Just before Xmas there was an article in the Times about an interesting development in the productivity of routine surgery at Guys and St Thomas’ Trust in London.
Then last week the Times ran a further deliberative article (unfortunately both behind their paywall) on the innovation that included interviews with the two anaesthetists who had led the change.
(Well done the comms people at Guys and Tommy’s!)
To underline its importance Steve Black posted about this in the HSJ. He raised a number of important points about why nearly every such initiative that changes the way in which parts of the NHS work will almost automatically get slagged off in social media.
This reaction returns to one of my overall themes in the autumn. If you work in the public services, carry on doing what you have been doing for the last decade and you will never have to justify yourself. Do something new and you will have to justify every breath. Not that such accountability is wrong but that the new has the be super accountable and the old rarely has to.
(Or to put in another way – before you do anything new grow a tough skin, and get ready to have a row).
The core change is straightforward. Making the surgery much more like a production line ensures much more surgery can be achieved. Most notably have patient A ready for the surgeon who, when finished, moves to another theatre where patient B is ready and waiting. When the surgeon finishes there move back to the original theatre where another patient is ready. Since the surgeon’s time is the rate limiting activity, make sure that nearly all their time is spent operating and much less hanging around waiting for the patient to be prepped.
Because there are teams of anaesthetists and nurses working on this with different patients, they can speed up all the activities that waste time. For example, normally 40 minutes is allowed for cleaning, in these teams, nurses ensure that the theatres are clean and ready for another operation within minutes.
Patient 1 is operated on in theatre 1 at 0800 am. Number 2 follows her in just after 0820. By 10.00 the team, divided between the two theatres, has performed 13 procedures and patient 1 is on her way home. By 1150 all 20 women’s surgeries have been completed. In a normal day, just six would be done over a full shift.
In other examples all left hip surgeries ae carried out in one session and all right hips in another. Carrying out all the left hip surgery at the same time means all operating theatre sessions and the staff are prepared for left hips with a resulting speed up in operations.
Of course, there are a lot of consultations where referrals can’t be organised in such a way as to get similar ones following each other. But there are quite a number that could and many of them constitute the current lengthy backlogs. If the NHS and patients spent next year organising these referrals, so that similar cases are seen in the same session it would help increase productivity.
When it comes to the ‘how’ of change one of the two anaesthetists running the scheme had this to say,
“There was a lot of resistance. Resistance normally comes from people who don’t want to move away from conventional working. You know, ‘Why should I work in two theatres? Why should I rush? Why should I do double the work? Is it safe? What you are doing is you are rushing’ (Imran Ahmad)
It’s important to say, as Imran does, that people arguing for change recognise that very few people will welcome it – however well-intentioned it is. ALWAYS expect that resistance and plan how to overcome it in the detail of all your initial interactions.
One of the main ways that Imran and his colleague helped others overcome these fears was by creating an ‘esprit de corps’ amongst all the staff involved. They knew they were doing something different and, crucially, doing it together. Whilst everyone involved would have to work differently, it was the surgeons who would most experience ‘the rushing’ described above. Luckily one of the anaesthetists had been a surgeon and could directly engage culturally with his fellow professionals as a colleague. This was of considerable benefit to facilitating the change.
In regard of the wider narrative of why this change was important, all the staff knew about the long waits for surgery, and that the distress caused to waiting patients was a bad experience. So if, as a group they could show how different working could help cut those long waits it was a morally worthwhile activity.
But more than that overall feeling of providing more and better care, the two leading doctors ensured that the whole team experienced being special together. Every day at lunchtime, when they were working in this new way, the anaesthetist’s bought pizza for everyone (and learned by so doing that a basic bike delivery can only carry six pizzas and since they needed a dozen, they ordered two deliveries. (The secret of all change is in the detail).
Having worked hard together, they all then had their lunch together. (And it being pizza, they could all have toppings that suited their cultures)
But they had thought beyond the specific change in their hospital to the wider incentives for change. How did the payment mechanism for doctors interact with making this innovation happen (or not)?
Imran’s colleague had an explanation. He had had the experience of working in different countries.
“I can speak for Canada from my practical experiences. People there in general are paid for work and not for time. As I always say ‘you pay for work you get work, You pay for time you get time. Here we pay for time. They pay for work. And we get time, and they get work’ (Kariem El – Boghdadly)
Having the experience of different payment systems for doctors, he knew how different financial incentives encourage different behaviours. It’s not that they ’determine’ behaviour but they have a very big influence. If you wanted to spread this initiative into a much larger number of hospitals, you would have to pay attention to changes in the way in which doctors were paid. Financial incentives and financial disincentives matter.
One final point about many of the innovations that, over the next decade, need to spread across the NHS. Whilst aspects of some of them are aways new, it is also the case that if you go back a couple of decades and you will find similar innovations.
NHS collective memory is short. We need to build on past experiences of change, not forget them.