Written Ministerial Statement

The content of this written ministerial statement is as received at the time from the Minister. It has not been subject to the official reporting (Hansard) process.

Department Of Health - Publication of the Review of General Surgery

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Published at 12.00 noon on Thursday 30 June 2022.

Mr Swann (The Minister of Health): On 16 June 2022, I made a written statement to the Assembly setting out my commitment to tackling the long standing issues facing our health and social care service. Today I am taking another positive step on that journey by publishing the Review of General Surgery.

As with other areas of care, the current general surgery service is not meeting modern demands as a result of increasing surgical specialisation, new technology, capacity gaps within the current structure and increase in demand.

In practice:

  • the changes due to sub-specialisation means that what used to require one surgeon now requires many, delivering much improved patient outcomes– however, sustaining this breadth of surgery skills is difficult in multiple sites.
  • new technology, such as wide use of MRI scanners, means that more precise diagnostic prevents the need to carry out open surgery, again difficult to sustain in terms of equipment and personnel in multiple sites.
  • new technology, such as interventional radiology, means that patients who in the past required open surgery to treat the problem now can receive much less invasive treatment (which can be as extreme as getting a permanent stoma instead of a temporary drain), again difficult to sustain in terms of equipment and personnel in multiple sites

By not setting the highest standards this can lead to sub-optimal outcomes for our patients. Across Northern Ireland we have practices that have stopped in other parts of the UK, simply due to our lack of change. I do not find this acceptable and we must therefore change.

There is also significant variation in practice and in waiting times across the region and there are specific issues relating to the requirement to maintain 24/7 rotas for emergency general surgery across multiple sites and the difficulties this creates in terms of staffing and meeting professionally mandated standards of care. General surgery has one of the longest waiting lists across Northern Ireland – something that is unacceptable and that must change.

I am therefore today taking bold action to improve our general surgery provisions. The Review of General Surgery Report clearly states the need for change. Through ten actions, solutions for the future are identified, with the overriding aim to ensure the best care for our population at a time and place when they need it.

The first two actions create emergency and elective general surgery standards. The standards will ensure that people across Northern Ireland who require general surgery receive the care and treatment they need when they need it.

The emergency standards provide the expectations across six categories:

  1. Model of emergency surgical care – each site must have the required number of surgeons with the required training and expertise to ensure best outcomes at all times.
  2. Clinical infrastructure – each hospital providing emergency general surgery have full access to theatres and critical care.
  3. Clinical interdependencies – both diagnostic and interventional radiology must be available where emergency general surgery takes place and there must be access to other diagnostic services, age appropriate provisions and other specialities.
  4. Surgical workforce – the emergency general surgery team must be split from the elective team and that the teams must be sufficient in size.
  5. Process and protocols – this category notes that the right processes and protocols must be in place.
  6. Quality assurance – each Trust must be a member of National Emergency Laparotomy Audit and must audit practice against activity, return to theatre, length of stay, readmission rates and patient experience.

The elective standards provide expectations for the delivery of elective general surgery. For high complexity patients, the standards match those of the emergency standards – as the patient needs are similar. Across other aspects of elective general surgery, such as day procedures at Day Procedure Centres and high volume, intermediate complexity procedures at Elective Overnight Stay Centres, the standards are more flexible as the patient needs is varied but can be controlled.

Going forward, the emergency general surgery standards must be in place in hospitals receiving emergency general surgery patients to ensure safe outcomes through the delivery of high quality, sustainable and equitable care and the elective standards must be in place where there are elective general surgery patients. These evidence based standards have been developed and refined with input from general surgeons, other clinicians, HSC Trusts, managers and service users.

The standards must also be used to drive regional and local decisions on the future delivery of emergency general surgery in Northern Ireland. Some hospitals will be able to meet these standards with developments within their existing footprints and within existing budgets. However, some hospitals will not meet these standards as currently configured. This means a higher standard of care will be delivered by reconfiguration of service delivery and cross-organisational working. The result may be a change in provisions to ensure better patient outcomes.

The Bengoa Report and Delivering Together clearly state that the stark options facing our health and social care system is either resist change and see services deteriorate to the point of collapse or embrace transformation and work to create a modern, sustainable service with improved patient outcomes as a result.

We must accept that the current approach to delivering general surgery does not provide the best care for patients and is inefficient. Stretching staff resources to maintain emergency surgery on too many sites leads to an overreliance on locums, increased pressure on small teams, short term decision making and services vulnerable to collapse at short notice. We have seen an example of this in the Southern Trust where an emergency temporary service change was required to ensure the delivery of safe and sustainable of emergency general surgery services

To be clear, this Report is not about closing any of our hospitals. Instead, it is about ensuring that our patients receive the care and treatment they need, when they need it. I believe that we can build centres of expertise and excellence to ensure that our population have timely access to the best possible services. Given the huge and growing demand for health and social care, we will need every inch of our hospital estate in the future to deliver first class services to our population.

Implementation of the elective care standards will also build on the success of the day procedure centre model and will lead to the establishment of Elective Overnight Stay Centres which is in line with the wider elective care policy direction set out in the Elective Care Framework. In the initial phase – subject to Trust decision making processes and public engagement – we will consider the Mater Hospital as an initial site. We will also identify  #a further centre in the wider design plan intended to be published in the autumn.

As I have previously outlined, I intend to set out my plans for a new and better health and social care system in the autumn. This Report goes a long way in providing one of the building blocks in that work – by providing standards by which treatment must adhere to.

My Department will work closely with Trusts to implement the standards and to develop reconfiguration/implementation plans where required. This work will be fully co-produced and will include consultation and engagement as necessary.

The Report outlines a further eight actions to support the standards and to help deliver effective general surgery.

Elective paediatric general surgery activity has been significantly impacted by the pandemic with dramatic reductions in patient throughput and potential adverse outcomes for patients. These surgeries are often time sensitive in terms of the impact on the development and long term wellbeing of the child. The Review is clear that to ensure good patient outcomes, we need to increase elective paediatric general surgery activity.

At the end of May 2022, I welcomed the Western Health Trust announcement that it will be providing a full day of paediatric general surgery per month at South West Acute Hospital in Enniskillen. I am delighted that other Trusts have also begun to prioritise paediatric day procedure lists. These initiatives are part of a Northern Ireland wide approach to improve access to elective paediatric general surgery that has been driven forward by this Review. I have put structures in place to ensure that there will be continued regional collaboration to rebuild elective paediatric lists and to tackle our lengthy waiting times.

By publishing the Review I am also providing commitment for Post Anaesthetic Care Units (PACU) across Northern Ireland.

PACUs provide an intermediate level of care for patients after surgery. As well improving the quality of care and safety of high-risk surgical patients, the development of PACUs will also release critical care capacity. In addition, it will reduce last minute cancellation of inpatient surgery and will provide better outcomes for individual patients and for services as a whole.

I also want to recognise the difficult staffing position we are in. Our health and social care staff are tired after two relentless years of the pandemic. It has been difficult to deliver services in general and general surgery in particular. The delivery of general surgical services depends on the skills and combined efforts of a wide range of staff – the surgical care team. Every member of the surgical care team makes a vital contribution to the successful delivery of the service.

Going forward we need to strengthen this team by identifying and filling workforce gaps but also by exploring opportunities for the optimum skills mix required to deliver any new service model. This will ensure that the contribution of the surgical care team is maximised to improve outcomes, efficiency and safety for patients.

The publication of this Review is an important first phase in the improvement of general surgery in Northern Ireland and will help as a building block for the wider transformation of our health and social care system.

The Review has made the case for change and developed a set of actions that will drive safety and sustainability and lead to better outcomes for our patients.

We must now move ahead with the next phase of this journey – implementation of the actions in the report.

I am therefore creating a Regional General Surgery Network that will drive forward the multifaceted transformation programme for general surgery at a regional level, incorporating best practice from other parts of the UK.

We cannot stand still. We owe it to our patients and staff to deliver the best possible health and social care.

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