The reconfiguration of clinical services report provides new insights into the drivers of reconfiguration and the underpinning evidence. It builds on a major analysis, commissioned by the National Institute for Health Research (NIHR), of reviews of service reconfigurations conducted by the National Clinical Advisory Team (NCAT).
This page summarises the report's findings on the reconfiguration of acute surgical services.
Proposals reviewed by NCAT
Most of the proposals reviewed by NCAT focused on the concentration of acute surgical services, often separating acute services from elective care to create ‘hot’ (emergency) and ‘cold’ (elective) sites.
Key drivers of acute surgical service reconfiguration
Cost, workforce and safety were the primary drivers of this type of reconfiguration.
Context and relevant policy
- There are around 600,000 emergency admissions under the care of general surgeons each year in England. Just over half of them present with abdominal pain.
- Emergency anaesthesia and surgery make up an estimated 40–50 per cent of the surgical workload in the UK.
- Sir Bruce Keogh’s proposal to designate A&E departments as either ‘emergency centres’ or ‘specialist emergency centres’ will have implications for the supporting acute medical and surgical services.
- Recommendations from the NHS Services, Seven Days a Week Forum, including:
- all emergency admissions should be reviewed by a consultant within 14 hours of admission
- hospital inpatients must have access to diagnostic services such as X-ray, ultrasound, CT scanning, magnetic resonance imaging (MRI), echocardiography, endoscopy, bronchoscopy and pathology
- hospital inpatients must have timely 24-hour access, seven days a week, to consultant-directed interventions that meet the relevant specialty guidelines.
The current evidence base
Units providing 24/7 acute (emergency) surgery should ensure early consultant review and assessment (ie, within 12 hours). There should be consultant surgeons and anaesthetists available 24/7 to supervise operations on emergency surgical patients. Acute surgical services should be supported by a dedicated emergency theatre, appropriate critical care services, acute medicine and diagnostic services, including interventional radiology.
Outcomes for emergency surgery vary considerably between units. While centralisation of services may be one way of improving outcomes, the relationship between volume and outcomes is complex. There is also evidence that systematic application of improvement techniques, as well as high-quality peri-operative assessment and post-operative care, are key drivers of improvement.
The emerging field of telemedicine has the potential to improve access to specialist opinion and enhance the treatment of acutely ill patients.
Relevant college guidance
The Royal College of Surgeons of England recommends that the ‘on-take’ consultant, taking lead responsibility for emergency admissions, should be available for telephone advice at all times and on-site within 30 minutes when required. As an absolute minimum, patients not considered high risk are discussed with a consultant within 12 hours of admission.
The Royal College of Surgeons of England (RCS) supports the WHO surgical safety checklist as an ‘example of clinical best practice that is endorsed by the College and is currently being implemented throughout the NHS’. They also recommend that ‘peri-operative objective assessment of risk must become routine. Most importantly, identification of higher risk needs to trigger joint advance planning specific to that case’.
‘Concerns about the delivery and future viability of emergency general surgery are such that the College and the ASGBI believe NHS England should consider establishing a Strategic Clinical Network to oversee the delivery of safe, efficient care and ensure a whole systems approach… Decisions about service change need to be evidence based and aim to improve outcomes for patients. We fully support greater national clinical audit activity and research in order to develop the evidence base for improved patient care.’ (Royal College of Surgeons of England and Association of Surgeons of Great Britain and Ireland 2013, p 1)