PATIENT SAFETY
deep-dive visits. These visits revealed that a number of providers, which are constantly failing, have become extremely demoralised – the sheer imbalance between patient numbers and available resources is proving “almost insurmountable” for these providers, while recruitment is also proving a challenge. The second issue relates to cancer wait time targets. While most providers are performing relatively well, discussions during visits revealed some important concerns. Some providers felt that they had been forced to focus disproportionately on the ‘clock stop’ point of providing first treatment within 62 days of referral from primary care. For muscle-invasive bladder cancer, which can progress quickly, providers indicated that, while they were meeting the target by undertaking preliminary treatment, there was then often a prolonged delay before they were able to offer patients the more important definitive treatment. For prostate cancer, which often develops slowly, a common concern was that the target meant some patients were pressurised into receiving a treatment within 62 days, even when this was not clinically necessary. Given these concerns, the report recommends reconsidering the standards and identifying how these adverse effects of a positive aim could be avoided.
Staffing: changes needed
The report also calls for the further development of specialist urological nursing to deliver high quality, patient-focused care. The report highlights the need for a better career structure for specialist urological nurses, to extend their role and help deliver more treatment in an outpatient setting. Consultant urologist and the report’s
author, Simon Harrison, said: “Specialist nurses are key members of the urology workforce. It is time that training programmes for specialist nurses and other members of the workforce were developed within a proper educational framework. There is also a need for urology networks – it is clear that comprehensive high-quality urology services cannot be provided across a geographical region without a more structured approach to inter-departmental cooperation.” The report further recommends greater consultant focus on emergency care, helping to provide definitive diagnosis and treatment for patients who are admitted as an emergency with conditions such as urinary retention and urinary tract stones, which result in an estimated 6000 patients a year being admitted to hospital.
Key measures
The report presents 18 recommendations to improve the care pathway for people requiring urology procedures. Key measures include: l The national roll-out of dedicated urological investigation units (UIUs), to support greater emphasis on outpatient services and increase day surgery procedures. l Extending the role of specialist nurses
to lead on this outpatient work.
l Freeing up on-call consultants to provide consultant-led emergency urology care in every Trust.
l Establishing urology area networks (UANs), comprising clusters of adjacent urology departments, to provide comprehensive coverage of urological services, in order to optimise quality and efficiency.
It is expected that increased use of dedicated urological investigations units, outpatients’ services and day surgery will provide swifter diagnosis and treatment, without needing to admit patients. In turn, this will reduce unnecessary admissions, length of hospital stays and help improve waiting times for those requiring admission for surgery. Outpatient care is a major part of the urology workload, and a high proportion of urologists’ work is carried out in an outpatient setting. Much of this work can be undertaken by specialist nurses, according to the report.
Opportunities for savings
The recommendations outline opportunities for efficiencies and savings of up to £32.5 m including: l Increased use of day surgery. This could save up to 12,150 hospital spells a year, equivalent to a gross notional saving of £17.6 m
l Reducing unnecessary follow-up appointments by 150,000 per year could bring a gross notional saving of £13.3 m
l Reducing the number of cystectomy patients who have a length of stay greater than 12 days could save up to 2580 bed days equivalent to a gross notional saving of £890,000
l Reducing readmission rates for bladder outflow obstruction procedures could save 385 hospital spells and up to £720,000.
The recommendations are endorsed by the British Association of Urological Surgeons (BAUS) and the British Association of
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Urological Nurses (BAUN). They will be implemented in partnership with NHS Improvement and alongside bodies such as NHS England, NHS Right Care, as well as directly with hospital trusts, Clinical Commissioning Groups and Sustainability and Transformation Partnerships.
Neurosurgery: reducing length of hospital stay
The latest GIRFT report on cranial neurosurgery4
identifies opportunities for
streamlining the process from admission to surgery, so that patients are routinely admitted on the day of the procedure rather than in advance. Compatible and comprehensive electronic referral systems would aid this, giving providers the information they need to plan ahead. It is also possible to undertake some procedures as day surgery, rather than requiring overnight admissions. Already, five providers perform over three quarters of trigeminal neuralgia procedures as day cases. This is a short and minimally invasive procedure with a fast recovery time. If delivered as a day case as standard, this would instantly reduce pressure on beds. To address the issue of frequent cancellations, as well as identifying ways to free up beds, the report recommends that providers designate one of their operating theatres as an acute theatre and exclude it from elective list planning. It can then be used to accommodate emergencies, such as surgery for serious head injury, for subarachnoid haemorrhage or for life-threatening presentations of brain tumours. Currently, the nine providers with the highest cancellation rates do not have a designated acute theatre. This means any emergency admission throws the elective lists into disarray – which in turn results in cancellations and delays. Deep-dive visits found that a regular barrier to discharge is the lack of a bed in the referring secondary care provider for the patient to return to. In particular, cranial
SEPTEMBER 2018
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