Category – Bringing Patient Care Closer to Home
Introduction / Overview
Northumbria delivers integrated acute and community health and social care to the residents of Northumberland and North Tyneside. It is the largest geographical Trust in the UK covering 2000+ square miles.
Employing over 9000 staff – together each year we:-
- Care for over 73,000 patients and families on our wards.
- Provide treatment to around 167,000 patients in our A&E departments and minor injuries units.
- Perform almost 27,000 operations.
- See more than 45,000 people for day-case procedures.
- Carry out around 1.3 million appointments with patients outside of hospital.
- Provide adult social care support during 70,000 home visits.
This project describes a unique partnership and global collaboration that has brought care closer to home by introducing laparoscopic surgery as a new service to Tanzania.
Northumbria, with full support from our Board and Charity Development Group, approached this as a long term training development programme. Successful implementation required the total commitment of a dedicated team to see it through over a decade.
People may say that laparoscopic surgery is not an obvious choice for implementation in a less developed country due to the high-tech nature of the equipment and the high-level skills required of the surgical team.
The real challenge was to be able to develop the new service from Northumberland, UK, 7000 kilometres away!
The ambitious programme required a team effort over a sustained period of time, working within a challenging environment, with few resources and frequently without electricity! Each year new procedures have been introduced and keyhole techniques are now routinely used for diagnostics and biopsy, improving the health outcomes for hundreds of patients.
Recently secured AHSN monies will enable the learning from this project to be shared across the UK, as well as promote the innovation that can result from volunteering in less developed healthcare systems.
The benefits of laparoscopic surgery are numerous. For the patient: less invasive surgery and less anaesthesia, much reduced chance of haemorrhage requiring transfusion (HIV risk), fewer days in hospital, reduced incidence of infection, less chance of complications, less requirement for post-operative medication and nursing care, reduced need for outpatient visits or district nurse follow up, return to work quickly and, most important, less overall cost to the patient for the healthcare intervention.
For the hospital: reduced theatre time , ability to manage day case elective surgery to ease congestion on surgical wards, less patient aftercare required and lower costs of service delivery.
In 2002, Northumbria was approached by the Chief Executive of Kilimanjaro Christian Medical Centre (Tanzania) to explore the possibility of introducing this service to address the backlog of patients on surgical wards. With an average occupancy of 116%, the hospital needed to be able to process more patients each month and discharge them quickly.
What Was Done?
Surgeon Liam Horgan, sister Lillian Broatch and sister Sue Colley provided dedicated support to the developing Tanzanian laparoscopic team through annual training visits to KCMC. In between, Tanzanian surgeons and senior theatre nurses visited Northumbria for specialist training. The project gained further momentum with the donation of two laparoscopic stacks from sponsors.
The development of a new service is a challenge and there are many stages in the acquirement of new knowledge and skills before competency is assured. With the full support of the KCMC Surgery Department, Northumbria was able to develop and implement innovative training methods to fast-track the creation of a new laparoscopic service for Tanzania.
Furthermore, since 2008 the Northumbria team has supported KCMC to deliver annual laparoscopic surgery training courses for surgeons and nurses from across Tanzania. This was followed in 2011 by the development of a laparoscopic surgery module within the medicine undergraduate course at Tumaini University.
With the UK training team so far away, thoughts turned to distance learning possibilities but an internet msn/skype link would not be sufficiently reliable and a dedicated satellite connection proved to be too costly. The team developed a dedicated audio-visual link between Theatre 1 at KCMC and Hexham General Hospital to support training. UK surgeons could view images from the laparoscopic endoscopy camera beamed from Tanzania and guide the surgeons while the surgery actually took place.
The innovative surgical tele-mentoring link gave the Tanzanian surgeons the opportunity to gain greater experience and confidence with each transmission. Within Tanzania, images from the endoscopic camera were also linked to the seminar room so that the surgeon could talk to students and answer questions throughout each procedure. Previously up to 20 medical students would be crammed into the operating theatre to observe.
Impacts / Outcomes
Before the introduction of laparoscopic surgery at KCMC, open surgery was performed on all patients. This led to a higher possibility of post-operative infection due to overcrowding on the wards and patients needed a longer stay in hospital to recover. Laparoscopic surgery offered an alternative for patients which significantly improved their health outcomes.
Following two years of intensive training, a regular weekly laparoscopic cholecystectomy list was established at KCMC during 2005, the first hospital in Tanzania to do so. Dozens of patients were treated with improved laparoscopic techniques within the first few months.
Further advanced training took place over successive years and as KCMC established itself as the only government hospital to offer a laparoscopic service, people began to travel from across Tanzania, and further afield from Kenya, to book laparoscopic interventions for gall bladder removal, removal of the appendix and inguinal hernia repair.
By 2013 keyhole surgery was also being used more widely for diagnostic procedures, reducing the number of multiple-site open incisions which may be required during emergency surgery, especially when high quality diagnostics may not be readily available.
Now all gall bladder and appendix removal is undertaken laparoscopically.
Keyhole surgery is also now being used in terms of diagnosis of potentially terminal conditions, providing a better chance of the patient being able to return home to their loved ones for their final days rather than remaining in hospital for post-operative care following conventional open surgery.
The project has been able to contribute to the development of Tanzania’s health service through the introduction of laparoscopic surgery as a new service for the population of Tanzania. KCMC has prospective audit data for over 400 procedures. When, in future, laparoscopic surgery is available at all Tanzanian consultant-referral hospitals, the numbers of beneficiaries will be in the thousands.
Other factors contributing to the success of the project:-
- Determination of the team to find innovative solutions despite the obvious and significant geographical, and financial barriers.
- A shared vision, friendship and strong partnership between two organisations that has developed over more than 10 years now.
- The support from Northumbria Trust Board and commitment to a long term partnership with Tanzania, from which everyone benefits.
- The governance arrangements developed for this work are cited as best practice in government reports, including the recent All Party Parliamentary Group report on Global Health
Northumbria has launched a Global Health Fellowship as part of its leadership programme in acknowledgement of the unique developmental opportunities provided by international work.
There has been money secured from the North East Academic Health Science Network to continue the work
- Firstly remember ‘Pamoja Tunaweza’, which in English means ‘together we can’.
- This unique project brought together teams of engineers, surgeons, theatre nurses, operational managers and external stakeholders to work together over a number of years to advance surgical teaching and training in Tanzania and launch a new surgical service and bring vital care closer to home..
- The shared vision and strong partnership working of the UK and Tanzanian teams gave the momentum needed to struggle through new uncharted territory and succeed on two levels: service development and innovative workforce development.
- That while the benefits for Tanzania are obvious, Northumbria, as a well resourced organisation, has gained just as much from this partnership as Kilimanjaro Christian Medical Centre.