General Surgery

Improve coding of emergency general surgical activity. Actions: 1A: Surgeons to meet trust regularly with information team and coders to review activity attributed to them. 1B: Trust management to ensure emergency general surgery data is incorporated into the appraisal intelligence as per recommendation 14. 1C: GIRFT to create speciality-specific methodology focused on accuracy of coding, beyond the current validity methods, working with national bodies, such as NHS Digital, as appropriate. 1D: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Introduce national policy levers to drive case ascertainment (completeness) in national audit programmes to a level approaching 100%. Actions: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Improve routine data collection quality. Actions: 3A: Mandated national audits to report data completeness and field validity, reporting at a provider level the proportion and count of submissions that are both complete and valid. 3B: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Enhance national audit programmes by recording the number of patients with a relevant diagnosis, not just those who underwent a surgical procedure. Actions: 4A: GIRFT programme to develop a methodology to collect data on patients who have surgical illness but do not undergo an operation, including the reason why no operation occurred. 4B: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Design and progress implementation of an optimum care pathway for colorectal patients, and review national cancer targets in light of the resulting evidence. Actions: 5A: GIRFT clinical lead to work with the Association of Coloproctology of Great Britain and Ireland (ACPGBI) to design the optimum care pathway for patients presenting with suspected colorectal cancer, and other urgent colorectal cases. 5B: GIRFT to progress implementation of this pathway with providers. 5C: A review to be conducted on national cancer targets, in light of evidence emerging from 5B.

Instigate pricing transparency in procurement for general surgery and use the resulting insight to deliver more cost-effective procurement. Actions: 6A: GIRFT to work with the PPIB team to develop a specified list of surgical items and consumables that meet the correct standard at the most rational price point. 6B: GIRFT and PPIB to identify centres of good procurement performance, and providers to implement the best practice identified. 6C: NHS Improvement to enable pricing transparency for items on the specified list. 6D: Trust management to ensure this list is used to reduce costs.

Review options for consolidation of procurement at a national level. Actions: 7A: GIRFT to engage with relevant national programmes to develop solutions, within the scope of the programme's procurement work stream.

Identify centres of good procurement performance and understand what factors lead to the most favourable procurement prices. Actions: 8A: GIRFT and PPIB to identify centres of good procurement performance and work with them to generate an understanding of related factors, to inform national procurement consolidation as per recommendation 7.

Require reversible risk factors to be addressed prior to non-urgent procedures, using a patient-centred approach utilising shared decision-making. Actions: 9A: Guidance to be developed by GIRFT on the management of reversible risk factors prior to surgery, with the involvement of the Royal College of Surgeons of England (RCSE) and the Association of Surgeons of Great Britain and Ireland (ASGBI), working with the Royal College of Anaesthetists, and the GIRFT perioperative care project. 9B: Providers to adhere to new guidance. 9C: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Where not already described, define optimal care pathways in national guidance so they can be implemented locally with minimal, if any, variation. Optimal care pathways already defined in guidance should be implemented locally with minimal, if any, variation. Actions: 10A: Optimal care pathways to be defined by GIRFT, in new national guidance, to address the following issues: the use of radiotherapy for rectal cancer; the surgical approach for colorectal cancer; persistent abdominal stomata. 10B: Surgeons to implement the pathways referred to in 10A, and trust management to facilitate and monitor this. 10C: Surgeons to implement the British Association of Day Surgery guidelines on anti-reflux procedures. Trust management to facilitate and monitor delivery. 10D: Commissioners to ensure that access to bariatric surgery complies with the recommendations in the NICE guideline "Obesity: identification, assessment and management". This should be delivered by amending any contrary referral or prior approval policies and auditing results. 10E: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Adopt a "zero-tolerance" approach to known avoidable surgical complications, on which there should be reliable data and national guidance. Actions: 11A: GIRFT to establish an audit of incisional hernia in England. 11B: Trust management and surgeons to ensure all cases of surgical complications are discussed in morbidity and mortality meetings, with a view to reducing incidence towards 0%. 11C: Surgeons and trust management should consider adoption of the 'small bite' technique to minimise hernia risk. 11D: Surgeons and trust management to ensure mesh repair is used as routine for incisional hernia repair. 11E: Surgeons and trust management to ensure an infection prevention bundle is in place. 11F: GIRFT to ensure national guidance is developed on the surgical risks noted, and others as considered appropriate. 11G: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Strengthen the clinical morbidity and mortality meetings by expanding the current focus on deaths and major complications. Actions: 12A: GIRFT to collaborate with national bodies to agree plan for improved morbidity and mortality meetings. 12B: Surgeons to implement this plan. Trust management to facilitate this practice, and audit of it. 12C: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Improve understanding of the causes of litigation and take action to reduce common errors that lead to claims. Actions: 13A: GIRFT to produce guidance outlining the causes of litigation in general surgery and strategies to ensure claims are reduced. 13B: Providers and training programmes to use this guidance for practice and education purposes. 13C: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Make available and require at appraisal surgeon-level intelligence on activity and outcomes. Actions: 14A: Trust management to ensure all appraisals are informed with required intelligence input, including the alternative measures of surgical performance listed earlier. 14B: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Develop a means of identifying the best performing teams and enable others to visit them as part of CPD. Actions: 15A: GIRFT to develop methodology to identify high performing teams. 15B: Royal Colleges, Health Education England (HEE) and other CPD providers or certificating bodies to develop and roll out mechanism for formal CPD accreditation for peer visits. 15C: GIRFT to facilitate a programme of peer visits and buddying.

Conduct a national review, assessing the NHS model of clinical autonomy against international comparators, with a view to reducing unwarranted variation in clinical practice. Actions: 16A: GIRFT team to engage with all relevant national stakeholders to determine scope and organisation of the review. 16B: An appropriate national body to conduct the review and report recommendations. 16C: GIRFT team to develop implementation strategy, as appropriate.

Require data to be collected routinely about operation duration to establish a measurable benchmark for different types of procedures. Actions: 17A: Data indicating "operation duration" to be collected and included in the Model Hospital. 17B: GIRFT to commission research assessing "optimum" operation durations. 17C: Benchmarks resulting from 17B to be included in the Model Hospital. 17D: Surgeons and trust management to utilise this information to drive efficiency improvements.

Undertake a capacity planning study to enable theatre capacity to be principally organised around emergency care. Actions: 18A: GIRFT to undertake study and produce guidance based on resulting insight. 18B: Surgeons and trust management to implement this guidance. 18C: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Provide consultant-delivered emergency general surgery in each trust. Actions: 19A: GIRFT to provide national guidance on best practice in emergency general surgery, reflecting the need for consultant-delivered care, and drawing on existing evidence concerning increasing throughput. 19B: Providers to reshape the emergency general surgical service to ensure consultant-delivered care. 19C: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.

Require every trust to identify a consultant lead for emergency general surgery, with allocated time in their job plan. Actions: 20A: Providers to identify relevant emergency general surgery lead, with allocated time in their job plan. 20B: National policy levers to be developed by GIRFT in collaboration with national bodies, such as NHS England and NHS Improvement, as appropriate.