After the onset of Covid-19 pandemic many non-urgent elective activities were postponed to free up inpatient and critical care capacity. The Nuffield Orthopaedic Centre (NOC) faced a challenge in increasing its elective capacity and reducing the backlog which built up during the pandemic. In addition, insufficient patients were ‘fit for surgery’. Without the option of a personalized pre-op assessment (POA) service, many patients needed multiple face-to-face appointments to prepare them for surgery. Another limitation was the lack of differentiation between high and low complexity cases. All POA appointments were conducted face-to-face approximately 4-6 weeks before anticipated surgery.
The NOC’s health professionals and management team identified an unmet need for digital collection of health screening data completed by patients when listed for surgery. They also identified the need for early identification of patients requiring investigation or treatment before surgery to prevent subsequent surgery postponement.
The NHS Transformation Directorate Adoption Fund supports elective recovery through innovations that help people stay well or get well at home. Health Innovation Oxford & Thames Valley (HIOTV) led a successful bid for funding with the Buckinghamshire, Oxfordshire and Berkshire West (BOB) Integrated Care System (ICS) receiving £424,000 for four projects including PRO-MAPP.
PRO-MAPP is an engagement tool which provides intelligent decision support to optimise the preoperative assessment process in the pre-assessment clinic triage (PACT) pathway for high volume, low complexity (HVLC) orthopaedic cases. This digital transformation allowed a more personalised approach to the individual needs of patients on the hip and knee surgical waiting list. Patients are triaged for either a face-to-face or telephone assessment. Previously all patients had an in-person appointment prior to surgery. Now more than 70% can be assessed effectively on the phone instead. In-person outpatient appointments remain available to those who still need them, with PRO-MAPP identifying medically complex patients or those needing specialist investigation. As a result, fewer pre-op assessment appointments have been cancelled or missed (down from 8% in 2021 to fewer than 1% in 2022). With potential issues identified and dealt with at an early stage, the number of operations cancelled further down the line is also reduced.
HIOTV carried out a real-world evaluation of PRO-MAPP at the NOC (part of Oxford University Hospitals), working with key stakeholders to determine the potential impact of the technology and suitability for spread and adoption. The evaluation found that PRO-MAPP reduced cancellation rates for surgery and preoperative appointments, leading to better use of resources. With more patients assessed remotely instead of in person, the NHS saves money and can reallocate resources and facilities to other services. This new approach is being used prior to planned hip and knee replacement surgery at the NOC. The potential to apply this model in other specialties is being explored.
The new pathway also reduced outpatient attendances and unnecessary travel to OUH. A sustainability and social value review found that implementing PRO-MAPP could lead to a significant decrease in carbon emissions due to reduced patient travel with 70% of patients assessed as being suitable for a telephone consultation after their first outpatient clinic visit. During the real-world evaluation, PRO-MAPP saved 51,382km (more than 32,000 miles) of travel. In the UK, average CO2 emissions per car equate to 171 grams per km, according to the latest data from the Department of Transport. Therefore, this distance equates to 8.8 tonnes of CO2 saved. For comparison, one tonne of CO2 is the equivalent of a return flight from Paris to New York, meaning that during the evaluation period (April 2022-January 2023) use of PRO-MAPP saved almost nine return flights from Paris to New York.
Working with the York Health Economics Consortium (YHEC), a health economic analysis found significant potential cost savings. The analysis indicated that implementing PRO-MAPP into the clinical pathway for those on the hip and knee surgical waiting list saved £152 per patient, rising to £769 per patient when length of stay was considered. Length of stay can be influenced by a multitude of factors, and it was thought that the introduction of PRO-MAPP might not directly influence this, even though a reduced length of stay was noted in the evaluation.
The HIOTV contribution supported the development of a business case for implementing PRO-MAPP. It also conducted a service evaluation to gather real world evidence relating to initial implementation of the technology at Oxford University Hospitals. HIOTV also worked with key stakeholders to help design the new clinical pathway, gathering feedback on the innovation from patients and healthcare professionals.
The evaluation found that PRO-MAPP reduced surgery cancellation rates and preoperative appointment cancellations, leading to better resource utilisation and cost savings. All patients surveyed during the evaluation were either satisfied or very satisfied with their visit, indicating that there are few barriers to adoption from a patient perspective.
The utilisation of PRO-MAPP has been recognised as a national exemplar of best practice in the NHS and has been included in the NHS Digital Playbook for Perioperative Care. In March 2024 this initiative won a bronze award in the Most Effective Contribution to Clinical Redesign category at the HSJ Partnership Awards. A case study has also been included on NHS England’s website as a guide for providers and integrated care boards on earlier screening, risk assessment and health optimisation in perioperative pathways. HIOTV is creating an implementation support pack to help roll out this innovation across the NHS.
