Imagine if you will…
…two identical twin brothers, aged 59. Both would describe themselves as leading sedentary lifestyles (both at work and at home). They are overweight and have stressful management positions within a leading IT Company in Scotland. They have no known other comorbidities. One lives in Edinburgh and the other in Glasgow. Both attend their local hospital on the same day and are informed they have early bowel cancer and require an operation. One brother, is offered to attend an innovative service providing advice and guidance on how to get fit for his surgery (mentally, physically and nutritionally) as this is known to improve recovery following the surgery. He decides to watch the videos on exercise sent to him by the surgical team and attend a regular exercise class which he was also referred to following discussions. The other brother, because of where he lives, is given some general advice regarding nutrition and exercise.
Similarly, when they go in for their operation on the same Friday in different hospitals, one brother follows an Enhanced Recovery Pathway. On return to the ward within the first 24 hours his intravenous drip is removed, he returns to an oral diet, his urinary catheter is removed and he is encouraged to mobilise around the ward.
The second brother, who did not have the Prehabilitation programme, does not get his drip removed within the first 24 hours, for no medical reason his catheter stays in for two days as that is what the consultant does for all of HIS patients. As it is a Saturday and only physiotherapy staff can mobilise patients for the first time following major surgery in this particular hospital and there is no weekend service for this aspect of care (it’s a prioritised service for Chest Physio only) and he has a catheter in place anyway, he does not want to nor does he expect to be out of bed on the first day following his surgery.
One brother stays 4 days in hospital and the other stays in for 7 days. Following discharge, one is phoned at home on day 10 following his surgery as that is completed for all surgical patients whilst the other is not, as the service has not yet been established.
Following a period of recovery, the brother who underwent Prehabilitation is returning to the rehabilitation programme as this was arranged prior to surgery…… can you guess what happened to the other brother?
What do you think their family’s conversations about the pathways of care would be like? What would you want for you if you were or your relative was the patient? Is it acceptable to allow such variation in care provision?
Now this may seem a little farfetched (and for clarity is completely made up!) but in reality, some aspects are not that distant from the truth still in the UK. I am glad to say that NHS Scotland is beginning to make real changes but we still have a long way to go …… and as AHP’s we have a hugely important role in this!
Addressing the Problem
How do we address the problem of variation in health care? If there is a single document that I think summarised current healthcare and what we need to consider it is the first Realistic Medicine Report from our current Chief Medical Officer Dr Catherine Calderwood.
It brought together a number of key areas of thinking in one document, the challenge is then how do you implement this and at scale across the NHS.
For me, I like to keep it simple and think of three broad areas which can be applied to local as well as national pathways of care and when we consider the two brothers in the story how we can improve cancer care across Scotland:
- Identify the Variation
- Agree consensus
- Monitor adherence
The aim of all health care pathways is to ensure evidence based care is delivered every time to the right patient at the right time thus ensuring the optimum outcome. Through looking at the variation in care provided, whether that be on a local level (e.g. in a ward setting) and then at a national level we can begin to understand what is Artificial Variation (i.e. the way we design services or the way we apply care) and manage more optimally Natural Variation (i.e. that our patients are all individuals with different needs and present to services at different time points in their particular journey).
By identifying variation in health care pathways, gaining consensus on the optimal pathway and monitoring adherence to the agreed pathway you can fundamentally improve care and outcome.
Enhanced Recovery After Surgery – is a multimodal approach to understanding how all interactions with a patient (for example the brothers above) impact on each other and how through understanding each interaction the sum of the parts adds a cumulative benefit to the patients’ recovery.
In 2016, across NHS Scotland we launched the National Enhanced Recovery Colorectal Initiative (NERCI). Consensus was obtained from all sites on the acute hospital stay pathway. Adherence to the pathway increased at all sites and resultant outcomes of our patients improved. Learning from each other, by collecting a minimum dataset and meeting regularly to understand how to address common issues has resulted in patients being discharged 2 days earlier than previously with decreased morbidity and mortality across the country. (http://nhsscotlandevent.com/sites/default/files/EF-23.pdf). The local teams have also established telephone follow up calls across the country which were not previously routine.
The next step in improving care is to look at how the Acute Care episode is enhanced further by making patients as fit as possible prior to surgery and ensuring they have access to Rehabilitation following surgery where appropriate.
Prehabilitation is a key factor in improving outcomes and we need to consider how we can improve our patient’s wellness (physically and mentally) prior to major surgery and support their recovery following surgery in a person-centred approach. Across Scotland, there are different programmes being developed such as the Macmillan Move More Programme or HARP in Ayrshire and Arran. However, these are not available to all patients and with relatively short lead in times for major cancer surgery we need to radically think about how AHP services are provided and how we can achieve equitable access across the country.
This is not an easy task however, I believe we have an ideal opportunity as AHP staff to design, test and imbed programmes of Prehabilitation and Rehabilitation across Scotland for not just Cancer patients but all patients undergoing major surgery. I encourage you to get involved. I believe the time is now to radically evolve the service model currently provided to our patients and with digital technology advances the opportunities have never been greater.
If you would like to be involved or share how your local team has progressed this area please get in touch and together we can strive to imbed the optimum car pathway for every patient every time.
Dr David A McDonald – @davidmcd07
Service Improvement Manager, Whole System Patient Flow Programme, Scottish Government
Senior Research Fellow, NMAHP Research Unit, Glasgow Caledonian University
And still occasionally, Senior Physiotherapist, Orthopaedics, Golden Jubilee National Hospital, Clydebank