Select Committee on Health Written Evidence

Evidence submitted by the Improving Surgical Outcomes Group (ISOG) (NICE 75)


  1.1  The ISOG is an independent medical group comprising surgeons, anaesthetists, critical care consultants and others involved in operative management and care. The group is concerned with improving patient outcomes and modernising care for patients undergoing major surgery. [86]


  2.1  Overwhelming scientific evidence shows that haemodynamic optimisation (maximising the flow of blood from the heart) of patients undergoing moderate and major risk surgery reduces the number and severity of post-operative complications. As a consequence, as patients feel better and need less post-operative care, they can be discharged sooner.

  2.2  The clinical benefit therefore translates into economic benefit as the cost of the patient's hospital stay is reduced. In 2004 it was shown that the benefits shown in the clinical studies, of better patient outcomes at less cost, could be delivered in the NHS at Trust level.

  2.3  In February 2005, NICE decided that they did not believe that this procedure falls within its remit and stated that this was because oesophageal Doppler monitoring is considered standard clinical practice with risks and benefits that are sufficiently well-known.

  2.4  Despite the fact that NICE decided that oesophageal Doppler monitoring was considered to be "standard clinical practice" the reality is that two years later, up to 90% of all NHS patients are still being denied the monitoring system.

  2.5  Despite the fact that NICE made this decision two years ago, there has been no widespread implementation of haemodynamic optimisation in the NHS and as a consequence, ISOG has had to produce an implementation document to drive this treatment forward. The reasons why the NHS has been slow to implement the treatment is multi-factoral but the main reason has clearly been lack of funding.

  2.6  This submission will examine only the term of reference concerning the consequences of the NICE decision that oesophageal Doppler monitoring constitutes "standard clinical practice".


  3.1  ISOG welcomes the confirmation by NICE that improving patients' post-operative prospects with haemodynamic monitoring during surgery should indeed be standard practice for patients undergoing surgery but we bitterly regret that this just isn't being implemented in many UK hospitals at the moment. NICE may think this is a standard practice but the figures show that this is in actual fact far from the case.

  3.2  Over 90% of patients undergoing surgery are not benefiting from a technology that is totally in line with Department of Health policy to implement the modernisation of care and improve surgical outcomes for patients. The NHS Confederation has also been urging Trusts to make the new NHS a reality by using new practices and technologies that can save lives, time and money.

  3.3  Oesophageal Doppler monitoring involves the measurement of blood flow velocity in the descending thoracic aorta using a flexible ultrasound probe.

  3.4  The economic benefits of the introduction and use of haemodynamic optimisation are enormous and arise because the technique not only saves lives but also saves money. Government initiatives like "spend to save" however, need to be more proactive to allow the faster introduction of procedures, approved by NICE, that are proven to benefit patients and save money for the NHS.

  3.5  The clinical studies suggest typical reductions in length of stay for haemodynamically optimised moderate and major risk surgical patients of around four days and audits of the real world impact have reported reductions of up to three days per patient. Even if these reductions were only in the lowest cost wards in UK hospitals at around £200 per day, this saving still equates to £600 to £800 per patient. It costs £50 to £60 to optimise each patient.

  3.6  Based on the body of clinical evidence which has accumulated, mostly from UK hospitals, over the last 10 years, there are about 1,000,000 NHS patients a year who would derive a clear clinical benefit from haemodynamic optimisation. If lengths of hospital stay for these patients were only reduced by two days each, the UK NHS would free up nearly 5,500 beds—the equivalent of 11 hospitals of 500 beds each. The saving would be, at the lowest estimate, £350 million a year rising to over £1 billion. This would represent a magnitude of cost-saving that could allow huge reductions in the deficit of an average NHS Trust

  3.7  The resources freed up by haemodynamic optimisation would be redeployed to enable the other two step ISOG recommendations at minimal additional cost.

  3.8  The benefits of haemodynamic optimisation are now well accepted by the majority of UK anaesthetists and those involved in intensive care. However, we estimate that no more than 40,000 NHS patients were monitored with appropriate equipment to allow doctors to haemodynamically optimise them in 2004.

  3.9  At the rates of technology adoption typical in the NHS it will be many years until the remaining 960,000 patients receive the treatment evidence based medicine and basic economic sense demand they receive today. As a result, thousands of patients will continue to die unnecessarily each year, many more will carry on suffering the pain and misery of avoidable post-surgical complications and NHS hospitals will continue to spend hundreds of millions of pounds treating compromised patients who need not have been so ill in the first place.

  3.10  Examples demonstrating better use of surgical/anaesthetic resources include improving surgical outcomes by intra-operative haemodynamic optimisation and other techniques.

  3.11  These interventions reduce both the number and severity of post-operative complications.

  3.12  A study conducted at York District Hospital on the use of improved intraoperative care involving haemodynamic optimisation and other interventions, combined with the planned transfer of patients to ICU, resulted in a reduction of the mortality rate to 3% compared with 18% in the control group.

  3.13  The study also demonstrated a reduction in the patients' length of hospital stay—in terms of total bed days as well as ICU bed days—without increasing costs.

  3.14  A Department of Health funded study at Worthing Hospital assessing "goal directed" fluid administration during bowel surgery (using oesophageal Doppler probes) showed a significant reduction in post-operative morbidity, faster return of gut motility and shorter length of stay.

  3.15  Recent work from St Georges Hospital using goal directed fluid therapy in high risk surgical patients in intensive care after surgery reduced post-operative infections by 50% and cut length of stay by almost 40%.

  3.16  Improvements in pre-operative assessment and preparation, peri-operative care and post-operative support have provided an important reduction in the mortality rate as well as decreasing the number and severity of complications suffered by patients following surgery, which has in turn provided savings in terms of ICU/HDU bed days per patient.

  3.17  In addition to reducing the mortality rate, the study conducted at York demonstrated that haemodynamic optimisation reduced the number of ICU or HDU bed days used by 40% compared with routine care (median 3.3 days vs 5.5 days), and total bed days per patient were reduced by 41% (median 13 days vs 22 days).

  3.18  The capital and running costs for providing improved pre-operative, peri-operative and post-operative support are marginal in comparison with the potential savings.

  3.19  Pre-operative surgical risk assessment of patients undergoing major surgery can be measured by use of Cardio-pulmonary exercise testing (CPX), which is cheaper and more effective at predicting individualised pre-operative risk than many of the tests that are currently conducted to assess surgical risk (such as resting echocardiography) which are poor at predicting actual risk.

  3.20  Consistent implementation across the NHS of existing treatments known to be effective at preventing post-operative complications (such as measures to prevent the formation of deep vein thrombosis) would also reduce unnecessary post-operative morbidity. Evidence on this particular issue has recently been given to the Health Select Committee.

  3.21  For haemodynamic optimisation, the potential savings in terms of reduced hospital stays have been estimated for an average NHS trust to be in the order of over £2 million, based on reduction in stays of 22-31% and taking into account capital outlay of £60,000 and running costs of £150,000.

  3.22  Overall, the package of improvements described would be cost effective. In addition, the introduction and use of haemodynamic optimisation into the NHS could realise savings for the NHS in the region of £1 billion which would have an enormous impact on the current and potential deficits in the NHS.

  3.23.  Due to the delay in implementing haemodynamic optimisation within the NHS, ISOG had now produced a second document intended to assist Trusts with its introduction. Lack of funding is clearly a major issue for some Trusts and this is severely hampering a technology that will substantially help patients and ultimately save Trusts money.

  3.24  NICE has an important role to play in the introduction of such technologies and it is regrettable that despite a positive outcome from NICE, no real advance has been made in the last two years to introduce this technology into the NHS, despite enormous support from the medical profession. Simple, straightforward steps can be taken to allow this to happen which will benefit patients, Trusts and the NHS.

  3.25  The ISOG would be prepared to offer oral evidence if requested to do so by the Committee.


  4.1  Government initiatives like "spend to save" need to be more proactive to allow the faster introduction of procedures that are proven to save money for the NHS.

  4.2  A better system of disseminating information to Trusts is essential to make sure that all stakeholders are aware of NICE Guidance.

  4.3  A streamlined system is needed to help facilitate the introduction of NICE appraised devices into the NHS.

  4.4  The Government should consider mechanisms whereby the Interventional Procedures arm of NICE can attract compulsory funding in the same way as drugs positively appraised under NICE's Technology Appraisals arm.

Improving Social Outcomes Group

March 2007

86   The members of the group responsible for this submission are as follows: Professor Monty Mythen; Portex Professor of Anaesthesia and Critical Care, University College London; Head of The Portex Anaesthesia, Intensive Care and Respiratory Unit, Institute of Child Health, UCL; and Council Member of the Intensive Care Society of Great Britain & Ireland; Professor David Bennett; Professor of Intensive Care Medicine, St George's Hospital, London; Mr Eddie Chaloner; Consultant Vascular Surgeon: University Hospital, Lewisham. Back

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