PATIENT SAFETY
thousands more patients to receive the care of cranial neurosurgeons.” The report’s recommendations will be implemented by GIRFT’s teams working with NHS Improvement and alongside bodies such as NHS England, NHS Right Care, the Society of British Neurosurgeons (SBNS), and the Royal College of Surgeons, as well as directly with trusts, Clinical Commissioning Groups and Sustainability and Transformation Partnerships.
Cardiothoracic surgery: need for smarter bed management
According to the GIRFT report on cardiothoracic surgery,5
smarter bed
management and using designated specialist teams for key cardiothoracic surgery procedures could also deliver substantial benefits for patients suffering from conditions such as blocked arteries, lung cancer, and heart valve disease. In addition to identifying opportunities to improve patient outcomes, the GIRFT review further identifies significant opportunities for the NHS to deliver savings of up to £52 m.
Long waits for urgent care
The GIRFT team visited 70 Trusts that offer vascular surgery in England and identified several key areas of variation. Waiting times for surgery was a particular concern as data showed that many patients experience long waits for procedures that are clinically urgent. For example, minor strokes or transient ischaemic attacks (TIAs) are recognised as a key warning that a patient is at risk of a major stroke. To prevent this, a carotid endarterectomy (CEA) – which involves improving blood flow through the carotid arteries to the brain – is often recommended. NICE guidance says that CEA should take place within 14 days of diagnosis. At least 18 providers failed to meet this standard and in four areas, the average wait for CEA was 28 days or more. By contrast, two providers were able to go from diagnosis to surgery within five days – thus making it far more likely that a major stroke can be avoided. Mr David Richens, cardiothoracic surgeon and author of the report, has identified 20 recommendations to improve practices, process and outcomes. Among these include: l Ring-fencing beds on intensive care units (ITU) and general wards for the care of cardiothoracic patients
l Sub-specialisation for certain critical procedures
l The use of less invasive thoracic surgery known as VATS (video-assisted thoracoscopic surgery) for lung resection surgery. According to the report, VATS reduces complication rates and length of hospital stay
l Ensuring that individual cases of deep sternal wound infection (DSWI) are reviewed by a multidisciplinary team, led by a consultant microbiologist
l Establishing a national formal policy for complex and very high-risk cases
l Establishing collective responsibility for clinical outcomes
l Centralising and reducing the number of lung cancer multidisciplinary teams (MDTs)
l Ensuring that a thoracic surgeon is present at every lung cancer MDT meeting.
The report recognises the importance of using specialist surgical teams for certain critical procedures, such as aortovascular surgery for aorta rupture, and mitral valve surgery, and it calls for emergency surgery rotas for major trauma to be covered by both thoracic and cardiac surgeons, ending the practice of using cardiac-dedicated surgeons to provide cover for emergency thoracic surgery. It also proposes that all patients should be reviewed by a consultant pre- and post-operatively, seven days a week, which will support more timely patient discharge, particularly over weekends.
Other cost efficiencies to be made through procedural changes, include improved pricing transparency in procurement of equipment, and litigation costs. Together these potential efficiencies could save the NHS up to £52 m. The recommendations will be carried out by GIRFT’s implementation teams, working with NHS Improvement and alongside bodies such as NHS England, NHS Right Care, the Society for Cardiothoracic Surgery and the Royal College of Surgeons, as well as directly with the trusts, Clinical Commissioning Groups and Sustainability and Transformation Partnerships.
Conclusion
the evidence that it is producing change, on the ground, includes the following: l Length of stay for primary hip and knee replacements has fallen by half a day, freeing up the equivalent of 50,000 bed days
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WWW.CLINICALSERVICESJOURNAL.COM
The GIRFT programme is already delivering significant results in the area of orthopaedics alone. According to a report by the King’s Fund,2
l Orthopaedics sees more litigation when things have gone wrong than any other surgical specialty, and claims had been rising over the years. In 2013/14, the number of claims rose by 8%. But in 2014/15, they fell by 5%, and by another 8% in 2015/16
l Three-quarters of hospitals that responded to a questionnaire reported that they have renegotiated their contracts for implants, achieving lower prices
l Costs for ‘loan kits’ have fallen as surgeons rationalise who is doing which type of the less common procedures, and where.
Ultimately, one of the strengths of the GIRFT Programme is the fact that it is led by clinical leaders who understand the challenges on the frontline and are driven by the desire to improve care for patients. The programme comes from the belief that “good treatment costs less than bad”, and that reducing variation in practice will improve the sustainability of the NHS, as well as improving care for patients. There is evidence to suggest that positive changes are being implemented and this could have a significant impact on care quality, outcomes and efficiency when rolled out across further specialties.
References
1 Source: GIRFT; accessed at:
http://gettingitrightfirsttime.co.uk
2 Timmins, N, Tackling variations in clinical care: Assessing the Getting It Right First Time (GIRFT) programme, King’s Fund, June 2017. Accessed at:
https://www.kingsfund.org.uk/sites/default/files/ field/field_publication_file/Getting_it_right_Kings_ Fund_June_2017.pdf
3 Harrison, S, Urology: GIRFT Programme National Specialty Report, July 2018
4 Phillips, N, Cranial Neurosurgery: GIRFT Programme National Specialty Report, June 2018
5 Richens, D, Cardiothoracic Surgery: GIRFT Programme National Specialty Report, March 2018
SEPTEMBER 2018
CSJ
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