There are 16 million hospital admissions, 10million surgical procedures and >250,000 critical care admissions, every year in the English NHS. While it is intuitive to think that Surgical, Perioperative, Acute and Critical carE (SPACE) takes place exclusively in secondary/tertiary care settings, it in fact begins and ends in the community: with recognition and/or management of early acute or critical illness, patient selection and optimisation for surgery, and post-discharge monitoring and care.

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Deterioration is responsible for all non-elective care, and avoidance of deterioration a national safety and policy priority. Mortality after major surgery ranges from ~1% within 30 days of elective care to ~10% after emergency abdominal surgery. Complication rates after major elective surgery (>1.5million procedures annually) are ~15%, and associated with reduced long-term survival and quality of life. (Moonesinghe et al. Brit J Anaes 2014) Ten of the NHS's fifteen 'Never Events' are applicable to SPACE, of which five are specific to it. Because of the acuity and complexity of SPACE settings, healthcare errors can have particularly significant impact on patient health and outcome. Hogan et al (BMJ Quality&Safety 2012) found that patients with preventable deaths are more than twice as likely to be admitted under surgical specialities.

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In addition to these established risks, rapid technological advancement and changes in service design and delivery, continuously pose new safety challenges across the NHS, but perhaps particularly so in SPACE. The NHS's "elective recovery" challenge is well-known, with >6million patients awaiting treatment, and waiting times longer than since modern records
began.

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This context brings unique challenges with very specific patient safety risks, for example:

• demand exceeding capacity: reduced resources (particularly workforce but also physical capacity)

• patient-level risks increased because of delayed presentations and/or deterioration in clinical condition while waiting longer for surgery

• impact of pandemic-related pressures on staff mental health, wellbeing, sickness and retention, with consequent risk of functional impairment

• rapid introduction of new, untested innovations/services: e.g. virtual wards, high-volume low-complexity hubs for surgery. 

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These new risks compound existing, long-standing and more generalisable risks, many of which are identified as strategic priorities in the NHS Patient safety strategy. Previous research has confirmed that patients from deprived geographies, and some ethnic minorities, requiring surgical, perioperative, acute or critical care are at risk of worse health outcomes. These inequalities could potentially be exacerbated by the context described above, particularly if patient activation and/or literacy limits their capacity for engaging with their own healthcare.