BULLETIN

Page 27 | Bulletin 93 | September 2015
expectations and reduced morale are all
these unhealthy behaviours co-exist
presently compounding this situation.
Despite this, we often expect GPs to
assist in optimising our patients in
advance of major surgery. Anecdotal
feedback from primary care suggests
that there are often communication
difficulties between primary and
secondary care which hinder this
process. This has ineffect created a
non-integrated ‘silo’ mentality between
healthcare professionals, which is suboptimal
for patient care. It is important
to recognise, however, that this does
represent a generalisation, and that
there are examples of good integrated
practice across the UK.
At a minimum, improved
communication and abolition of the
silo mentality will be required before
we can begin to make significant steps
forward. The NHS Five year Forward
Plan 6 also sets out a vision of integrated
services delivered within the primary
care setting for enhanced and more
cost-effective patient care. This may
well represent the way forwards prior
to elective surgery; indeed it may be the
panacea.
The future – prehabilitation
and service integration
The preoperative period, and the
primary care environment specifically,
may represent a unique opportunity
to facilitate change improvement prior
to surgery. Reduced time-constraints
and more cost-effective patient
management represent two possible
benefits in this respect. However to
facilitate change in this setting it is
important to recognise where we can
feasibly make a difference to patient
management. It is unlikely that primary
care will eliminate the requirement
for specialist secondary care referral
in particularly high-risk patients,
however it is important to acknowledge
that this still represents a minority
group. Perhaps greater rewards can
be achieved through addressing areas
more amenable to change.
The preoperative period,
and the primary care
environment specifically,
may represent a unique
opportunity to facilitate
change improvement prior
to surgery.
So what can be done?
■■
Shared knowledge and education
– between primary and secondary
care staff represents an ideal starting
point. This could be achieved
by providing GPs, and other
primary healthcare professionals,
with enhanced knowledge of the
adverse perioperative impact of
unhealthy patient behaviours and
poorly recognised co-morbidities
e.g. anaemia, frailty, cognitive
impairment. Agreed local guidelines
for identification and management
of these conditions across
boundaries would go some way to
improving on the current situation,
without a significant financial
investment. Collaboration and closer
communication are also likely to be
improved as a direct result.
■■
Patient engagement and behaviour
change – this is one of the critical
steps in facilitating change. We
have moved some way towards this
through the ‘shared decision making’
model. However further engagement
is required.
The impact of unhealthy behaviours
leading up to surgery creates an
excellent example. Low fitness levels,
active smoking, alcohol-excess and
nutritional imbalance all predispose
patients to a significantly increased
risk of adverse perioperative outcome
in their own right. This risk increase
is not marginal, with reported
increased complication rates up to
five-fold for each individual unhealthy
behaviour. Importantly there is a
confounding factor here in as much
as evidence suggests that several of
■■
simultaneously within individual
patients. 7 This is a major concern
perioperatively and surely warrants
our serious attention. Indeed it is
likely that this situation creates
a far more significant impact on
adverse surgical outcomes than
stable cardiorespiratory disease per
se. Of course, it is well recognised
that unhealthy behaviours and
co-morbidities are inextricably linked.
There is light at the end of the tunnel:
it appears that surgery creates a
‘teachable moment’ for patients
to facilitate behaviour change that
they might not otherwise embark
upon. Importantly, there are also
an optimal number of unhealthy
behaviours that can be addressed
simultaneously when patients
may be most receptive, without
feeling overwhelmed. 7 The number
of behaviours appears to be two
to three, with this creating an
opportunity to address smoking,
alcohol excess and inactivity as a
minimum in the weeks available
prior to surgery. Although a major
challenge, the benefits accrued
by achieving change would be
substantial.
The final component to consider is
whether it is most appropriate to
adopt a ‘stick or carrot’ approach
with patients to yield maximal
benefits. There are arguments for
and against both strategies with
further research and psychology
collaboration required to investigate
this untapped area further.
Prehabilitation – this concept
has recently entered the medical
literature, and has been defined
as ‘the process of enhancing an
individuals functional capacity
before scheduled surgery, aimed at
improving the patients tolerance to
upcoming physiological stress’. 8
To date there remains limited
evidence as to the benefits of
preoperative exercise training
programmes in improving