Productivity in the operating theatre and the role of logistics

Last week I posted about the NHSE-led front page story in the Times in which the NHSE recognised the importance of improving productivity.

That post provoked a lengthy comment from someone claiming to be a consultant anaesthetist. Since the comment was (understandably) posted anonymously it has not been possible to verify the identity of the contributor, but I have heard similar comments from NHS staff members in face-to-face meetings.

I have often made the point that many NHS staff have clear ideas about how greater productivity might be achieved. This comment, whether genuine or not, is representative of remarks I have heard elsewhere so I thought it worth responding to the points it makes in a dedicated post.

I am afraid this makes for a longer post than normal. (Original comments below in italics)

“I am a Consultant Anaesthetist. I started my training in anaesthetics in the great MTAS shake up of 2007 when I became an ST2. I’ve also done a bit of work on productivity and more recently safety.

We have a huge productivity problem in theatres, which are one of the most heinously expensive parts of the system. We are as far from a well-oiled team as it is possible to be. There are many reasons why this is so, but one of the biggest is not theatres, it is logistics. We simply cannot get our patients to theatre. The ‘sending time’ – the time it takes to get a patient to theatre, is highly variable. This means that if you send to early you end up with a patient arriving and sitting in an anaesthetic room, and if you send to late you end up with fallow theatre time. This is not really a healthcare problem. It is a logistics problem. I have recently had 3 wards tell me they do not have the staff to bring the patient to theatre. Maybe we need to re-examine the whole ‘sending’ process.”

As a society, we have, over the last 20 years, become used to logistics making chains of activity work with greater efficiency. When you buy a Nissan car, for example, you can potentially make a million different choices. For most people it’s a few hundred choices to create the car they want. When you press the ‘buy’ button you expect the whole car to start coming together (and you expect it to be your car). Its components will come not just from across the country but from manufacturers across the world. Assembly is driven by logistics.

When it leaves the final production line, we expect all the different choices we made – the colour, the seats and the engine – to have been assembled correctly. This is normal. If it doesn’t happen, it’s an unusual disaster.

We take the current complex world of logistics for granted   Complex work logistics have become the norm.

The point being made by my correspondent is such an important one for NHS care. It is that the key logistic for the NHS is the patient. And they need to be ‘sent’ to the theatre at the right time. Patients are different from scalpels – that also need to be there – and need a different input into the system.

If, from the very beginning, the patient is not made aware, in understandable terms, of what is involved in the surgery (so that they and their loved ones can prepare), they might get frightened at the last minute and duck out. So early involvement and discussion recognises their humanity. The sending process starts weeks before the day of the operation and must actively involve the patient. That’s the logistics of working with people.

“We change list orders on the morning of surgery because equipment is not available. The wards or admission areas have got the first patient ready, and then we decide in theatres to have a different patient. We often change patients because the list order has been decided by a non-clinical administrator, not taking into account the type 1 diabetic or child with additional needs that should go first. Nobody seems to know who has responsibility for anything. How can wards get patients ready if they do not know which ones to get ready?”

These are all examples which a logistics organisation could sort out. Equipment not being there is like getting onto a plane and expecting it to take you somewhere when no-one has thought to fill it with fuel. OK, it does happen but it’s so rare that when it does, we are outraged. Here it appears normal.

20 years ago, I was impressed by an NHS combined organisation that carried out operations for hips and knees in southwest London. They had organised their lists so that younger patients would come in first thing in the morning as there was a chance that, being younger, they might be a day case. This knowledge is from 20 years ago when it was possible to pre-organise lists. Intellectually we know how to do this.

The phrase “Nobody seems to know who has responsibility for anything” is telling. Logistics runs this as a form of flow. Again, as a society we have known how to do this for decades. For the NHS to not be doing this with “the most heinously expensive parts of the system” is a colossal error and a waste of public resources.

“Patients are on increasingly complex drugs. Often drugs that are great for their condition, DOACs and gliflozins are good examples, but which require careful perioperative management, which can be overlooked. Again, more on the day cancellation, postponement or input required to make decisions that should have been made weeks upstream,”

Intellectually we have known about the importance of perioperative management for some years. Immediately after a patient has been told they need surgery, the more time that they and their teams have to prepare for the operation the better. Patients need help to act on this information, to get as fit as they can and vary their drugs are crucial parts of the human preparation for the operation. We have known this for a long time, the fact this does not happen anywhere in the NHS is shameful and inevitably leads to same day cancellation.

I have commented in the blog before about my own perioperative preparation, for a 10-hour cancer operation at Guys and a 5-hour plastic surgery operation at St Thomas’s. This was not just extensive, but all the staff made sure that I understood what was going to happen to me. My mind and body were both thoroughly prepared which meant my fears and anxieties were dealt with way before the day.

I make this point to illustrate that we really do know how to do this.

“The way we run emergency and trauma lists is baffling. Every day feels like a surprise, when there are cases from the day before which could have been prepped and good to go”

This is another issue for a logistics organisation with some good AI. Almost by definition emergencies are different from electives. There is less notice for the patient and for the hospital. But even with emergencies, it is vanishingly rare for any emergency to be a ‘one off’ that has not been encountered before. A logistics organisation will have learnt from similar emergencies and would be able to apply that knowledge.

“Inexperienced staff are a large part of this, They have safety drilled into them and the myriad of checks are done for the most part quite poorly, and people speak over each other carrying out other tasks. This is to the detriment of safety and the other tasks. Senior leadership is often in budget meetings. I cannot recall the last time I saw our theatre manager in theatres”

Regular blog readers will recognise the comment about inexperienced staff. My CIPFA IfG analysis from last August made this point, as NHSE did (from my recent post) In that  I reported that NHSE was going to have a management blitz on upgrading new staff. Which is good but which should be done when they are appointed. Keeping senior staff away from where they really needed and putting them in meetings is a waste of their expertise. They don’t want to be there. We and they need them supervising real patient care.

“More senior clinicians are not always helpful either. Particularly for the general emergency and trauma lists where we seem to find lap choles for the upper GI surgeons and ankles for the ankle surgeons.  But the bog standard fractured hip hemiarthroplasties do not get done. Even there we have an issue because with the move towards total hip replacements we need specialist hip surgeons”

For decades the increase in super specialisms has saved lives. But the point about “bog standard operations” is repeated over and over in the NHS. There are many operations that happen again and again but need to be carried out with as much skill as the specialist work. For the sake of the hundreds of thousands of patients who need ‘bog standard’ operations we need to find a better way of congratulating that work alongside the specialist work.

“Training experience for surgeons and anaesthetists have tumbled. We struggle to get 3 hips done in a day. 4 can be done but it’ll mean a late finish (again). This drives down morale. We need to be honest about managing very senior Consultants who are simply not delivering, and also work out how to support newly CCTd Consultants who do not have the experience, and frame that around productivity, whilst at the same time maintaining safety. No easy task”

My correspondent is right about the work and status of senior consultants. Not all of them are difficult to manage, but the task of clinical directors in doing so needs support throughout the hospital. The point about morale is key to the next few years’ increase in productivity in the NHS. Staff want the organisation around them to be better so that they can do more work. So that they have more ‘time to care’. Morale is low because staff know they could do more with better logistics.

“Do we get a lot right, absolutely. But productivity has plummeted over not just the last 5 years, but the last 15. Would more money fix this, possibly but I suspect not because of the tax issues”

As they go on to say (below) this needs better organisation and not necessarily more staff. 15 years of plummeting productivity will not be put right overnight. But the quicker we start the better morale will be.

“Waiting lists are not going to be done for discretionary overtime where there is a 62% take from the state. My taxable income is now approaching 100k after the recent pay rise. So, if I do an extra weekend list, even for £1500, I am giving 62% of that straight back to the government. Many people right balk at that. Even worse if you have childcare and lose it”

It’s important that work is worthwhile. And that extra work is worthwhile. For some, with certain responsibilities and at certain pay grades doing overtime, this will not be the case. For others it will.

But the main point in this comment is that day-to-day – not at weekends – we can improve productivity with better logistics. That is a gain for everyone. And (see above) will improve morale.

“There is layer upon layer of tax, pay, morale, teamwork and safety tweaks that over the years have slowly choked the system. When it goes right it is a wonderful thing to be part of. Such feelings are getting rarer and rarer”.

This is a powerful cri de coeur. (And not an unusual one). My friend Ara Darzi once told me, as a surgeon, that the happiest and best place for a surgeon was in an operating theatre. I am sure the same is true of anaesthetists. We need to build much better logistics around them to maximise that “wonderful thing to be a part of”.

“Finally, I do not think more staff is the answer. We seem to have too many people around already. We need less people getting in the way, not more.”

In policy terms this is an important point. The increase in the number of hospital doctors by 19% over the four years between 2019-2023 is a large number of new staff. The point is made here that we need to organise the staff we have already. And to do that we need world class logistics.