Acute surgery covers a range of surgical specialties. Initially we are focussing on emergency general surgery, vascular surgery, urology and orthopaedics and have established an Acute Surgery Group to support this work.
Our mapping exercise has shown that acute general surgery services are currently provided on 29 sites; acute urology is provided on 21 sites. In the next phase of work we will consider whether the current configuration of these services provides all the agreed components of a high quality service.
Increasingly the components of a high quality service are being described for a range of clinical services. Taking Vascular Surgical Services as an example the Quality Framework developed by the National Planning Forum in 2011 set out optimal models of care. For vascular surgery this included a population base of 800,000 and access to intensive care and complex interventional radiology. This has necessitated the development a model whereby multi-disciplinary teams provide complex vascular surgical care on a regional/cross boundary services in support of local hospitals who direct patients to such specialist units when it is required. Implementation of this framework is underway through the NHS Board regional planning structures. In some areas such as the West of Scotland implementation requires service reconfiguration, while in the North of Scotland, they are setting up an integrated vascular service for NHS Grampian and NHS Highland, delivered through a clinical network. Few would disagree that this is the correct approach to the delivery of a complex service such as vascular surgery. The implications of the requirement for safe surgery to be undertaken by large integrated teams will require to be considered in planning for a sustainable seven day service in other clinical areas.
We are also exploring the quality of decision-making and access to investigations at weekends in surgical wards across Scotland. As part of this we are undertaking a review of ward rounds at weekends in order to measure their effectiveness. Effective ward rounds improve patient care by providing an opportunity for the clinical team to:
- establish, refine or change clinical diagnoses
- review the patient's progress against the anticipated trajectory on the basis of history, examination, early warning scores and other observations, access to and the interpretation of tests and radiological investigations
- make decisions about future investigations and options for treatment, including do not attempt resuscitation and any ceilings of care
- formulate arrangements for discharge
- communicate the above with the multidisciplinary team, patient, relatives and carers
- carry out active safety checking to mitigate avoidable harm.
As well as emergency patients, such interactions can have a positive impact on the on-going management of non-emergency patients, enabling their care to be progressed.
While we are exploring this through our Acute Surgery Group, it is applicable across a number of the Phase One areas. Once we have gathered a picture of current practice we will wish to consider whether guidance, a checklist or some advice for NHS Boards on this issue is required.