Classification: Official

Publication reference: PR2096

This guide has been developed by NHS England in partnership with the Centre for Perioperative Care and the Royal College of Anaesthetists.

Foreword

The need to support patients to have the best possible health outcomes has never been greater. We have a collective responsibility to ensure that long-term conditions are identified and managed well, and patients supported to improve their health and fitness.

These aspirations are particularly important in perioperative pathways. Patients who are unfit or have co-morbidities that impact on their day-to-day living are at higher risk of complications and mortality from surgery. Complications increase length of hospital stay and health resource use in both primary and secondary care, and are associated with reduced long-term survival and quality of life. Though complications can often be avoided through health optimisation and high-quality perioperative care, clinicians commonly need to cancel patients in the days running up to planned surgery because they consider the risks of proceeding without optimisation are too high. This can be hard for the patient and disruptive for the system. Opportunities to optimise patients’ health and fitness must be taken as early as possible.

Local systems and providers will determine the best ways of achieving these core requirements. Implementation of digital pathways, and ensuring appropriate support for patients unable to access them, is in keeping with wider NHS policy. Appointing perioperative care co-ordinators can support the non-clinical aspects of delivering this modernised perioperative pathway, boosting the efficiency of existing preoperative assessment nurses and teams.

These changes to perioperative care have the potential to transform patient experience, patient outcomes and service efficiency. I hope this guide supports you in delivering the required changes to improve perioperative patient care.

Professor Ramani Moonesinghe OBE
National Clinical Director for Critical and Perioperative Care, NHS England

1. Introduction

The NHS delivery plan for tackling the COVID-19 backlog of elective care commits to strengthening perioperative care pathways starting at the point of referral or listing for surgery to support patients’ preparation.  This is vital for the recovery of elective care as up to one third of on-the-day cancellations are owing to clinical reasons, such as patients being unfit for the type of surgery or anaesthetic they were listed for.

In the first instance, providers are asked to screen all adult patients waiting for inpatient surgery and where necessary begin their optimisation as early as possible in the patient pathway.  Section 3.20 of the 2023/24 NHS Standard Contract sets out that providers “must, by no later than 31 March 2024, implement a system of early screening, risk assessment and health optimisation for all adult service users waiting for inpatient surgery, in accordance with the requirements on perioperative care co-ordination set out in the NHS Elective Recovery Plan”.

Providers should now determine which surgical pathways are their highest priority for implementing early screening and optimisation but, as a minimum, introduce the five core requirements (see section 2) for all inpatient pathways by April 2024.

In the first instance, providers are asked to implement these requirements for adult patients waiting for inpatient surgery. By April 2024 we expect them to be in place across all adult elective inpatient pathways. However, these principles can be of benefit to patients on all surgical pathways and providers are encouraged to consider how these can also be extended to outpatient surgical pathways.

This guide supports providers and integrated care boards to implement early screening, risk assessment and health optimisation for patients waiting for surgery. It builds on the clinical guideline Preoperative assessment and optimisation, published by a cross-specialty, multidisciplinary working group (including the Royal College of Anaesthetists, Royal College of Surgeons of England, Royal College of General Practitioners and the Centre for Perioperative Care) in June 2021.

Early screening, risk assessment and health optimisation aims to:

• improve short and long-term health outcomes and health-related quality of life
• reduce the proportion of on the day or short notice cancellations for avoidable clinical reasons
• reduce perioperative morbidity and mortality
• reduce length of stay, unplanned critical care admissions and hospital re-admissions
• support efforts to increase the proportion of patients who are identified as suitable for day case surgery, avoiding an inpatient stay.

Improving patient health outcomes

Patients with lower levels of fitness or whose long-term conditions are not well managed are at risk of major complications after surgery. These can increase average length of stay three-fold or more, and can affect both long-term survival and quality of life.

Patients from deprived areas have worse short and longer-term outcomes (including mortality) following surgery than those living in less deprived areas (Poulton et al, 2020; Wan et al, 2018).

Earlier screening and risk assessment, and opportunity and support for patients to optimise their health ahead of surgery where necessary, should improve postoperative outcomes across all patients and reduce health inequalities in these.

Reducing on the day or short notice cancellations

One-third of on the day surgery cancellations are for clinical reasons, such as the patient being unfit for surgery or anaesthesia they are listed for (Wong et al, 2018).

Short notice cancellations in the days leading up to the booked date for surgery also occur when a pre-assessment clinic finds that a patient is not ready for surgery. This often results in unallocated time on theatre lists as gaps can be difficult to fill at short notice.

Theatre down time can be significantly reduced by:

1. Ensuring that patients are not given a date to come in for surgery until they have had a preliminary perioperative risk assessment and been confirmed as being fit or ready for surgery from a health point of view.
2. Establishing a pool of fit/optimised patients who can accept short notice surgery dates when unavoidable cancellations open up a surgery slot.

These steps can improve patient experience as well as the efficiency of the pathway.

2. Five core requirements for providers

The five core requirements are:

1. Patients should be screened for perioperative risk factors as early as possible in their pathway. This could be at the point they contemplate surgery or take part in a shared decision-making conversation about whether to be added to a surgical waiting list. At the latest, a screening assessment should be undertaken as soon as possible after they have been added to a waiting list.
2. Patients identified through a screening assessment as having risk factors for poor perioperative or surgical outcomes should receive proactive, personalised support to optimise their health before surgery.
3. All patients waiting for inpatient procedures should be contacted by their provider at least every three months to check that they still want or require the procedure and that their health status has not changed. Any reported changes should be acted on appropriately. Contact can be automated (for example, text message) but there should be follow-up if a patient does not respond to reminders.
4. Patients waiting for inpatient procedures should only be given a date to come in for surgery after they have had a preliminary perioperative risk assessment and been confirmed as fit or ready for surgery. Where a patient is not yet fit for surgery, but surgery remains in their best interests, they should be supported to optimise their health. A senior clinical decision maker should determine whether they should remain on the admitted waiting list while being optimised, taking into consideration local waiting times for surgery, and the likely length of time required for optimisation. Further support on how to manage this practically is in section 3.1 of a guidance document on the FutureNHS collaboration platform (you will need to register for an account to access this platform)
5. Patients must be involved in shared decision-making conversations to discuss the benefits, risks, alternatives and likely outcomes of the surgery, as well as the postoperative recovery period. This allows patients to confirm their decision to proceed with the surgery, seek further specialist advice if required or make the informed choice to pursue alternative options.

Providers and integrated care boards will determine how they can best implement these core requirements within their organisations and systems.

Surgical, anaesthetic, perioperative care, booking and scheduling teams and patients should be involved in designing the pathway and its implementation in their organisation.

In meeting these requirements, providers should ensure they comply with relevant equality legislation and the Accessible Information Standard. At the earliest opportunity, each patient should be asked what is their preferred means of communication; this should be recorded.

3. Enablers of the core requirements

Information sharing across primary and secondary care

Transfer of patient information between care settings at the point of referral improves triage to the correct specialty and makes the most effective use of the patient’s first outpatient appointment.

However, limitations in the interoperability of IT systems hinders the transfer of key patient information from primary to secondary care at point of referral. Some integrated care boards and local systems are jointly developing solutions.

NHS England is developing a standard form and patient questionnaire to make it easier to gather the relevant baseline information at point of referral. Once current manual processes are standardised, these will be digitised and made available for use in pre-appointment and pre-assessment pathways. Until then, providers are encouraged to use pre-consultation and preoperative screening questionnaires to ensure clinical staff have the information they need to make informed decisions. Refer to Appendix B as an example.

Shared decision-making and decision support tools

Shared decision-making ensures that individuals are supported to make decisions that are right for them. It is a collaborative process in which a clinician supports a patient to reach a decision about their treatment, based on the risks and benefits of the different options, and the individual’s personal preferences, goals, values and beliefs.

The NHS England shared decision-making webpages give further information. The Personalised Care Institute has a 30-minute e-learning course on shared decision-making: Your learning options, and provides further information and resources, including a video of Peter’s journey: an example of shared decision making (British Sign Language and subtitled versions are available).

In perioperative care, shared decision-making is important from the point surgery is contemplated through to making a final decision about consenting to proceed.

Decision support tools, also called patient decision aids, support shared decision-making by making treatment, care and support options explicit. They help patients consider what matters most to them in relation to the possible outcomes of different options, including doing nothing. NHS England has developed decision support tools for several procedures and treatments, and will continue to add to these. Decision support tools should be integrated into the pre-operative pathway where available.

Patients should have access to support to enable them to make an informed decision and to make lifestyle changes that will enhance their fitness for surgery and post operative recovery – this may be through health and wellbeing coaches, care coordinators and access to self-management education.

The Centre for Perioperative Care has published a guideline on perioperative care of people living with frailty.  This emphasises the importance of shared decision making, including discussion of the benefits, risks and alternative to surgery, and pre-operative assessment and optimisation of frailty, cognitive disorders and multimorbidity.

Digitally enabled perioperative assessment

The NHS Digital health and care plan (July 2022) sets the expectation that all providers will offer digital pre-assessment by September to free up capacity in pre-assessment clinics.

In 2021/22 the targeted investment fund and adoption fund supported providers to procure digital solutions to improve outcomes across the perioperative care pathway and we are monitoring and evaluating their functionality.

NHS England is working with suppliers to broaden the availability of patient engagement portals to support delivery of digitally enabled perioperative pathways.

The perioperative digital playbook provides clinical teams and organisations with digital tools and case studies that support the delivery of perioperative pathways – from primary care to postoperative follow-up. It provides digital solutions for:

• shared decision-making and digital consent for treatment
• supporting patients prepare for surgery
• supporting the physical and mental health needs of patients before and after surgery
• preoperative assessment.

We recognise that new national platforms will need to be tailored to local circumstances and the workforce trained in their use, to ensure they enhance care, reduce duplication and are used safely. 

Digital health assistants will be essential team members to help patients use digital solutions and provide alternative options for those who need these (see section 4) to help mitigate any risks of inequalities in access to digital technologies.

Close working between preoperative assessment, clinical validation and booking and scheduling teams

Effective implementation of the core requirements will require close working and communication between a provider’s preoperative assessment, clinical validation and booking and scheduling teams. This will ensure that all teams have up-to-date information about the health status of each patient, that patients are not given a date to come in for surgery until they are fit and the list of patients who could be slotted in relatively last minute is current.

Timely communication with every patient at each stage in the process will ensure they know where they are in their perioperative journey and what the next step is. For example, University Hospitals Sussex NHS Foundation Trust uses a two-way text messaging service to interact with patients as they near their hospital attendance. This is reducing cancellations and gives patients an easy way to alert the hospital to any changes in their circumstances.

4. Perioperative care workforce

The perioperative care workforce encompasses everyone supporting patients on their journey from contemplation of surgery through to post surgery follow-up. This includes dietitians, pharmacists, physiotherapists, occupational therapists and social workers, as well as preoperative assessment nurses, anaesthetists and surgeons. The core preoperative assessment team with responsibility for ensuring patients are prepared for surgery will be made up of preoperative assessment nurses, anaesthetists and non-clinical staff.

Implementation of the core requirements is likely to require some changes to the way preoperative assessment teams work. New ways of working and digital tools, as set out in section 3, can support this.

The section on preoperative assessment in Guidelines for anaesthetic services outlines the roles of preoperative assessment nurses and expert clinicians.

In the new context of early screening, risk assessment and optimisation of patients preoperative assessment nurses will:

• ensure that all patients waiting for inpatient surgery have an early assessment of their fitness for surgery and are supported to optimise their health, if indicated (including through referral to specialist teams or pre-habilitation and self-management support services), before they are given a date for their surgery
• liaise with surgical and perioperative teams about the management of higher risk patients.

Expert clinicians will be responsible for:

• developing and/or approving health optimisation plans including targeted pre-habilitation and specialist referrals
• developing and/or approving tailored perioperative pathways including postoperative enhanced or critical care referral, for patients who cannot be managed on standard protocols because of their individual risk factors
• leading discussions with patients, surgeons and the wider multidisciplinary team about the benefits, risks and alternatives to surgery where perioperative risk is high
• reviewing progress of patients who are on optimisation pathways; working with patients, surgeons and the wider multidisciplinary team to determine the optimal timing of surgery in line with criteria for consultant anaesthetist review.

The introduction of the core requirements for early screening, risk assessment and optimisation means providers and preoperative assessment teams may need to consider how they can best optimise skills, expertise and capacity within these teams. They will need to consider the role that both clinical and non-clinical team members can play in perioperative care co-ordination.

Some providers may wish to explore introducing non-clinical perioperative care co-ordinator roles, to give preoperative assessment nurses more time to focus on their clinical responsibilities. The tasks they could undertake include (subject to local clinical assessment):

• digital health assistant type tasks: supporting patients to complete health forms and online preoperative screening and assessment questionnaires, as providing alternatives for those unable to use digital resources
• under the direction of a preoperative assessment nurse, arranging tests for patients where measurements are missing or out of date in their initial referral or their health form indicates that tests such as HbA1c assays in patients with diabetes and Hb measurements in patients with risk factors for anaemia are required
• completing a preliminary desk-based screening assessment of a patient’s perioperative risk factors, for review and validation by the preoperative assessment nurse. This would typically involve a summation of preoperative screening tools, such as the Duke Activity Status Index, and basic triaging of non-complex risk factors such as smoking status
• under the direction of a preoperative assessment nurse, following up test results and referrals for patients requiring health optimisation before surgery
• supporting preoperative assessment nurses to signpost patients to local social prescribing services, health and wellbeing coaching or self-management education programmes. (social prescribing services can in turn signpost patients to health and wellbeing support available in local voluntary and community organisations.)
• ensuring all patients listed for inpatient surgery are contacted at least every three months, and more frequently if required. Automated contact by text or email is likely to be the most efficient approach for most patients; however, those who do not respond as well as those who are not digitally connected will require telephone contact. The co-ordinator could undertake this using a call script or proforma
• liaison with clinical validation and booking and scheduling teams under the guidance of the preoperative assessment nurse.

Appendix C gives an example role outline for a perioperative care co-ordinator. Providers can adapt this to meet their local circumstances and requirements, and take it through local job evaluation processes to determine grading; it is likely to be either a band 3 or band 4 level role.

Appendix B gives recommended minimum training requirements for staff coming into this role. Providers will wish to assure themselves that the training equips perioperative care co-ordinators with the necessary competencies to fulfil the duties of the role.

We have commissioned the Centre for Perioperative Care to develop bespoke learning modules for staff in non-clinical perioperative care co-ordinator roles, and expect these to be available in 2023.

5. Further information and contact details

To sign up to NHS England’s Perioperative Care FutureNHS page where you can find further information and useful resources, or to contact a member of the NHS England Elective Recovery team, please email england.electiverecoverypmo@nhs.net.

Appendix A: Example information in primary care referrals

The exact information should be agreed locally between primary and secondary care colleagues.

Appendix B: Example patient letter and patient information form

The example patient letter and patient information form are available on our website.

Appendix C: Example role description and training requirements for a non-clinical perioperative care co-ordinator in the preoperative assessment team

This example role description has been created with the Centre for Perioperative Care and the Royal College of Anaesthetists.

Example role description (indicative to be tailored locally)

The perioperative care co-ordinator is a new non-clinical role within preoperative assessment teams.

Their key working relationships are with preoperative assessment nurses and senior clinicians (for example, consultants in anaesthesia or perioperative medicine).

They are expected to provide a complete package of assessment and communication for patients waiting for surgery.

Specific duties could include:

1. Contacting all patients newly listed for a surgical procedure to ask them to complete a patient health form, and where required supporting them to complete the form.
2. Collating information provided at point of referral from primary care and in the patient health form.
3. Using this information to initially triage patients and identify those likely to require targeted optimisation (for example, for a known co-morbidity) or specialised optimisation (for multi-morbidity and/or poor fitness, nutrition, etc). Information should be compiled in a template suitable for clinical review and final determination of patient category. This triaging will be supervised by registered healthcare professionals and no clinical decision-making will be made by non-clinical staff alone.
4. Contacting low-risk patients to inform them of the outcome of their triage assessment, and where appropriate and under the direction of senior clinical support, using approved materials to provide them with universal advice about preoperative preparation, including diet, exercise/activity and healthy living.
5. Under the guidance of the preoperative assessment nurse and/or senior clinician, arranging an appropriate follow-up appointment for higher-risk patients.
6. Ensuring that all patients and their GP/GP practice are sent a copy of a letter outlining surgical risk and next steps. Encouraging and reminding patients to take this to any GP and practice nurse appointments they have.
7. Where relevant, encouraging patients to find out if their GP practice has a social prescribing link worker and/or a health coach, and how they can refer themselves. Working with the local integrated care board or healthcare system to identify local community links that may benefit patients, for example, the Swimming.org website. 
8. Following up on behalf of clinicians to ensure that referrals to hospital medical specialties or to support in the community have been picked up and acted on by the receiving teams/services.
9. Acting as the main point of contact for the preoperative assessment team for patients.
10. Supporting delivery of an agreed process for contacting all patients on an inpatient waiting list at least once every three months, and more often if clinically indicated, to find out if there has been any change in their health status or decision to proceed with the surgery. Most providers can be expected to automate this process (for example, text message, email or letter) but that to follow-up non-responders will be supported by the perioperative care co-ordinator).
11. Following up by phone any patients who do not respond to the three-monthly (or more frequent where indicated) contact.
12. Notifying clinicians of any changes in a patient’s health status identified at the three-monthly (or more frequent) contact.
13. Liaising with booking and scheduling teams about planned surgery dates and to keep them informed and aware of when a patient is optimised for surgery.
14. Supporting monitoring, evaluation and quality improvement.

Recommended training requirements, by training provider

Perioperative care co-ordinator e-learning module

Five e-learning modules, each 30 minutes duration, free at point of use and covering:

• overview of the role
• what early perioperative care is, why it is important and how it fits into the patient pathway
• risk factors for surgery
• triage process they will be doing
• importance of regular patient follow-up
• role of evaluation and service monitoring
• ASA grading
• use and basic interpretation of common risk assessment tools, for example, Duke Activity Status Index, Surgical Outcome Risk Tool; Clinical Frailty Scale; basic exercise test, for example, six-minute walk test; incremental shuttle walk test

Training should be completed by: Within first month in post.

Personalised Care Institute 

E-learning modules, free at point of use, in:

• personalised care core skills (1 hour)
• shared decision-making (30 min)

personalised care and support planning (45 min).

Training should be completed by: Within first month in post.

Personalised Care Institute approved provider of core communication skills training

Two-day care co-ordinator training delivered either face to face or in virtual classrooms.

Details of Personalised Care Institute approved providers and their costs: Accredited training (personalisedcareinstitute.org.uk)

Training should be completed by: Within three months in post.

Employing provider

• Mandatory and statutory training
• Equality, diversity and inclusion training, including training in:
  • supporting and making reasonable adjustments for people with a learning disability and/or autism: The Oliver McGowan Mandatory Training on Learning Disability and Autism – elearning for healthcare
  • meeting the needs of people who are Deaf/deaf including approaches to communication
  • meeting the needs of other marginalised and excluded groups.

Training should be completed by: To be determined by the employing provider.