Dr Pawa was invited to the American Society of Regional Anaesthesia and Pain Medicine in Las Vegas in April 2019. He was asked to discuss the delivery of Regional Anesthesia in the NHS

1. @amit_pawa
Regional Anaesthesia in a
Nationalised Healthcare System
Dr Amit Pawa
#ASRASpring19

2. Faculty Disclosure
Honoraria/Expenses GE Healthcare
Consulting/Advisory Board RA-UK President, B Braun Medical Ltd, Medaphor
Speakers Bureau
Funded Research (Individual)
Funded Research (Institution)
Royalties/Patent
Stock Options
Ownership/Equity Position
Employee
Other
Nothing to disclose
Yes, as follows:
Off-Label Product Use
Will you be presenting or referencing off-label or investigational use of a therapeutic product?
X No
Yes, as follows:

3. Regional An(a)esthesia Is GREAT!
@amit_pawa

4. I am not talking about…
Fascial Plane Blocks
Paravertebrals
Breast Anaesthesia
NO
BLOCKS
@amit_pawa

5. Regional
Anaesthesia
(RA)
In the NHS
My Point
of View
@amit_pawa

6. Compare & Contrast
@amit_pawa

7. My Opinion & Not:
1. My Employer’s
2. My Twitter Followers’!
This Talk

8. “Healthcare free at the
point of delivery based
on need not wealth”
Anuerin Bevan
5th July 1948 - NHS
@amit_pawa

9. NHS version…
@amit_pawa

10. The NHS is pretty complex

11. The NHS is pretty complex

12. Tax & NI Government Dept of Health
NHS England
Clinical Commisioning Groups (CCGs)
HospitalsPrimary Care
(GP)
Ambulance Private
Providers
£105.9 billion
Budget
£76.6 billion
@amit_pawa

13. Anaesthesia Department
Budget
Savings
Salaries
& Staffing
Drugs &
Equipment
Deliver
Service
(Fixed Fee)
CCG
Hospitals
Payment for service
“Back”
Charge
For
service
Charge for service
Surgical
departments
@amit_pawa

14. Anaesthesia = Hospital Cost
Fixed Fee For “Anaesthesia”
Aim to keep cost-neutral
Can “Upscale” fee for complex Services
(Cardiac/Thoracic)
RA viewed differently by “The Players”
@amit_pawa

15. The Players…
@amit_pawa

16. I don’t like needles!
Could I die?
Are you a doctor?
I want to be pain-free
What is Regional Anaesthesia?
The Patient
@amit_pawa

17. We need to DO MORE
We need to SPEND LESS
We need to BE FASTER
We must prevent cancellations
Manager
@amit_pawa

18. We need to DO MORE
We need to SPEND LESS
We need to BE FASTER
We must prevent cancellations
Manager
@amit_pawa

19. I don’t mind what you do as long as:
You are QUICK,
Patient is STILL,
Patient is ASLEEP
Surgeon
@amit_pawa

20. What about the
Anaesthetist?

21. I Love General Anaesthesia
I think my patients do great
I want to do the best I can
Anaesthetist A (Asleep)
@amit_pawa

22. (Block)
I Love Regional Anaesthesia!
I think my patients do great
I want to do the best I can
Anaesthetist B
@amit_pawa

23. (Block)
I Love Regional Anaesthesia!
I think my patients do great
I want to do the best I can
Anaesthetist BSometimes I feel like…
@amit_pawa

24. WRONG WAY
RIGHT WAY
@amit_pawa

25. A usual Day in NHS O.R.
Anaesthetic
Room
Operating
Room
PACU
@amit_pawa

26. A usual Day in NHS O.R.
Anaesthetic
Room
Operating
Room
PACU
@amit_pawa

27. A usual Day in NHS O.R.
Anaesthetic
Room
Operating
Room
PACU
@amit_pawa

28. A usual Day in NHS O.R.
Anaesthetic
Room
Operating
Room
PACU
@amit_pawa

29. A usual Day in NHS O.R.
Anaesthetic
Room
Operating
Room
PACU
@amit_pawa

30. A usual Day in NHS O.R.
Anaesthetic
Room
Operating
Room
PACU
@amit_pawa

31. A usual Day in NHS O.R.
Anaesthetic
Room
Operating
Room
PACU
@amit_pawa

32. A usual Day in NHS O.R.
Anaesthetic
Room
Operating
Room
PACU
More Cases = More Money for Hospital
LESS time here MORE time here
@amit_pawa

33. GA Only RA Only/GA & RA
Simple & Cheap
Universal Skill Set
Pt into OR quickly
Sent to PACU
100% Success rate
Dr Paid Flat Fee
No incentive to do more
Complex & Expensive
Special Skill Set
Pt in OR “slower”
Without Block rooms
Skip/Less PACU
<100% Success rate
Dr Paid Flat Fee
Requires motivation
@amit_pawa

34. @amit_pawa

35. Most “Players” Agrees That RA may
be better for patients…
How can we convince the surgeon accept
a longer anaesthetic time/ask for RA?
How can we convince Anaesthetist A
to be more like Anaesthetist B?
How can we convince the manager
that the extra expense is justified?
@amit_pawa

36. Most “Players” Agrees That RA may
be better for patients…
How can we convince the
Patient that they should be
asking for RA?
@amit_pawa

37. 1. Patients RA can’t mobilise
2. PCA Opiate is the answer
3. This surgery isn’t painful
4. RA takes too long
5. If I don’t “block”, there can’t be nerve damage
6. Awake surgery takes ages to “set up”
7. Surgery under RA has to be “AWAKE”
Myths - a few
@amit_pawa

38. Yup - difficult to implement in robust manner
Easier in USA? - Financial benefit of billing?
NHS Inertia to change - cost implications
RA enthusiasts often viewed as either:
Odd/Zealots or Super Heroes!
Is it Tough to do RA in the NHS?
@amit_pawa

39. Variety of surgical opinions
“Bad Press” of RA - Paralysis/falls etc
Lack of understanding that Blocks not all
the same (Adductor canal vs Femoral)
Patients lack of knowledge of RA
Barriers to change
@amit_pawa

40. How to Implement Change?
1. Audit patient outcomes (Pain/Satisfaction/LoS)
2. Compare with Centres of Excellence
3. RA education - Colleagues & Patients
4. Work with one Surgeon/Specialty first
5. “Smart” List Scheduling - LA/Block/LA/GA - EFFICIENCY
6. Block room Trial/Novel Working patterns/Non-Physicians
7. Audit Improvement in outcomes
@amit_pawa

41. Anaesthetists Respected as Physicians
Anaesthetic Opinions considered
Some hospitals do lots of RA
Most do at least some RA
Teamwork - between colleagues/specialties
RA in NHS

42. Variability in provision of RA
RA not focus of UK Anaesthetic Training
RA costs money
Not universally accepted by “Players”
BIG hospitals - RED TAPE
RA in NHS

43. Success Stories
@amit_pawa

44. Hand Surgery
In many NHS Hospitals - Under RA
Local RA Champions in most Hospitals
@amit_pawa

45. Block Rooms
2015
@drdamonkamming @drsanjivpatel
@amit_pawa

46. Block Rooms
2015
@drdamonkamming @drsanjivpatel
@LloydTurbitt @davejohnston24
@amit_pawa

47. Hip Fracture
2017 - 2018
@amit_pawa
PRE-OP BLOCKS

48. Hip Fracture
2017 - 2018
@amit_pawa
PRE-OP BLOCKS

49. Awake Breast Surgery
@amit_pawa

50. Awake Breast Surgery
@amit_pawa

51. Awake Breast Surgery
@amit_pawa

52. Summary
RA DOES happen in the NHS
Driven by the “Enlightened”
Provision of RA is increasing
RA DOESN’T “Make” Money (Limiting factor?)
RA must demonstrate efficiency & “benefit”
NHS Funding is limited
@amit_pawa

53. Take what I say with a pinch of…
@amit_pawa

54. “Healthcare FREE at the
point of delivery based on
need not wealth”
Anuerin Bevan
5th July 1948 - NHS

55. @amit_pawaamit.pawa@gstt.nhs.uk