‘The future ain’t what it used to be’– reflections on the evolution of anaesthesia

“The UK needs more critical care investment in order to improve peri-operative outcomes.” In an eloquent letter in this issue of the Journal, two trainees [1] have focused on the statistics suggesting that risk-adjusted mortality for non-cardiac surgery in the UK is three to eight times that found in the USA [2]. They looked at the comparative health care expenditure between the two countries, noted the lower investment in the UK and concluded that the UK needs to spend more. The sting in the tail is this is unlikely in the current economic climate, a poignant and depressing snapshot of British surgery and anaesthesia. But does the letter by Wong and Wickham reflect the reality of working for the NHS or have they both been infected by the national feeling of doom and gloom? The letter raises several important issues. The facts of the comparison are hard to understand, especially in the supposedly lower-risk population group. The findings are dependent on P-POSSUM risk-adjusted mortality rates [3]. Scoring systems such as this have limitations when comparing outcomes across different countries with markedly different organisations for delivering medical care, and some of these limitations are alluded to in the paper. The study [2] compared a single large teaching hospital in New York with two hospitals in Portsmouth, UK. While the result cannot be extrapolated across both countries, the lower mortality in the USA was consistent over all risk levels, and this cannot be ignored. Similarly, the median time to death was also significantly longer in the US patients, which also supports the hypothesis that outcomes were better in New York. Most strikingly, the overall mortality in the USA was 2.1%, compared with 9.9% in the UK. As a minimum, the study provides a guide to the level of mortality that can be achieved and suggests a target for which we should aim for in the UK. The above study [2] looked at operations performed between 1996 and 1998, and there have been some impressive changes in UK practice since then. Probably most important has been the increasing appreciation of the problems of postoperative care. The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) has reinforced the message and indeed, the very genesis of its recent report [4] was a reaction to the concerns and information that had already been gathered about this problem. The consequence has been a focus on the whole patient pathway, from initial referral, early decisions of the appropriateness of surgery and pre-operative preparation, to the choice of anaesthetic technique and assessment of postoperative care needs. There has been the development of outreach and, despite the controversies around its efficacy, it reflects an awareness of the problem and is an attempt to find a solution. It has come hand in hand with early warning systems as part of an emphasis on identifying patients at risk. This is often tied into critical care services, which are usually no longer isolated from the rest of the hospital. At organisational level, there has been a radical evolution of critical care medicine with enormous growth of the Intensive Care Society, and a new multidisciplinary Faculty of Intensive Care Medicine supported by seven parent Colleges, with its own examination and speciality recognition. All of these reinforce the reality that critical care has been extended out to the ward environment and should improve postoperative care. Similar changes have taken place in the recognition and development of pain medicine and this too will contribute to better postoperative care. Reports such as the Audit Commission’s ‘Critical to Success’ [5] and the Department of Health’s ‘Comprehensive Critical Care’ [6] have defined the role of critical care within the hospital, and resources and manpower dedicated to these patients have increased substantially. There has also been an enormous expansion in the number of critical care beds in the UK. Today, in some hospitals, 4–5% of all acute beds are in intensive care or high dependency care units, and almost every hospital has seen considerable expansion over the last decade. Outcomes have consequently improved significantly [7]. The NCEPOD report identified areas where progress still needs to be made. It highlighted the number of hospitals without a policy for assessing nutritional status, where there is no pre-operative assessment or system for recognising an acutely ill patient. However, these are recommendations for organisational changes that could be implemented relatively easily and quickly, without the need for much funding. Wong and Wickham’s letter draws attention to the economics of medical care. The proportion of gross domestic product (GDP) spent on health in the USA is some 80% higher than that of the UK and is predicted to reach 20% by 2020 [8]. However, the higher per capita expenditure in the USA does not directly translate into outcomes that are proportionately better. Analysis suggests that 16 Western countries are more cost effective than the USA in reducing mortality rates [9], and indeed, the UK is one of the most cost effective. Furthermore, health spending in the UK has increased from £20 billion (€24 billion; $32 billion) per annum in 1985 to about £126 billion (€152 billion; $199 billion) in 2011/12 [10], a substantial increase in real terms and a statement of intent. The reasons for the dislocation between expenditure and outcome are legion but commentators have included the inequalities in health care provision across the USA and the amounts that go into administration, unnecessary investigations and treatment, and the pockets of the doctors themselves. Money is only part of the fix. In their letter, Wong and Wickham correctly point out that the central message of NCEPOD was that more critical care beds were needed. It is easy to suggest that investment in critical care would directly decrease peri-operative mortality. However, the evidence for what is required and the impact this would have, are far from clear. For example, much of the peri-operative morbidity occurs several days after surgery. Admission to ICU on the day of surgery may not help all patients who have an adverse event. Detection of problems after discharge from the ICU requires improved staff training and numbers, supported by early warning systems. This is a cost effective approach that ones hopes will provide good care for many, rather than overkill for a few. Where does this leave us? Yes, there is a problem, but it is being addressed and much has already been done to improve outcomes for high-risk surgical patients. There have been recent expansions in critical care beds, albeit modest by American standards, but more importantly there have been other initiatives including recognition of the problem, early identification of patients at risk, and education and training for anaesthetists, surgeons, intensivists, nurses, therapists and hospital managers. The thesis that outcomes are improved by critical care beds presupposes that all postoperative co-morbidity is the consequence of the operation and immediate aftermath. If that thesis is incorrect, or only part of the problem, then the ‘bed fix’ would be phenomenally costly, in both money and manpower, but relatively ineffective. If there is a lesson for the development of British intensive care, it is that putting all our resources into a single, small, high-tech environment denudes the rest of the hospital of expertise and places large numbers of others at risk. Florence Nightingale initiated both enhanced recovery and intensive care by putting large numbers of surgical patients in an area with expertise in managing postoperative problems for the main part of the recovery period, with reputedly impressive results. This was not high-tech but it did deliver expertise, mainly nursing. In medicine, as with everything else, we should learn from history, and to do that requires awareness of what went before. Looking back, it’s extraordinary to recollect how much has changed in anaesthesia and intensive care over the last 35 years. When we first started our anaesthetic careers, monitoring consisted of a finger on the pulse, observation of the patient’s colour, a von Recklinghausen oscillotonometer to measure blood pressure, and a precordial or oesophageal stethoscope for the fussy or cautious. The ECG could only be displayed on a shaky oscilloscope, which was rarely available. Imagine giving an anaesthetic without oximetry and respiratory gas monitoring today. Many hospitals did not have an ICU at all, and those that existed were small and poorly equipped, run by enthusiasts or by reluctant anaesthetists. Then, as now, the outcomes were largely dependent on good nursing rather than technology and there is another lesson there. The anaesthetic drugs used today are almost all different, and training, manpower, equipment and standards have improved enormously. As a result, our patients are infinitely better cared for today than when we started our careers. The point is that things have changed fundamentally over our working lifetimes, and largely for the better. Society and medicine have evolved, although there seems to be the temptation for every generation to look fondly back on what went before. The consultants before us appeared to have lighter workloads and responsibility, as well as greater autonomy and respect. Others will argue that our generation have had the best of times and the future looks much less inviting. For us, working in anaesthesia and critical care has been interesting, rewarding and very fulfilling. Will today’s trainees look back on our period with envy? Yogi Berra said “The future ain’t what it used to be” (http://www.quotationspage.com/quote/27223.html). However, there is no reason to believe that future changes will not be as far reaching and as astonishing as those experienced over our working lifetimes. The NHS, along with the rest of the country, faces a difficult short-term financial future. Adversity is the mother of invention and intensivists are nothing if not inventive. The current problems can and will be addressed, but not necessarily just by injecting cash. On the other hand, despite the severe current restraints we are optimistic that major building work, expensive new equipment and even increased medical and nursing staff will occur within critical care over the working lifetimes of current trainees. History is important and it is regrettable that the history of anaesthesia and critical care is no longer formally taught or examined as part of standard medical education. From our experience we take some reassurance that the last three decades have seen spectacular changes in our practice. Without being complacent, we believe that the outcomes and experience for the vast majority of patients undergoing surgery in the UK have improved and are good by any international comparison. There is undoubtedly room for further improvement and present initiatives focussing on enhanced recovery for surgical patients [11] are likely to make outcomes even better. Wong and Wickham are quite right to highlight these problems. It is an encouraging sign of the times that not only do our junior colleagues feel so strongly about the perceived problems, but also that their concerns can be voiced and taken seriously. If we appear to be trying to be reassuring it is because we believe that the long-term trajectory of our speciality is on track. Despondency is understandable but unnecessary. We think you’ve chosen a great profession and an exciting speciality to which you can make an important contribution. The future is, as ever, uncertain. However, the next 35 years have the potential to be every bit as exhilarating, as challenging and as rewarding as the last 35 years. No external funding and no competing interests declared.