Elective surgery recovery
should also move out of theatres, as they are an expensive resource. “We need to make sure that theatres are used for the cases that need to be there,” he commented. NHSE has secured £1.9 bn, over three years,
to invest in elective recovery and a significant amount of this investment is now being spent on building surgical hubs.
“During the pandemic, we found that
organisations that could separate their elective flow from non-elective flow had fewer challenges, and we have learnt from this,” he commented.
National Theatre Programme objectives The National Theatre Programme works in close partnership with the National Perioperative Programme, as well as the GIRFT perioperative workstream. It aims to provide a cohesive programme of work to improve theatres productivity and flow, and to support rapid implementation of the high-volume, low complexity (HVLC) pathways. The National Theatre Board provides strategic
direction to the Theatre Programme to ensure that work is co-ordinated nationally to provide rapid support to regions in supporting their elective recovery programmes. Integrated Care Systems and Trusts have collective and individual responsibilities to develop elective care recovery plans, which maximise elective activity and reduce long waits, to meet the aims of the NHS 2022/ 23 priorities and operational planning guidance.1 There are a number of key areas of focus for healthcare providers – including optimising the use of theatre time. All systems are to achieve 85% capped theatre utilisation and meet or exceed the wider theatre productivity measures (late start, early finish, inter-case downtime). There are also objectives outlined in
relation to the surgical planned procedure setting – no more than 15% of all elective surgical procedures should be delivered as an inpatient admission. With regards to improving productivity and throughput, all providers must
minimise cancellations for avoidable clinical and non-clinical reasons and patients should not be given a TCI (To Come In) date for theatre until passed fit by pre-assessment. This is particularly important, Dan pointed
out: “Everyone has to do a lot of re-work when patients fail their pre-assessment at short notice, and it has a knock-on impact on knowing what is going on with the lists. Two days before surgery, providers won’t know what cases they are going to operate on if the lists have ‘fallen apart’; we’ve got to address this and plan better,” he asserted. To increase capacity and activity, theatre
estate for all providers should be fully utilised six days a week, 48 weeks of the year. All providers should have recovered their HVLC activity to above pre-COVID activity levels. Resilience is also key, and all providers must have access to a fully ring-fenced elective surgical facility. They must ensure that HVLC activity is maintained in winter months.
“It shouldn’t be the default that, as soon as
there are pressures, elective activity is shut down,” he commented. He highlighted the sequence of three steps
towards elective recovery – starting with maximising use of current theatre sessions. Providers need to ensure that all sessions are fully utilised (>=85% utilisation) with appropriate volumes of cases per list. The next step is ‘Right Procedure, Right Place’, maximising the number of procedures that can be undertaken outside of a traditional theatre setting, to release theatre sessions that can be repurposed for more complex care. The third step is the Hub Site Development to provide ring fenced elective capacity working to GIRFT standards. NHSE is asking Trusts to deliver on three key
areas (see Table 1), as well as calling for Trusts to review the following key areas: Pre-op assessment (POA): In an organisation with POA teams across sites, there is often variation in practice. POA should either be centralised, or processes standardised across sites. In addition, it is important to ensure there is uniform IT system access, with adequate training to ensure all staff are trained to an
Often the solutions are “already out there”, but silo working prevents them from being communicated. With this in mind, it is important to listen to the voice of staff working in theatres, decontamination, on the wards and admissions – to ensure all stakeholders are involved in the decision-making.
Operational Processes All theatre Sessions to achieve 85% Capped Touchtime Utilisation Cases per list to meet HVLC standard. l Non Cancer Lists to be fully booked by no later than 2 weeks prior to date of session
l Minimise Cancellations on the day through: l Check calls 1-3 days prior to TCI to confirm no change in patient status
l No patient to be given a TCI until passed fit by Pre-op
Clinical Pathway Transformation 85% of all elective activity at system level should be delivered as daycase or outpatient procedure l Ensure patients expectations are managed on LoS to day case as default.
l Anaesthetic protocols should support enhanced recovery, including reduced use of GA where clinically appropriate.
l Therapies teams to support early mobilisation / rehab on day of surgery. l Criteria-led discharge as default
Forward Planning 2023/24 Theatres to have planned sessions 48 weeks of the year, 6 days a week, 2.5 sessions a day l Ensure clinical job plans support prospective cover
l Review theatre staffing establishment, including capacity for training of new staff and apprenticeships
l Maximise use of green sites / hubs, including ring fencing of workforce against urgent and emergency care pressures
l Use of fallow sessions across organisations Table 1
equivalent standard and have the same access to relevant information. It is also important to ensure systems are fit for purpose (e.g. noting if patients are on an optimised pathway or already optimised). The pre-op process should be streamlined, using a pre-screening tool to assess patients. This will aid in booking appropriate patients to relevant POA clinics (nurses, anaesthetists etc).
Booking and scheduling: As standard practice, booking TCI dates should be for passed fit patients only. (It is important to ensure patients being booked to six weeks have already been passed fit by pre-assessment by developing a pool of patients.) Trusts should: l Develop a pool of passed fit patients to optimise list utilisation.
July 2023 I
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