In Shape for Surgery

We know that the healthier people are before surgery, the fewer complications they may have and the better their outcomes can be.
Eating healthily, being active and stopping smoking all make a real difference to health and people who are in good general health usually recover better from surgery and have fewer complications.

What is it?

On 1 December 2017 we implemented a health improvement initiative for people with specific risk factors, so that they can access support to improve their health prior to surgery.

This initiative is designed for patients undergoing non-urgent, elective surgery. It does not affect emergency or urgent surgery or diagnostic procedures.

It was rolled out in a phased approach, beginning with hip, knee and hernia, with the possibility of more procedures being introduced in the future.

How will people be supported?

The pathway recommends early detection and management of risk factors, with GPs working with patients to improve their health before a referral for surgery where the additional benefit of primary care treatment can be had.

This could mean helping the patient to manage their diabetes or blood pressure or it could mean helping them to stop smoking. In some more complex cases, patients will be referred into secondary care to help them improve their medical health, prior to being referred for surgery.

There is support available to help people improve their health. Patients will be signposted to healthy lifestyle services by their GP and by secondary care clinicians.

An important feature of this work is consistent messages from all healthcare professionals and consistent access to support services.

We believe that we all have a responsibility to promote healthy behaviours and integrate prevention of ill-health into our services.

We also believe that we should be encouraging people to take a greater level of personal responsibility for their health and wellbeing and this is also an important priority of the NHS Five Year Forward View.

What is the criteria?

A set of criteria have been developed by primary and secondary care clinicians in Cornwall and Devon.

The criteria covers blood pressure, anaemia, irregular heart rate, heart murmurs, diabetes and smoking status.

The criteria define the level at which a patient’s risk in surgery may be increased and are based on best practice.

What are the benefits to patients?

This is a comprehensive attempt at improving the safety, effectiveness, experience and value for money of surgery.

There are clear benefits as it will help us reduce the risk of complications and the resulting length of stay in hospital and achieve improvements in surgical outcomes.

There are also longer-term positive impacts of controlling chronic disease and avoiding risky health behaviour. These are significant for individual patients and their families and they are also important for the NHS and for social care.

Questions and answers

Is this about saving money?

No. The point of improving people’s health prior to surgery is to avoid complications and to improve the outcomes of surgery.

Poorly controlled diabetes, high blood pressure, anaemia, problems with heart rate and the structure of the heart and whether a person smokes or not are all shown to affect how well surgery is likely to go.

All of these aspects have the potential to be improved prior to surgery and we are now putting more emphasis on this.

There may be some financial benefits but these are difficult to quantify. If a person spends less time in hospital or needs fewer trips to the GP after surgery because they recover better and sooner, for example, it will effectively cost the NHS less to treat them but this doesn’t always free up any actual money.

Many of the areas of health we are targeting to improve before an operation are actually influential on a person’s health in the long term too. If we can support people to keep going with health improvement and management of their conditions not just before but after surgery, we hope that this will make them healthier in the long term. Where this happens, they may require less use of the NHS in the future as a consequence of being healthier.

Are you not doing this already, what is new?

We already do this to a large extent and there is already a high degree of best practice. GPs work with patients to improve their health and routinely refer people to secondary care specialists and to the various support services available to support healthier lifestyles.

The key change we have made is to make sure that the messages about the importance of pre-operative health that patients receive are the same across primary and secondary care. We want to make sure that patients always think of these messages when proceeding to surgery.

We have also made sure that the clinical criteria professionals use to judge fitness before an operation are consistent regardless of which GP practices or local hospital you attend. Our review has taken latest evidence into account.

GPs work with patients to improve their health and routinely refer people to the various support services available. We have been looking at how we can help patients to recover better from surgery and doing everything possible to improve patients’ general health is one way of doing this. This initiative is designed to ensure that best practice is being followed across the county and that patients realise they have an important role to play in boosting their recovery times by adopting healthier lifestyles. At present, some people’s surgery can be cancelled because of these conditions so encouraging healthier lifestyles earlier will reduce the risk of this happening.

Does this mean that you have been operating on people who haven't been fit enough for surgery?

Patient need determines whether surgery takes place and a clinician will always balance the risks of a patient having or not having surgery. It does happen that sometimes health issues are picked up later in the pathway so sometimes operations can be cancelled further on in the patient’s journey to surgery. We are now taking a standardised approach across Cornwall and Devon. Health improvement will happen earlier in the pathway which means fewer late cancellations and less inconvenience to patients.

What about people who are in real pain, will these measures require them to remain in pain for longer?

It’s important for all patients that their operation goes well. All patients will be assessed according to their needs. Assessing those needs balances the need to reduce their risks of complications by waiting slightly longer while treating a medical problem, versus the pain that they may currently be experiencing. This is not a change to current practice. Where patients are in pain and they and their doctor agree that a delay to improve their fitness is best, techniques and treatments for pain management will form part of their treatment where that is needed.

What support will you put in place to help me stop smoking?

You will not be expected to do this alone. Your GP and hospital clinicians will provide information on the various stop smoking services that are there to help you.

Healthy lifestyles support and information can be found below:

Will these services be able to cope with the additional demand?

We have looked at the potential impact of this programme and we believe that the current healthy lifestyle services are well equipped to care for any additional patients who would be accessing them prior to surgery.

Is this for all types of surgery and does this affect emergency surgery?

This relates to referral for non-urgent, elective surgery. It does not affect emergency or urgent surgery. It will be rolled out by speciality, starting with knee replacement, hip replacement and hernias.

We have seen that other health communities have also set criteria for weight loss for obese patients, prior to surgery. Why have you not done so?

Weight can be important in surgery and is already a consideration, both for people who are very underweight or very overweight. For patients in these categories (body mass index less than 18kg/m2 or above 40 kg/m2), their doctors will consider this with them, but this new scheme work does not include any blanket weight threshold for surgery.

What is the criteria and thresholds for intervention?

The criteria for pre-referral medical management intervention are as follows:

  • diabetes (HbA1c level in known diabetics, or at risk of diabetes)
  • blood pressure
  • pulse check for atrial fibrillation
  • detection and investigation of any heart murmurs
  • anaemia (for major surgery i.e. TKR/THR)
  • smoking cessation

More detailed information on the thresholds is available on the Referral Management Service website.