Cardiothoracic Surgery

Make electronic referral management tools and related processes available in all cranial neurosurgery providers and referring trusts. 1A: Trusts to implement referral management tools and appropriate technologies for information sharing where not already in place.

Accelerate the referral to treatment time for ALL patients identified as in need of cranial neurosurgery, whether identified via a screening programme or any other route. 2A: Trusts to develop cranial neurosurgery outpatient facilities, considering the possible tariff-related impacts when doing so, and where possible based on nursing staff or AHP availability. 2B: NHSI Clinical Productivity workstream to consider workforce implications, and any appropriate response. 2C: GIRFT Hubs to collect case studies for inclusion in a Good Practice Manual, illustrating how new outpatients' facilities have been implemented.

Improve outpatient efficiency through greater use of non-consultant and non face-to-face outpatient appointments. 3A: Trusts to increase use of telephone-based outpatient appointments, and explore better use of other technology to enable non face-to-face appointments. 3B: GIRFT Hubs to collect case studies for inclusion in a Good Practice Manual, particularly focusing on use of technology.

Increase day of surgery admission rates. 4A: Trusts to review day of surgery admission rates against benchmarks of 55.4%, 80.2% and 90%, and seek to achieve the highest feasible rate by addressing any unnecessary expectations of early admission, conducting pre-operative checks in outpatients and use of electronic referral. 4B: NHS Specialised Commissioning to consider use of contractual levers to incentivise day of surgery admission rates, seeking GIRFT input as needed.

Increase the proportion of procedures undertaken in the day-case setting, and increase the rate of short-stay admissions. 5A: Trusts to implement an enhanced recovery programme for cranial neurosurgery procedures, as far as practicable. 5B: GIRFT Hubs to collect case studies for inclusion in a Good Practice Manual, such as University Hospital Southampton's glioma pathway and the Leeds Teaching Hospitals pathway for pituitary surgery.

Reduce the proportion of primary malignant brain cancer patients that are admitted via the emergency/non-elective stream. 6A: Unless contraindicated, trusts to provide an urgent care pathway for malignant brain cancer, consisting of elective admission, preferably on the day of surgery, within a week of referral. 6B: GIRFT to produce guidance on how to replicate the University Hospital Southampton model, also referred to in recommendation 5.

Implement the NCEPOD recommendation relating to access to acute theatres, through designating one or more of their existing elective neurosurgical theatres as an acute theatre with a robust plan for speciality specific staffing. 7A: GIRFT to produce an operational model for inclusion in a Good Practice Manual, detailing how to implement a designated theatre and what changes to staffing and planning may be required. 7B: GIRFT Hubs to identify a suitable low-volume site to pilot the model and provide relevant support. GIRFT to refine the model as necessary based on pilot programme. 7C: All providers to roll out the refined model.

Improve patient flow between critical care and wards. 8A: GIRFT to develop a model pathway for critical care to improve bed usage and patient flow. 8B: GIRFT Hubs to support providers to adopt this pathway and take other steps to improve patient flow.

Improve time to procedure to the 48-hour standard for emergency subarachnoid haemorrhage as per NCEPOD recommendations. 9A: GIRFT and the Society of British Neurological Surgeons (SBNS) to work together to improve the quality of data relating to time to procedure for emergency subarachnoid haemorrhage. 9B: Drawing on the data gathered, GIRFT and SBNS to work together to define appropriate pathways that will enable all such procedures to take place within 48 hours.

Assess the evidence base on low-volume operating across surgical specialties, and consider policy development from resulting insight. 10A. GIRFT to commission research and discuss outcomes with relevant stakeholders.

Provide treatment for extremely rare conditions, such as rare tumours (for example, chordoma) within a small number of high-volume centres. 11A. NHSE Specialised Commissioning to consider commissioning certain low volume procedures defined by the Specialty Society (SBNS) as a Highly Specialised Service through a more limited number of centres.

Address delayed inter-hospital transfers and discharge by increasing the rate of discharge to home for non-elective cranial neurosurgery procedures, ensuring a timely transfer to rehabilitation centres for major procedures, and timely repatriation to referring hospitals. 12A: Trusts to implement seven-day ward rounds and increase engagement with physiotherapy, to enable faster discharge, including weekend discharge. 12B: GIRFT Hubs to support providers to agree and implement local repatriation arrangements that reflect the capacity commissioned, working collaboratively across local systems as necessary. GIRFT national team to ensure collaboration with the Urgent and Emergency Care programme on stranded and super-stranded patients. 12C: GIRFT to collect and share examples of effective local protocols and working arrangements, such as Healthcare for London's Standards for Inter-Hospital Transfers. 12D: GIRFT to consider a snapshot audit of specialty level delayed transfers to help quantify the scale of the issue. This could include acute to acute transfers, discharge practices and rehabilitation bed supply, and any alternatives. 12E: GIRFT to consider development of a rehabilitation and discharge support package, tailored to specialties as appropriate.

Improve data collection in cranial neurosurgery, with particular reference to increasing accuracy of coding, and improving audit data quality to enable its use for quality improvement. 13A: GIRFT to work with existing cranial neurosurgery audits to explore scope to improve audit collection. 13B: Surgeons to meet with trust information teams to implement changes to coding practice which would provide improved clinical accuracy as defined by NVR and GIRFT. 13C: Trusts to agree any proposed changes internally then, for any change impacting on NHS Standard Contract service conditions on the counting and coding of activity, propose change to commissioners. Any adjustments to prices to be agreed if necessary. 13D: If and once agreed with commissioners, trusts to implement any change. 13E: Surgeons to meet trust information team and coders and review activity attributed to them once a month. 13F: Trust management to facilitate time for surgeon and coder engagement, using job planning if needed. 13G: GIRFT and SBNS to develop guidance on coding, consistent with existing coding guidance, to support improved collaboration between coders and surgeons, following engagement with NHS Digital.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and the spreading of best practice. 14A: GIRFT to work closely with sources of procurement data such as PPIB and relevant clinical data to identify optimum value for money procurement choices, considering both outcomes and cost/price. 14B: GIRFT to identify opportunities for improved value for money, including the development of benchmarks and specifications, and locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. 14C: Trusts and STPs to work with GIRFT and the new Category Towers, to benchmark their products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs. 14D: GIRFT to work closely with NHS England's HCTED programme so that better value can be obtained for HCTED devices.

Reduce litigation costs by applying the GIRFT Programme's five-point plan. 15A: Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts will have received an updated version of this for cranial neurosurgery in the GIRFT 'Litigation in surgical specialties data pack', December 2017. 15B: Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk 15C: Once claims have been verified, clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trust's panel firm should be able to provide support. 15D: Claims should be triangulated with learning themes from complaints, inquests and serious untoward incidents (SUI) and where a claim has not already been reviewed as a SUI, this should be carried out to ensure no opportunity for learning is missed. 15E: Where trusts are outside the top quartile of trusts for litigation costs per activity, GIRFT to ask national clinical leads and Regional Hub directors to follow up and support trusts in the steps taken to learn from claims and share examples of good practice where it would be of benefit.