Surgical practice has come a long way, barely recognisable from the risky “art” form it once was. With the scientific advancement of anaesthesia, infection control, surgical equipment and surgeon skill, surgery is now an integral part of health care and treatment provision. The focus now is on improving surgical precision and minimising the adverse impact of surgery on patients.
Minimal access surgery (MAS – also known as minimally invasive, laparoscopic or keyhole surgery) has been around for thirty years or more. When used appropriately, it can dramatically improve patient recovery, whilst achieving the same surgical outcomes as open surgery. This results in an improved patient experience and quality of life, and shorter inpatient stays: good news for patients and for our financially and physically constrained NHS.
Despite this, there is variable adoption of MAS across NHS Trusts, and the utilisation of minimal access techniques is low for many procedures. Given the continuing evolution of surgical techniques, including the forthcoming robotic era, it is important to understand how surgical technologies are adopted in the health care system in the UK and what challenges are faced when making implementation decisions.
A review of the literature demonstrates the growing evidence base supporting the clinical and cost-effectiveness of MAS for three specific procedures: hysterectomy, ventral/incisional hernia repair, and lower anterior resection. However, despite the benefits, uptake of MAS is highly variable.
To better understand why, we interviewed 12 key stakeholders and decision-makers – surgeons working in the NHS and private sector, clinical directors, and finance directors – to identify the potential barriers affecting the uptake of MAS and offer solutions.
Surgeon preferences play a key role in choice of surgical routine, and are a product of experience, interpretation of the evidence-base, and core medical training – with those professionals more recently trained being more familiar with and open to MAS. The importance of a “clinical champion” is apparent, and in settings where such an individual is lacking, the necessary enthusiasm to drive change and secure investment in innovation may pose a barrier to MAS. In some settings a cultural change is required; better equipping patients with information could provide a catalyst to increase the uptake of MAS.
A lack of suitably trained clinical staff was identified as a key barrier. Whilst there are plenty of training opportunities for surgeons in the UK, a lack of funding and time to access them appear to be the main issue. Investment in training and incentives to take-up the opportunities should be encouraged, and the importance of ‘on-the-job’ training should be recognised.
Constrained NHS capacity should be seen as a motivator for MAS; the slightly longer operating time (a matter of minutes or hours) is more than offset by a shorter in-patient hospital stay (a matter of days). Whilst the trade-off is generally well understood, improved financial and systems oversight is required, and a reduction in “silo-thinking” which prevails where short-term budgetary constraints are allowed to drive decision-making.
Technological innovation can support an expansion of the application of MAS, either to new procedures or by making MAS amenable to more surgeons. Robotic-assisted MAS represents the biggest technological innovation of today, but the high costs associated with its delivery are currently prohibitive in most settings.
There is a growing awareness of the need to promote innovation which can realise improvements in patient care and outcomes, and help to build a sustainable health system for the future. MAS is one such innovation, but there is a need to address a number of these barriers to harness the benefits of MAS.