Invited Service Review Report Report on the Upper Gastrointestinal (GI) and Emergency Surgical Service Norfolk and Norwich University Hospitals NHS Foundation Trust

Reported and at times repeated cancellations and delays to laparoscopic cholecystectomy surgery for acute cholecystectomy cases needs to be addressed. The Trust should continue to prioritise an increased emergency surgical provision for patients presenting with acute gallstone related pathology. The review team would draw attention to national guidelines13 and commissioning guidance.14 This should include but is not limited to: (i) Improving the effective and efficient utilisation of the current hot gallbladder theatre lists by taking steps to minimise late starts and ensure theatre staff availability. (ii) Taking steps to change the current hot gallbladder theatre list arrangement of two half-days to one full day or to move at least one of the two afternoon lists to a morning. (iii) Continue with the recent changes (including appropriate plastics cases being diverted), which had reportedly reduced the demand on emergency theatre lists.

The issues which have affected, and, appear to continue to affect team working in the consultant upper GI service must be explored. Any which remain unresolved should be identified and addressed by the Trust in order to build a cohesive and mutually supportive team. These issues include but are not limited to: (i) The difficulties reported in interpersonal interactions identifiers redacted. (ii) Perceived limited opportunity for open and supported discussion of complications. (iii) Uncertainty in respect of mutual trust and support. (iv) Lack of strong leadership. (v) The distribution of types of sub-specialty procedures.

The current team based approach for patients admitted with acute biliary pathology, needs to ensure that changes in consultant surgeon responsibility of care does not negatively impact the quality and continuity of care. Improvements should include, but are not limited to: (i) The consultant surgeon who undertakes the surgery is able to be part of the clinical decision making regarding the planned surgical pathway and/or there is a system in place which supports the ability to review and challenge the planned surgical pathway. (ii) The systems in place for handover are robust, agreed, documented and adhered to.

Audit information seen by the review team in respect of complications of acute laparoscopic cholecystectomy cases, had been presented in 2018. There is a need for a more up to date audit (and regular audits going forward) to be undertaken as part of clinical governance and to be shared to support the discussion of complications as part of shared learning.

Regular morbidity and mortality (M& M) meetings must be scheduled and attendance monitored to ensure opportunity for discussion of complications amongst the consultant surgeon team as part of good clinical governance. There should be documented minutes and attendance records maintained.

Consideration should be given to integrating into the hot gallbladder service some of the operating time of the consultant general surgeon who is an experienced HPB surgeon and has significant experience in performing cholecystectomy. This should include the availability of specialist HPB support and oversight of the service and also discussion and collaboration in cases of complex disease.

Steps should be taken to improve two-way communications between Trust management and the upper GI surgery service. These should include but are not limited to: (i) Improving opportunities for staff to be involved in decisions about the service. (ii) Improving the communication and timeliness of appropriate information to staff. (iii) Improved utilisation of the emergency surgery meetings as a vehicle for the flow of two way communication.