18 Weeks for Clinicians

Waits for a hospital appointment are now at their shortest since NHS records began. Median waits across the NHS in January were 8.6 weeks for admitted patients and 4.6 weeks for those not requiring admission to hospital.

Shorter waits mean less worry and stress for patients and their families, as well as the obvious benefit of earlier relief from pain or discomfort. New care pathways allow patients to track their progress and understand more about each stage of the journey from referral to tests, pre-assessment and final treatment.

Patients who receive quality treatment more quickly, and who know what is happening at each stage of their journey along the pathway, are likely to be happier and more relaxed.

In the Patient section on this website, we give an overview for patients on 18 weeks, and what it means for them, outlying our commitment, and theirs to achieving this.

We're dedicated to seeing and treating your patients as quickly as possible, from the moment they are referred to the conclusion of any post-operative care. 

We aim to treat all patients within the 18 week referral to treatment target set by the Department of Health.

With the introduction of 18 week targets, primary care and hospital trusts need to work together to ensure patients receive timely treatment.

Summaries forwarded with patient referrals are invaluable in assessing patients’ past medical history, current medication plus investigations carried out so far.

In that light, some emerging best practice is suggested below to be used at the time of referral. 

• Check - or ensure someone in the practice checks – the patients' address and daytime telephone number and include them on the referral letter
• Include relevant medical history with the referral letter – information about other medical conditions and BMI, BP and smoking status as a minimum
  
• Work towards a practice standard of sending the referral letter within 24 hours of the decision to refer (either by attaching to Choose and Book, or by post/fax)
  
• Access all available diagnostic tests and treatment within primary care to reduce unnecessary referrals, and where possible, patients should have all the necessary investigations carried out prior to referral.

Click here for further information on our Choose and Book systems

Explain to the patient how NHS waiting times have changed.  This is no longer about getting onto a long waiting list, but a moving process that will start immediately they are referred.  Make sure patients are ready for this, both practically and mentally.  Patients need to make their appointments promptly, ideally within seven days (using Choose and Book).

Encourage patients to consider whether they are personally willing and prepared for appointments, tests and treatment, including surgery where appropriate, over the next 18 weeks, typically with the first appointment within 3- 5 weeks. If they are undecided, give them the option to advise the practice when they are ready, and only then send the referral.

Explain to patients that if they do not attend for their appointments their referral may be returned to you, their GP, which will delay their treatment, as well as wasting NHS resources. 

Do not refer patients if you know they will not be suitable for surgery in an 18 week timeframe (unless you are referring for an opinion only).

The process of the patient pre-operative assessment has changed.  All patients added to the waiting list need to attend the pre-operative assessment unit.  Patients should allow up to half a day to see the surgeon and attend the POA Unit.

At the centralised POA Unit situated on Level A at the Royal Surrey County Hospital, patients will have a pre-operative assessment to ensure their suitability and fitness for surgery and be screened for MRSA.

All patients will have a physical assessment by a trained pre-operative assessment nurse with a selection of patients being required to return for a full anaesthetic review by an anaesthetist.

Cancer cases will be treated as a priority and every effort made to investigate and treat co-morbidities.

Patients having non cancer surgery occasionally have co-morbidities that may increase their perioperative risks. For known conditions that are already under review by a physician at the Royal Surrey County Hospital, we will arrange for appropriate reviews if required. When de novo co-morbidities are uncovered which need investigating we may need to discharge these patients back to the GP. We will indicate in this discharge letter how to get the patient back into the system.

To minimise the risks of surgery and anaesthesia, patients should be as fit as possible for their operation.

Please review any patient with a chronic disease to ensure it is stable and optimised as this will minimise the risks of perioperative complications.

Factors affecting operative risk:

Procedure specific:

• Major surgery such as vascular, major colorectal, major urological, complex joint revision and oesophagectomy

Patient specific:

• Active cardiac conditions such as previous myocardial infarction, unstable angina, severe arrhythmias, severe valvular disease and heart failure
• Previous stroke
• Renal failure
• Diabetes
• Obesity BMI>35
• Increasing age
• Physical fitness

Obesity

Obese patients are more at risk of peri-operative cardio-respiratory complications, wound infection, and thrombo-embolic disease. Ideally patients should aim to reduce their weight prior to referral. We do not have a cut off BMI for surgery but risks are increased in the morbidly obese BMI >35. Specialised bariatric equipment is required if patients are over 180kg, with theatre tables accommodating up to 250kg.

Patients with symptoms of obstructive sleep apnoea should be investigated and established on CPAP prior to referral to reduce their risk of peri-operative respiratory complications.

Smoking

Patients are up to 6 times more likely to develop respiratory complications following surgery if they smoke and also more likely to have problems with wound healing.

Giving up 8 weeks prior to surgery reduces this risk significantly. However giving up any closer to surgery is associated with a higher risk of chest infection.

Fitness

Patients who are physically fit have lower peri-operative risks, patients should be encouraged to improve their fitness prior to surgery.

Alcohol and recreational drug use 

Patients with a high alcohol intake of over 50 units per week should be investigated for signs of liver problems and should cut down their intake prior to surgery. Alcohol withdrawal symptoms in the post operative period are associated with poor outcome.

Other recreational drugs may interact with anaesthetics, causing unexpected reactions, and delay recovery. These agents may take up to a week to clear from the body.

Dental problems 

If patients have outstanding dental work, this should be carried out prior to surgery to reduce the chance of dental damage during intubation or risk of disseminating infection.

We collect information pertaining to all cancellations on the day of surgery. Common reasons include:

• The patient is unwell. If a patient presenting for elective surgery has a heavy cold, flu or diarrhoea the procedure should be postponed for 2-4 weeks after the patient has recovered, as the risks of respiratory complications are high for this period. This does not mean that the patient goes to the end of the waiting list. Patients should phone the admissions office as soon as they are sure they won’t be able to attend so that we can rebook the theatre space.
• The patient has unstable or undiagnosed hypertension.
• The patient has inadequately fasted.
• The operation is no longer required.
• The patient is unfit and was not adequately assessed preoperatively.
• The patient did not attend.