care planning 2. Help people get the right advice or treatment in the right place, first time Enhance NHS 111 so that staff are able to access patients medical information, allow patients to speak to a wider range of professionals and book an appointment at the most appropriate service 3. Provide a more responsive urgent care service outside of hospital Faster access to primary and community care services Harness the skills and experience of community pharmacists Develop ambulances to become mobile urgent treatment services, not just urgent transport services Support the co-location of community-based care services in coordinated Urgent Care Centres 12

13 NHS England s urgent and emergency care review Proposals 4. Ensure that people with more serious emergency needs receive treatment in centres with the right facilities and expertise Introduce two levels of hospital based emergency centres: Emergency Centres: capable of assessing and initiating treatment for all patients. Suitable patients will be managed by the local hospital services on the same site, while those needing specialist treatment will be transferred Major Emergency Centres: larger units, capable of assessing and initiating treatment for all patients and providing a range of specialist services. They will have consistent levels of senior staffing and access to specialist equipment and expertise. Implement seven day working 13

14 NHS England s urgent and emergency care review Proposals 5. Connect the whole urgent and emergency care system through networks Develop emergency care networks, building on the success of major trauma networks. Major Emergency Centres will have responsibility for the quality of care and operational performance across the network they support. Support the introduction of an efficient critical care transfer and retrieval system to ensure that patients with specialist needs reach the best possible care Ensure that networks extend to community services, with free flow of information and expertise between the hospital and community 14

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