The NHS Improvement report on operating theatres: surgeons‘ personal experience vs. data analysis

I thank Anaesthesia for the opportunity to reply to Professor Pandit's editorial on the NHS Improvement (NHSI)/Getting it right first time (GIRFT) report ‘Operating Theatres: Opportunities to Reduce Waiting Lists’ 1, 2. In fact, the report is a celebration on how well we have done in the NHS to reduce waiting lists for surgery by improving efficiency within the theatre environment. In 2007, there were > 500,000 patients on waiting lists who had been waiting at least 12 months for surgery. In November 2018, this number was just > 2000 despite an ageing population and year-on-year increases in patients requiring treatment. This highlights the hard work of all NHS staff and should be applauded. However, we have to ask ‘could we be even more efficient and productive in this area given the rising demand and increasing waiting lists?’ Theatres cost on average £1200.h−1 to staff and run, an expensive asset that must be used efficiently. In my individual GIRFT visits to all acute hospital Trusts, I have found significant variation in theatre usage and efficiency. Surgeons in some Trusts find late starts, slow turnarounds, early finishes and consequent cancellations, very frustrating. Pandit's theory is admirable, but differs from this reality on the ground in the NHS at present. I was happy, therefore, to support the initiative by NHSI about how we could investigate and address theatre efficiency and productivity. Data collected from the 92 participating Trusts recorded the reality within some Trusts, and identified simple ways in which we can improve things. The report only looked at lists that ‘ran’, and not those that were cancelled due to lack of beds. Over 30% of lists started 30 min late and 19% over an hour late. Over 30% of lists finished 30 minutes early, and 24% finished at least an hour early. The NHSI report is designed to support surgeons and management when looking at their theatre efficiency and to improve it where they can. We concentrated on eight specialities and looked at common surgical procedures, identifying a mean time that these procedures should take. The results demonstrated that 291,000 extra routine surgical procedures could be done if we used our theatres more efficiently, enabling our patients to receive more timely treatment. Talking to clinicians on the ground, it is clear that team working is essential for providing efficient, effective theatres. All-day operating lists are the most efficient, especially those involving the same surgical team and anaesthetist. The report also highlights the ‘down time’ lost between cases, which should act as a call to management to ensure that the patients are admitted appropriately, consented and transferred to theatre as efficiently as possible. It is up to all theatre personnel to make sure that we are as efficient and effective as we can be, while providing the best care. The report also highlights that theatres can be staffed and available but not running due to the ‘lack’ of beds. In order to address this, we are piloting a ‘hot/cold split’ model in Trusts where two or more geographical operating sites exist. This model has been rolled out successfully in a number of Trusts, has proven its worth and I believe represents the way forward for improving patient care, deploying theatre teams efficiently, and training new theatre personnel. I value the editorial debate, but reiterate that my personal GIRFT experience, together with data from the NHSI report, shows that we can do more to improve the efficiency of one of the most expensive items in our hospitals, by working together. Getting it right first time is a clinically driven, peer-to-peer review that has now extended across 40 specialties including intensive care, paediatric and neonatal intensive care and peri-operative care; everywhere we assess, we not only find examples of world class care but also significant unwarranted variations in care which need to be addressed. Improving efficiency in theatre is an example of this.