This General Surgery Blog will keep track of all the activity undertaken by the General Surgery Specialty Group, noting and reporting insights along the way, and will be a shared point of contact for anyone who wishes to keep up to date on the groups progress or contribute to the ongoing work. If you have any enquires about the project or any of the blog posts, please go to the Scottish Access Collaborative contact page and email us direct.
In January 2019, the Digital Health and Care Institute (DHI) began work with the NHS Scotland General Surgery Specialty on improving surgery pathways for patients and staff. Under the umbrella project The Scottish Access Collaborative, the specialty group and the DHI team will work together to unpick current general surgery services and make some recommendations for service innovations based on the findings and insights gathered over the coming months.
The aim of the Scottish Access Collaborative is to sustainably improve waiting times for patients waiting for non-emergency procedures. The program is guided by its six founding principles which foreground patient experience, clinical benefit, and transparent services. The six principles can be seen here.
The DHI was established as a collaboration between the University of Strathclyde and the Glasgow School of Art and is part of the Scottish Funding Council’s Innovation Centre Programme. It is part funded by Scottish Government. DHI support innovation between academia, the public and third sectors and businesses in the area of health and care.
The DHI was commissioned by Scottish Government to design workshops for the Scottish Access Collaborative clinical specialty-led programme. These workshops involve a range of clinical staff from primary and secondary care, health managers, patients and third sector organizations undertaking a cycle of design-led workshops.
In this first workshop, the aim was to map out the common symptoms and conditions general surgery deal with currently as part of their non-acute out-patient service, and prioritize what issues the group want to focus on in the next two workshops.
Following a morning of free discussion around common symptoms and opportunities for improvements, the group decided to prioritize four areas for the next two workshops. Moving forward general surgery will concentrate on four areas: hernia; lumps and bumps; right upper quadrant pain; and perianal symptoms.
Why focus in this?
To help prioritize the aims for the next two workshops, it was useful to reflect on each common symptom and ask ‘why’ this would be a good area to focus on.
The next steps for general surgery will be to dig deeper into the issues and opportunities for the four identified prioritised areas and highlight any recommendations for service improvements in line with the Access Collaborative principles. This will take place over two further design workshops facilitated by the DHI team. While the Access Collaborative aims to develop new ways of working for NHS services, there is also recognition that there are national work programs already underway as well as existing innovations in individual boards and hospitals. Over the coming months the DHI team will also work with the general surgery group to promote relevant national initiatives and share examples of best practice through this blog.
If you would like to know more about this work or would like to attend the next workshops, please contact the DHI project team via email
The Policy Context
We know that demand for health and care services is increasing and in order to meet that demand we must consider how to make optimal use of the resources we have to ensure the best possible care for patients. We need to:
· Move away from short term firefighting to long term fundamental change
· Ensure effective leadership
· Improve governance and the scrutiny of decision making.
Healthcare professionals must view themselves as the stewards of healthcare resources. We therefore need to invest in the people, tools and training so that professionals across the system can tackle unwarranted variation and deliver personalised care that will deliver a sustainable NHSScotland.
The shared Vision for Scotland is that:
‘by 2025, everyone who provides healthcare in Scotland will demonstrate their professionalism through the approaches, behaviours and attitudes of Realistic Medicine.’
Realistic Medicine is not about rationing healthcare or saving money. The aim of Realistic Medicine is to improve patient care; ensuring that people receive appropriate and beneficial care that is evidence-based and in tune with their personal preferences.
To achieve this, people using healthcare services and their families must feel empowered to discuss their treatment fully with healthcare professionals, in language and using information that is appropriate to help their understanding. This should include any possibility that a suggested treatment might come with side effects – or even negative outcomes. Everyone should feel able to ask their healthcare professional why they’ve suggested a test, treatment or procedure, and all decisions about a person’s care should be made jointly between the individual and their healthcare team.
We must create the conditions that facilitate more meaningful conversations between people and their healthcare professionals; conditions that help people make informed choices about their treatment and care options, based on what matters most to them.
Realistic Medicine also aims to reduce harm, waste and unwarranted variation, manage the inherent risks associated with healthcare, and champion innovation and improvement. These concepts are essential to a well-functioning and sustainable NHS for the future
We know that both overuse and underuse of investigation and treatment can result in harm to patients. By seeking out and eliminating harm and waste, we can provide appropriate healthcare that is in tune with what people really value.
Variation in healthcare exists for all sorts of legitimate reasons, but identifying and tackling unwarranted variation is essential to improving outcomes derived from healthcare across Scotland. Unwarranted variation is variation in healthcare that cannot be explained by need, or by explicit patient or population preferences. We need to ensure the prevention of harm and waste from overuse and overtreatment, freeing up resources currently used without benefit to clinical outcomes in order to address under-provision of care elsewhere.
Realistic Medicine is not an endeavour for one profession alone, nor is it solely the remit of healthcare professions. The best, high quality care in the complex environment that we now live and work can only be fully achieved through working together in teams, in networks and in partnership with people; understanding and valuing the contribution that each of us can make for the individuals and to the communities of people that require health and social care.
In summary, we aim to implement Realistic Medicine by:
The Role of the Atlas
An Atlas of Variation shows variation in population health - the provision of health and care services - and healthcare outcomes across different geographical areas. Scotland’s Atlas of Healthcare Variation help to identify over treatment (unwarranted medical interventions) and under treatment (insufficient treatment) across Scotland, supporting clinicians to address this by providing publically accessible information in informative way.
The Atlas will, in time, highlight areas where access to health and care services differ and stimulate questions and debate about the health and care needed by people in those areas.
It is expected that the Atlas will support healthcare professionals, as the stewards of healthcare resources to develop provision that is appropriate to the needs of all people across Scotland.
It is important to note that the strength of the Atlas is not to provide answers, but to prompt and stimulate questions that lead to better understanding of the reasons for variation and help identify variation that is unwarranted. Atlas maps do not suggest an ideal level of service, or rate of procedure or treatment, nor do they suggest that high is bad, or average is ideal. This is important, as atlas maps cannot be used as a tool to judge performance of one area against another. Instead, they are intended to facilitate debate and reflection and for this to be used by professionals to drive improvement.
Data and information presented in the Atlas will not always explain the reason for the variation, however the strength and power of atlases is in the questions they raise about equity, effectiveness and value.
In time, the Atlas will contain hundreds of publicly accessible maps. As the Atlas evolves over time, it will help to deepen our insights into variation in health, treatments and outcomes seen across Scotland.
By publishing atlas maps that show variation in 1) population health, 2) the provision of healthcare services and 3) healthcare outcomes across different geographical locations, healthcare teams will be able to have informed conversations that will seek out variation that is unwarranted and generate solutions that will reduce waste and harm.
A publically accessible Atlas of Variation for Scotland, supported by an engaged cohort of clinicians trained in understanding variation and influencing improvement of practice, is therefore viewed as an essential tool in our quest to practise Realistic Medicine and deliver a sustainable NHSScotland.
Why publish a National Atlas of Variation for Scotland?
Persistent unwarranted variation in health and health care affects equity of access to healthcare. We need to ensure the prevention of harm and waste from overuse and overtreatment, freeing up resources currently used with little benefit to clinical outcomes in order to address the under-provision of higher value care.
We want to know whether people in different parts of Scotland have equal access to the same quality of evidence-based NHS services according to their need. We are interested in the value and impact of NHS services provided as it is important to identify ineffective practices that lead to wasted resource and patient harm.
In many countries across the world, including the USA, England, Wales, New Zealand and Australia, publicly available Atlases of Variation have been used as a stimulus to start a search for unwarranted variation, and act as a springboard to releasing resources for re-investment in value based healthcare for patients and local populations - evidence based care that people really value.
Public monitoring and reporting of variation at multiple levels – regional, NHS Board, Integrated Authority, GP Cluster and outcome level, will help ensure transparency. Variation arising as a result of different organisational performance - the particular practices of clinicians and of healthcare organisations – may represent unwarranted variation.
We must continue to deepen our insights into variation seen across Scotland in the activity and outcomes for patients and understand whether the data variation observed is random, warranted (i.e. true clinical variation based on geographical variation in need or population preference) or unwarranted and caused by under or over provision, failure to implement evidence guidelines, or poor access for patients because of travelling times, socioeconomic factors or poor health literacy.
The Scottish Atlas of Healthcare Variation has the potential to support improvement in priority areas such as waiting times, by providing professionals with the information they need to seek out and tackle unwarranted variation, identify inappropriate care and help redirect wasted resources to more appropriate care.
In February 2019, the General Surgery specialty met for a second design led workshop to discuss and develop recommendation for improvements to current General Surgery services. In the first workshop the group developed some key symptom profiles and started to map out issues with current services for each agreed symptom. In this second workshop the group would add detail to the issues and opportunities for each key symptom, going on to develop some ideas and actions for how to address them.
The team broke away into three sub working groups, taking a symptom each to scrutinise and unpick the issues and opportunities that relate to the specific symptom’s associated patient pathways. The first question asked of each group was: what are the key issues and opportunities for your symptom?
For Lumps and Bumps:
The practice of dealing with the benign nationally varies, for example in Highland General they remove lots of lumps and bumps, mostly by locums. Removing lumps and bumps is good training for junior doctors and reducing the number of procedures could be a significant asset loss to remote regions who do a lot of these.
There is an opportunity for technology to play a role in referral and triage of lumps and bumps. Dermatology are developing technology on this area to support diagnosis of skin lesions.
There are high DNA rates for minor lump and bump operations, circumstances often change while patients wait for their appointments, they are no longer worried or anxious about their lump or bump and so they do not turn up for their procedure.
The current referral practice raises patient expectation that lumps or bumps will be removed. Often a referral might be for a more informed opinion and this may not result in a removal.
There is a question around the true cost of the ‘business’ of removal of benign lumps and bumps. Currently it is not known what the financial implication of change would be.
It is agreed that symptomatic hernias are something that should be dealt with by the NHS, but there is no clear recommendation which procedure should be the national standard. There is a question around giving patients the option of procedure type (open or laparoscopy). If patients are given the choice it will be important to balance the information delivered to support decision making, as currently advice is varied and inconsistent.
Asymptomatic patients may not actually need to come and see a surgeon, yet current practice will direct some patients to surgeon led consultations. Current information about the risk and benefit of procedure does not do enough to empower patients to make considered decisions about their options. Primary care doesn’t have enough time with patients to have the risk benefit conversation with them.
The definitions of what constitutes symptomatic, asymptomatic and minimally symptomatic are unclear. The lack of definition doesn’t help primary care colleagues with referrals.
Current practice utilises consultant time for preoperative work that could be taken on successfully by other roles within the NHS services.
For Right Upper Quadrant Pain (RUQ):
The question raised in the discussion about gallstones was how to get gallstones dealt with on an index admission. Not doing so is an inefficient use of resource, results in return appointments, recurrent admissions, and unhappy patients. The impact is an increase in bed days, pressure on primary and emergency services, morbidity and mortality, and an inappropriate use of investigations as a mechanism for delaying or denying a procedure. This puts pressure on on-call teams, and emergency theatre time. It is an issue for everyone including the family of the patient.
Each group were then asked to translate their identified issues and opportunities into a series of symptom specific challenges. Each challenge was framed as a question starting with ‘how might we..’, and each question subsequently discussed within the whole group. The following lists the how might we challenges for each symptom.
For Lumps and Bumps:
How might we….
How might we…..
How might we…..
Finally, each group were asked what they could do to address the most salient of their how might we challenges, and what needs to happen next to start a transition.
For Lumps and bumps:
The ultimate aim is to develop nationally agreed, implemented and adhered to lumps and bumps guidelines to ultimately reduce the number of consultations and minor operations for benign lumps and bumps.
The first step will be to map stakeholders to include in development of guidelines. To prepare for developing the guidelines some assets should first be put in place. Current guidelines including examples from NHS England should be collated. Baseline ISD data on lumps and bumps procedures collected. Current technology landscape mapped looking at assistive diagnosis technology especially developments in dermatology. The challenges will be engaging the clinical community and achieving consensus. There is also a risk of adverse impact on surgical training for junior staff.
Moving forwards any development in this area should take into consideration the future technology landscape that could impact on future practice and influence guidelines.
The potential impacts of a new agreed protocol are: free up resource (theatre time, admin, consultant, surgeon, after care, complication costs, and more); less travel for patients; can prevent harm (complications, pain of procedure and recovery); reduce variation
The aim is for a nurse led service guided by national referral pathways based in secondary care with national information and resources.
The first steps will be a consensus meeting plus an evaluation of the guidelines that will need to be updated. To prepare for development, existing nurse training material, information leaflets, assessment tools and existing guidelines should be gathered. The barriers might be arriving at a consensus, demonstrating the value of change and that the change will work, and achieving national consistency. There may be some implications in terms of lost training opportunities for junior staff.
If successful, the outcome from this work would be a streamlined consistent high quality hernia service. Resulting in a more informed population and workforce, a more efficient use of resources, reduced waiting times, enhanced operation capacity, better patient experience, freeing up some outpatient clinics for other work.
The aim is to develop a nationally agreed operational procedure, with standardised care costs, improved waiting times, and standard expectations for patients and staff.
The next steps for this work will be to obtain agreement via a consensus meeting, followed by development of national guidelines, resulting in cost savings. This will need financial support to develop the new guidance. The potential barriers are arriving at the consensus and determining the cost implications.
The outcome will be standardised care with associated cost savings, improved waiting times, and standard expectations.
The first aim is to reduce the number of unnecessary MRCPs. This will be achieved through a national adherence to the accepted AUGIS guidelines, which should be adopted Nationally. Enabling emergency cholecystectomy during the index admission would be another aim to be explored in the future.
The first steps will be an audit to record local practice versus national guidelines. The aim is to investigate how many patients, had guidelines been followed, would have been managed differently. The plan initially will be to develop a proof of concept looking at a local level. The suggestion is to begin with an audit of the last 40 inpatient MRCPs in on board to assess. The next phase would be a national consultation.
The impact of a change in MRCP practice would be a reduction in bed days, it would free up radiology slots for other work, and should reduce waiting lists for radiology.
The next step will be to re-visit the remaining how might we statements, develop more ideas to address the challenges and associated action plans. All the agreed actions will be documented as recommendation in the General Surgery report to be published via this site.
The Scottish Government, Scottish Enterprise and NHS Scotland are running a Small Business Research Initiative (SBRI) competition designed to identify innovative new ways to improve dermatology services.
The competition is divided into two phases. In phase one, which lasted 6 month, 5 companies developed proof of concept ideas. At the end of this, 2 companies were selected for phase 2, which will last for 18 month. During phase 2, the companies will develop and demonstrate their prototypes in a variety of health boards in Scotland.
The two shortlisted companies are Storm ID and GP Commissioning Solutions (GPC). Storm is developing an asynchronous virtual clinic model that allows patients to log into a website and upload photos and answer questionnaires that can be then reviewed by the consultant. This includes the ability to request more information from the patient. The consultant can then decide on the appropriate outcome, in much the same way as a traditional appointment.
GPC are developing a set of software applications that uses machine learning to help GPs to carry out more accurate diagnosis and treatment of skin conditions, assisted differential diagnosis and context sensitive education materials. They are also developing a patient planner application to assist patients with reminders, help and advice and adherence to their treatment plan. This will include integration with Amazon’s “Alexa”.
The links below are to a recent Health and Social Care Innovation Network meeting where both companies presented their work to date. Please see “HSCN19 - Murrayfield - 230119 – Dermatology” for links to the slides and the video of the presentation.
In March 2019, the Scottish Access Collaborative General Surgery specialty met for their third and final design led workshop facilitated by the Digital Health and Care Institute. The ultimate aim of the collaborative is to collectively enhance clinical pathways for staff and patients so patients who need primary and secondary care are identified, diagnosed, and treated appropriately and efficiently. For General Surgery, this involved mapping current service designs, identifying current issues, responding with ideas for new innovations, and also identifying and replicating best practice where possible. In the previous two General Surgery workshops, some common symptoms were proposed and some common issues identified, resulting in a number of specific symptom profiles and challenges for current service designs. Small working groups re-framed these current challenges as a series of ‘how might we’ statements, that positively restate an issue as an opportunity for change. In the previous workshop the group tackled some of these challenges, developing some ideas for innovation and action plans for the next steps. In this third workshop, small working groups revisited the remaining ‘how might we’ statements, selecting the most salient and developing some more ideas and action plans.
What follows are short summaries of the ‘how might we’ statements that the General Surgery group prioritised in the workshop, the symptom profiles they relate to, the group responses to the challenge, and some more action plans for next steps.
Ideas and Action Plans
How might we: optimise referrals for hernia surgery?
Current patient and healthcare expectations are that patients with a suspected groin hernia should be referred and listed for a hernia repair. These expectations are supported by many of the currently available information sources such as EIDO and refHELP. However, subspecialty and National Guidelines do not support this management pathway.
To change expectations to those supported by best evidence will require the development of information sources for both patients and healthcare providers. Enhanced information should be Nationally standardised, and contain details of risks and benefits of procedures. Information is also required to support and advise those who are considered appropriate for no-surgical management. This information should be made available through GP referral systems and through a validated online source for patients. There should be a considered public health campaign disseminating the information to targeted groups of likely patient groups. The role of a secondary care enhanced hernia vetting or triage service would be an alternative means of delivering the change in practice.
Should enhanced patient and healthcare provider information be successful this should reduce patient harm by avoiding unnecessary travel and procedures, improve patient quality of life if managed conservatively, improve patient knowledge for informed consent if proceeding to surgery and potentially increase GP, clinic and theatre capacity. However, the reduction in surgical intervention could also result in more repeat consultations for GPs, or emergency presentations than currently seen. There could also be a rise in anxious patients and this should be considered with this new pathway idea.
The next steps to implementing this change would be a working group of GPs, secondary care, patients, and IT specialists to develop patient and healthcare provider information platforms supported by best evidence. This group may also decide whether the interventions are aimed in Primary care, at source of patient contact, or as a new secondary care service.
The longer-term actions would involve information dissemination and support for health care providers. There would also be a role for a public health care campaign to disseminate the information to patients. These interventions would help with the challenge of managing patient expectations and the increased time required for GPs or secondary care to consult with patients about the realistic options for their symptom.
How might we: improve patient information and communication?
A more patient centred approach for this symptom will involve patient education and involvement in shared decision making. It will take better, realistic, patient facing information from a trusted source perhaps based on current NHS England information. This information should be of quality and come early in the patient journey, delivered through multiple modalities including App and technology supports. The aim is to consistently reassure the many patients for whom reassurance is all they need.
Quality pre-referral information will maximise appropriate referrals. A consistent approach can reduce local variation and keep it national. Therefore, existing assets like NHS inform should be used. Patient expectations will be managed better, and hopefully reduce anxiety, unnecessary travel and in some cases appointments.
The next steps for this implementation will be to engage the key stakeholders including GPs, NHS 24, and secondary colleagues. The actions will be to adapt current NHS Inform resource, the priority being to develop written information to accompany a clinical letter with a digital link to online resource. This will help to set expectations. In the longer term, clinical groups will need to embrace the current technology developments, specifically SBRI App developments, that will enhance the referral process between primary and secondary. The key barriers to these changes will be obtaining a national consensus on guidelines, and then ensuring implementation.
How might we: increase awareness, and ensure compliance with, established guidelines for management of patients with biliary colic and cholecystitis.
The idea is that all boards adopt and ensure compliance with the AUGIS Guideline. This advises on the use of MCRP for a clearly defined group of patients in the patient pathway. The change in current management is aimed primarily at general surgeons and radiologists who can be over cautious and unnecessarily utilise imaging for this symptom.
There is the risk of unintended harm using MRCP specifically, delay to definitive surgical treatment and possibly unnecessary ERCP. Compliance with the AUGIS guidelines could have the effect of reducing harm and would also increase radiologist and MRCP capacity for other activity. The other impact would be to focus attention on the AUGIS guidelines in other areas of gallstone disease management.
The first action is to audit current MRCP practice in Scotland and compare to AUGIS guidelines. Health boards will need to be involved as will a lead for radiology. The outcomes from this will be a government communication, providing a succinct message that can be disseminated nationally. This change links to NHS Patient Safety Program and to Realistic Medicine. The challenges will be getting the right information to everyone who needs it and communicating it succinctly so it is meaningful and useful.
The Group also took the time to consider the European Consensus Statement on haemorrhoid management published in 2019. Haemorrhoid management, discussed at the first working group meeting, had not been pursued because of the anticipated European Statement release.
Currently a number of procedures and pharmaceuticals are offered across the country for symptomatic haemorrhoids. Some of these are expensive and the evidence base for many is limited. The European Consensus Statement, which included Scottish specialists, was published in March 2019. This was reviewed taking into account British health economic standards.
With standardised patient management and information, patient harm would be reduced and the cost of haemorrhoid surgery should reduce. It is also anticipated that theatre capacity would increase although there would be an anticipated increase demand for outpatient activity. It is anticipated that there will be consultants who wish to develop alternative techniques. This would be an option as part of an appropriately governed clinical trial.
The next steps would be to evaluate the evidence, volume of use and cost of over the counter treatments in Scotland. A consensus group to produce standardised patient information regarding symptoms and treatments was proposed.
Senior clinicians from four health boards reviewed the European consensus statement as it may apply in Scotland. The agreement of the working group was that Grade 1 and 2 haemorrhoids should be managed with banding only. For Grade 3 haemorrhoids where banding has failed, arterial ligation without ultrasound is clinically and cost effective. For symptomatic 4th degree haemorrhoids after failed banding, a Milligan Morgan haemorrhoidectomy is the appropriate intervention. Stapled haemorrhoidectomy is not cost effective. Other treatments should only be offered within a clinical trial.
The next step would be a National consensus meeting to take forward the recommendations of the European Consensus statement. The aim will be to establish an agreed National management pathway for haemorrhoids and a Nationally agreed information platform.
The next step for the General Surgery work will be for the DHI team to collate all of the recommendations made by the SAC General Surgery group into the final report. The recommendations will be presented to the SAC board later in 2019 and opportunities or further work identified. The final General Surgery report will be made available through the SAC website.