Case study: NHS South Central

This case study was developed prior to the NHS Listening Exercise. The outcomes of this exercise have led to some changes to the policy, and this case study may not reflect the current policy position. More information can be found in our detailed response to the NHS Future Forum.

The Enhanced Recovery Programme
NHS South Central has been running an Enhanced Recovery Programme to enable many people to return home well after only one or two nights in hospital, with replacement hips and knees or after having major cancer surgery.

The programme aims to make patients better prepared for surgery. This means they should require less input from their GP and community services and are less likely to be readmitted than previously. By using best evidence, patients’ recovery from major surgery is quicker with improved outcomes and satisfaction.

This is a widespread programme taking place across the region. It is working to prepare and inform GP consortia about basing commissioning decisions with the patient and their recovery in mind.

The GP consortium in Buckinghamshire is working with the local NHS Trust to ensure that Enhanced Recovery (ER) is adopted throughout different patient pathways. The GP consortium has worked with the PCT to ensure ER is included in contractual agreements for 2011/12 so will be a basis for future commissioning decisions.

Why is the programme needed?
Traditionally patients were admitted to hospital a number of days before surgery and spent more time waiting to be discharged from hospital. Their recovery was delayed; they were at increased risk of hospital acquired infections, deep vein thrombosis and other complications.

Patients were also encouraged not to eat for prolonged periods leading up to surgery, resulting in semi-starvation and fluid, electrolyte and nutritional imbalance.

Delays could occur due to other illnesses, system inefficiencies and lack of patient education.

Activity to date
The Royal Berkshire Hospital and Winchester and Eastleigh NHS Trust were initially chosen as innovation sites for the national Enhanced Recovery Programme. Now every organisation across NHS South Central is working to introduce Enhanced Recovery pathways in each surgical speciality and length of stay in surgical specialities has been reduced significantly across the region.

The Royal Berkshire Hospital has embraced ER as a way of working in four specialties (colorectal surgery, orthopaedic, gynaecology, and urology). They have appointed a nurse to ensure that each of the above specialities is focused on promoting enhanced recovery.

Southampton University NHS Trust also has an established enhanced recovery project which includes GP consortia members.

The SHA has actively promoted ER through a series of engagement events at local, regional and national levels. It has developed a network of clinicians from all related spheres of expertise to share learning. This work culminated in the hosting of an international conference in April 2011.

A video is being produced aimed at professionals and patients explaining the benefits of the work and their role in the process.

There are 20 ‘Enhanced Recovery’ principles including active encouragement of eating and drinking (instead of pre-operative starvation) early mobilisation; good quality analgesia and avoidance of nausea. All of these actions help the patient to feel better sooner after surgery.

From the outset (from GP referral onwards) patients are better informed – knowing what to expect and what is expected of them. Families are also involved. Dr Geoff Watson, Clinical Director Planned Care at NHS South Central, says; “carers and relatives are included from the beginning, so they can help and support the patient back at home”

The patient is admitted to hospital on the day of surgery already knowing when and how they expect to return home. Modern approaches to surgery and anaesthesia, nutrition and symptom relief minimise the negative side effects of their operation enabling their stay in hospital to be reduced. Overall outcomes are better and patient experience is improved.

Working in partnership
The Department of Health ERP team has supported the innovation sites and produced evidence to support the programme.

Locally a multi-disciplinary team approach has ensured the engagement of primary and secondary care clinicians, patients and carers and third sector organisations.

Benefits for patients and clinicians
The patient experience is greatly improved as they feel more in control, reassured and confident about their treatment.

Pre-operative classes teach people about what to expect of their surgery and recovery process, including post-operative exercises, use of crutches and stoma care. Relatives and carers also attend to ensure they are able to help the patient’s recovery.

“Schools before surgery make you much more competent to use crutches than if you are taught afterwards, the same applies to exercises”, says Dr Geoff Watson.

Next steps
The health community in South Central is working to make sure that the new ways of working are sustainable and that they become the norm rather than the exception.

They are also working to roll out the programme to other specialties so that new processes are adopted universally across the region. Dr Geoff Watson says it’s a success story:

“ERP ticks all the boxes, it’s much better for patients as well as saving money, resources and making us work more efficiently.”

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