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Wednesday 28 September 2016
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Making the cut: reaching quality standards for minor surgery in primary care

Patients & Services

DAWN STOTT

Managing Director
Association for Perioperative Practitioners

Dawn has worked in healthcare for more than 15 years. Currently, she runs the Association for Perioperative Practitioners, a membership organisation and charity promoting safer surgery. Previously she worked for a private hospital group and managed successful projects, including new hospital builds and IT implementations. When made redundant she called upon these skills to work freelance with a surgery in Harehills, commissioning their new build. This gave her the desire to move into primary care. Dawn recently completed volunteer training with the Prince's Trust, mentoring young people embarking on new business ventures

In an ever-changing healthcare environment, it is important that standards are set to meet changing needs. Innovation in healthcare commissioning means that an increasing diversity of providers will tender to deliver minor and intermediate surgical services.

The new registration system being introduced in 2010 to improve health and adult social care across the population will require all GP practices to register with the Care Quality Commission (CQC) in line with a set of regulations issued by the Department of Health in 2009.

The national minimum standards for adult social care and independent healthcare and Standards for Better Health for the NHS are being replaced by new regulations: essential standards of quality and safety across the care sector. The new regulations are enshrined in law in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2009, which came into force in April 2009.(1)

Registration isn't just about initial registration; providers will be monitored to assess whether they continue to comply with regulations. A new wider range of enforcement powers will be used to make sure that swift action is taken where providers are not compliant. New ways of carrying out continual monitoring and checking is currently in consultation with the CQC and their internal and external stakeholders.

The new registration system will improve health and adult social care as follows:

  • Service users can expect all registered health and adult social care providers to meet essential standards of quality and safety and to respect their dignity and rights.
  • The same set of standards will apply right across the care sector, making it easier for one provider to be compared to another and for providers to work together.
  • It marks a change from regulation principally based on policies to regulation primarily based on outcomes, such as what constitutes a quality experience for people who use services.
  • Continual monitoring and checking will make sure that potential problems are identified early and that swift action is taken where services are failing people.
  • Better use will be made of information about providers. The following will continue to take place:
    • Inspections will be carried out and these will be more frequent where providers have less data.
    • Concerns will be followed up as and when they arise.

Implementation of government targets requires an ever-increasing need to assess and improve the efficiency of care and ensure that patients are treated safely by dedicated healthcare professionals motivated to deliver the highest standard of care to everyone.

Human factors training can assist practitioners: to understand why they make errors and the systems that threaten patient safety; to improve the culture of teams and organisations; to enhance teamwork and communication; to deal with stressful situations and to heighten their awareness of their environment and surroundings.

The NHS operating framework 2010/11 confirms that focus remains on stability and improvement in terms of frontline services:

"We must continue to:

  • Deliver safe, high-quality service with rapid improvement where there are unacceptable levels of variation. Deliver on those priorities that matter most, both nationally and locally.
  • Provide cost-effective services to keep people well, alongside delivering appropriate care at the earliest opportunity when it is needed."(2)

Surgery in the community
With all this in mind, more and more GP practices across the country now provide minor-surgery facilities as part of their surgery environment. Surgery in the community is cost-effective, as the overheads are low. If the service is maximised and the skills optimised, then it should deliver value for money.

However, procedures that need the infrastructure and skills of a hospital should be carried out in a secondary care environment. Primary care surgery is appropriate if the patient is receiving the right care from the right person in the right environment. The quality of patient care should not be compromised in any way by offering this service in the primary care setting.

The purpose of surgery in the community should be to maximise the number of patients appropriately managed in a community setting and in turn contribute to the 18-week Referral to Treatment (RTT) pathway. The overall aim should be to reduce the time it takes for patients to move from a GP referral to treatment for an identified minor-surgery procedure.

Practice-based commissioning (PBC) has allowed GPs or PBC consortiums to design, or redesign, patient pathways, enabling them to expand the scope of primary care.(3) For a decade now, government policy has supported the concept of PBC by providing GP practices with an indicative budget to support development and commissioning of services.

The commissioning of a comprehensive minor-surgery service in the community by primary care trusts (PCTs) has provided many PBC consortia with the opportunity to deliver services from premises that are easily accessible by private and public transport networks. It allows providers to offer flexibility in appointment times in order to deliver and meet the access needs of local communities.

When tendering for this scope of work, the aim of any PBC group should be to provide a high quality, community-based minor surgery service that will:

  • Improve patient access to minor-surgery services by developing primary care services.
  • Ensure patients are seen and treated in an environment most appropriate to their needs.
  • Maximise on value for money.
  • Deliver on waiting-time initiatives (18-week RTT).
  • Deliver appointments through the Choose and Book system.

It is important for any local surgery or community hospital to have very strong policies and procedures in place in order to manage the patient throughput.

Through contractual agreement and service level agreements (SLAs) with the PCT, a clear understanding of what is in or out of scope should be established, ie, which type of procedures will be delivered within the primary care setting. They will agree the tariff and budget, and cover issues such as audit, waiting times and clinical governance.

Sound criteria for patient management, ie, exclusion criteria etc, should be established at commencement to ensure that only patients meeting the laid-down criteria are treated.

All patient information should be produced in a range of formats and languages to suit the local patient population. This should include information on booking and scheduling appointments.
It is important to have a strong complaints procedure that meets the requirements of the local PCT and CQC.

A schedule of regular audits should be planned to monitor and improve services. The audit procedure should monitor untoward incidents and manage adverse incident reporting. The provider should deliver the services in accordance with Good Clinical Practice and the Department of Health's Good Practice Guide,(4,5) and should comply with the standards and recommendations contained in Standards for Better Health.(6) Robust clinical arrangements should be demonstrated should emergency situations occur.

In order to scrutinise performance, quarterly reports should be implemented to monitor complaints, numbers of patients treated, trends, performance against national standards, etc.

Management of the minor-surgery area
The British Medical Association's (BMA) guidance for minor surgery in general practice states the importance of consistent standards being applied throughout the UK.(7) For example, experience and training should be sufficient for accreditation by the health association or health board; consistent standards should be met in respect of facilities, premises and equipment. Reaccreditation should be required after a period of no more than five years.

Like most areas of business, the management of a minor-surgery suite relies on a number of fundamentals: good communication skills; sound administrative procedures; competent staff and appropriate surroundings and equipment.

A competent supervisor should be designated to run the minor-surgery area of the practice, with responsibility for organising the systems of work within the area. Their responsibilities would include ensuring adequate staffing with the competencies required to carry out the planned procedures.

Forward planning and scheduling will ensure the facility is used to maximum effectiveness. The Clinical Governance framework is an excellent benchmark for setting standards in the minor-surgery area, particularly around agreeing best practice, monitoring outcomes and reviewing procedures.(8)

Clinical human factors
Human factors are all the things that make us different from machines – the way we interact with other people and equipment in our work environment. They are the human elements of how we perform in our roles and how we can optimise that performance to improve safety and efficiency. They are essentially the elements that affect our personal performance.

Promotion of the human factor in maintaining patient safety is often forgotten among continual professional development requirements, benchmarking, audits etc that make up the clinical arena. However, increasing awareness within clinical practice of human factors can often lead to a reduction in clinical error.

Many untoward incidents in a clinical environment arise because of human behaviours such as a breakdown in communication or a lack of knowledge of who is in charge. Raising awareness about how teams work together and the human factors involved in making that team function effectively can assist with increasing patient safety.

It is difficult to provide a full understanding of the role human factors play in development, management and prevention of critical incidents and near misses in healthcare. However, briefing and debriefing to engender an environment of learning within a workplace can bring about cultural change within a group and in turn improve patient safety.

Conclusion
A universal approach to healthcare does not necessarily mean uniform – what is right in one area may not meet the needs of a different community. Local needs require local solutions. A locally led, clinically driven approach to the right care for patients can help prevent ill health, improve access and ensure that care is effective and safe.

With the increasingly high expectations of our patient population and the changing demographics of our society, whatever services you choose to provide within the primary healthcare setting need to be effective, meet the clinical needs of your catchment area and, most importantly, be safe.

References
1. Office of Public Sector Information. Health and Social Care Act 2008 (Regulated Activities) Regulations 2009. Available from: http://www.opsi.gov.uk./si/si2009/uksi_20090660_en_1
2. Department of Health. The NHS operating framework for England for 2010/11. London: DH; 2009. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
3. Department of Health. World class commissioning: competencies. London: DH; 2007. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
4. Medicines and Healthcare products Regulatory Agency. Good Clinical Practice. Available from: http://www.mhra.gov.uk/Howweregulate/Medicines/Inspectionandstandards/Go...
5. Department of Health. Good Practice Guide. Available from: http://www.dh.gov.uk/en/Healthcare/Longtermconditions/Bestpractice/index...
6. Department of Health. Standards for Better Health. London: DH; 2004. Available from: http://www.dh.gov.uk/en/PublicationsandStatistics/Publications/Publicati...
7. British Medical Association. Minor surgery – specification for a directed enhanced service. Available from: http://www.bma.org.uk/employmentandcontracts/independent_contractors/enh...
8. Department of Health. The Essence of Care: patient-focused benchmarking for health care practitioners. London: DH; 2001. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...

Resources

Association for Perioperative Practice. Standards and Recommendations for Surgery in Primary Care. Harrogate: AfPP; 2008.

Clinical Human Factors Group
www.chfg.org