The latest report to be published by Getting It Right First Time (GIRFT) reveals the deficiencies and opportunities for improvement in the way cranial neurosurgery services are provided by the NHS. In contrast to previous GIRFT reports which have focussed on learning from variation in practises between NHS Trusts, GIRFT’s cranial neurosurgery report highlights that patient pathway inefficiencies and delays are being experienced in all of the 24 NHS hospitals which perform cranial neurosurgery, to the detriment of patient care and the frustration of the neurosurgeons.
The report specifically states that it is not a call for additional financial investment. Many of its recommendations can be implemented by NHS Trusts with minimal effort yet deliver an immediate impact on surgical capacity and throughput, resulting in more procedures taking place and patients who need urgent surgery receiving it faster. Implementation of its recommendations will optimise the use of existing resources to avoid delays and cancellations, free up hospital beds, deliver a better and faster service to patients whilst saving the NHS up to £16.4 million each year. NHS Improvement’s deadline for implementation of GIRFT’s cranial neurosurgery recommendations is June 2019.
What is cranial neurosurgery?
Cranial neurosurgery is a sub-specialty of neurosurgery which covers a range of surgical procedures performed on the brain or on the nerves in the skull. It includes the care and treatment of serious conditions and emergencies, such as traumatic brain injuries, intracranial bleeding and brain tumours, where timely surgery can save lives.
Cranial neurosurgeons also carry out elective (non-emergency) surgery, such as relieving pain caused by nerve damage, and have a key role in monitoring patients with head injury.
In England, cranial neurosurgery is carried out in only 24 NHS hospitals which, together, admit 75,000 neurosurgery patients each year. In many of these cases, the patients were admitted for investigation, such as an MRI or CT scan or for monitoring after a head injury but did not have surgery. 40% of cranial neurosurgery admissions were for emergency treatment, most commonly for cranial trauma (head injury).
Cranial neurosurgery patients often need a lengthy stay in hospital owing to the severity of their condition and the longer recovery period from highly invasive surgery. For many, their care takes place in a critical care unit followed by extended monitoring on a ward, before moving on to rehabilitation. The average length of stay for patients following non-elective cranial neurosurgery was 19.4 days. 14% of patients stayed longer than 28 days.
Areas of concern arising from the report
GIRFT found that, without exception, all 24 NHS Trusts experience patient throughput delays which the frustrated neurosurgical teams believe are preventing them from seeing more patients and treating them sooner. After their treatment, patients are staying under the care of cranial neurosurgery longer than is clinically necessary, delaying the admission and treatment of new patients and resulting in high cancellation rates of those already admitted for elective surgery.
Two-thirds of trusts fail to meet national 18-week referral-to-treatment targets for admitted neurosurgical patients, with eight trusts treating fewer than 60% of patients within the 18 week deadline. One in ten patients with subarachnoid haemorrhage or SAH (bleeding between the membranes surrounding the brain) do not receive surgery within the target time of 48 hours from diagnosis. This is a serious failing because any delay in treating SAH exposes the patient to the risk of severe brain damage or death.
Even where cranial neurosurgery is not urgent, unnecessary stays in hospital cost the NHS more money, take up beds that delay treatment for other people and increase distress and infection risk to the patient.
The bottlenecks are experienced at every stage in the patient’s pathway. Patients have to wait for critical care beds to become available and these may be occupied by post-surgical patients awaiting discharge because the cranial neurosurgical centre has difficulty moving the patient on to other hospitals, rehabilitation centres or discharging them to a home setting with adequate rehabilitation support. The problem is compounded for tertiary (specialist treatment) hospitals because they are contractually obliged to accept referred patients requiring a specialist cranial neurosurgical procedure, whereas district general hospitals are not, and with their own stretched bed capacity and lack of rehabilitation resources, they can be unwilling or unable to take their post-surgical patient back.
The GIRFT cranial neurosurgery report recommends several ways in which hospitals can improve patient pathways to reduce delays and cancellations, speed up access to vital treatment, start post-operative rehabilitation sooner and improve patient experience:
- Admitting patients on the day of surgery rather than in advance, particularly for minimally invasive procedures which don’t need anaesthetic and surgery for some brain tumours, to free up clinical care beds for more patients.
- Reorganising the way operating theatres are used by designating one (existing, not new) theatre for acute procedures with open slots to cater for emergency admissions. This will avoid disruption, cancellations or delays to patients already booked for elective procedures who are currently having to make way for emergency patients with higher clinical priority.
- Speeding up discharge from cranial neurosurgery by making commissioning changes to compel referring hospitals to take their patients back once the patient is clinically ready. The success of this depends on better integration with community services to provide adequate and timely physiotherapy, OT and other rehabilitation support.
- Avoiding thousands of neurosurgery admissions for non-surgical procedures, such as scans and post-operative checks, and consultant time spent in communicating scan results, which could be carried out by other multidisciplinary team members in outpatients or the patient’s home by phone or video-link.
- Combining multiple consent and pre-admission clinic appointments to reduce the number of appointments that the patient needs to attend.
- Avoiding delays by electronic information-sharing of patients’ scans and records between district general hospitals and the cranial neurosurgery centre, to avoid patients having to undergo repeated scans or long waits to be seen by a consultant because their information is not readily available.
The GIRFT team envisaged that freeing up consultants from many of their 20,000 appointments each year will improve the use of resources, speed up discharge, reduce admissions and increase critical care bed capacity for when it is clinically required.
Freeing up just one extra bed per NHS trust per day would allow thousands more patients to receive the care of cranial neurosurgeons each year with no additional increase in resource – a goal that GIRFT believe is possible for each of the 24 NHS Trusts to achieve.
GIRFT estimate that implementation of their cranial neurosurgery recommendations will result in improved patient experience and outcomes whilst saving the NHS £16.4 million per year.
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