Published: 16/05/2002, Volume II2, No. 5805 Page 16 17
Eighteen months ago, the government controversially signed a deal with the private sector to carry out operations for which the NHS lacks capacity. An estimated 100,000 NHS-funded operations have been carried out privately since then, and health secretary Alan Milburn announced last October that he was prepared to increase that number by a further 25,000 a year.
At the same time, he allocated£40m to the NHS to cover this.
An Audit Commission report, published today, reveals a startling lack of information about how efficiently the NHS uses its own operating theatres. If they were used more effectively, could many of those operations still be done on the NHS?
More than 3 million operations are performed a year in the NHS in England and Wales. Staff costs (excluding surgeons and anaesthetists) are more than£500m a year. As much as this again is paid out for consultants. The stakes, says the Audit Commission report, are 'high in every way'. Every hospital is to receive£35,000 to help reduce the number of cancelled operations, the Department of Health said in February. In the third quarter of 2001-02, 20,000 operations in England were cancelled at the last minute for nonclinical reasons, according to the DoH hospital activity statistics.
Yet the current picture presented by the report, after visiting 70 trusts in England and Wales, is alarming. It will inform the audit being carried out by the commission for the rest of the year, looking at how a hospital's operating theatre regime affects the acute trust as a whole.
One of the biggest problems, according to Philip Brough, senior health specialist with District Audit, who carried out the work for the Audit Commission, is the time lost between operations - a problem that has arisen over the last few years because junior doctors no longer do operations alone.
The reduced role for junior doctors follows revised guidance from the Royal College of Surgeons and the Royal College of Anaesthetists, the new deal reducing junior doctors' hours (1991) and changes as a result of the 1993 Calman report on hospital doctors' training.
The changes might have been for the best of reasons. But they meant that the consultant anaesthetist has to spend time in recovery with a patient after an operation and then could take some time preparing the next patient for surgery. This means the operating theatre is empty and the rest of the team left twiddling their thumbs - for as long as half an hour.
The new rules also mean that, whereas junior doctors may have closed up a patient after surgery, the consultant now has to do this, which takes time and stops them working on another patient.
'The only way they can get round it is by having two anaesthetists, ' says Mr Brough. 'I have been told that having a surgeon sitting around for an hour or more is not unusual.' Some trusts, have got around the problem by using staff-grade anaesthetists - people who have opted not to be a consultant but who are fully qualified, rather than juniors. They tend to work 9-5 office hours.
Lack of adequate information, or information of sufficiently high quality, has made it nigh-on impossible for hospital managers to tackle the problem effectively, says Mr Brough.
'I've seen trusts where the system was no longer used because the hard disk was too small. They hadn't got round to having their hardware upgraded. And I have been in meetings where, when you raise a question about their data, they start laughing round the table. It is notoriously bad.'
Many trusts had sophisticated computer systems, but few were able to use them for strategic planning and routine management of theatres. The emphasis was on collecting historical data, but they did not show how much theatres were used at certain times of day or at weekends or evenings, which would show whether there was scope to carry out more operations at these times. The next problem is how the surgeons' time is allocated and the number of slots they are given.
'Often it is based on historical levels, where a surgeon had three slots a week and that is how it has been for years, ' says Mr Brough.
'But as case complexity changes, these things need to reviewed - and often they are not.
'You get situations where consultant A has more slots than consultant B, and A may think he needs them. A new consultant may be continuously overrunning their time because they are trying to get lots of work done because they have a long waiting list. It is about trying to get away from that historic pattern.'
Consultants, he admits, are not the easiest people to negotiate with. But managers haven't had the right information with which to challenge them. He suggests an alternative model to operating theatres being booked to a surgeon for some time in advance.
Why not book them at four weeks' notice, and have the consultants bid for time in them?
That often reduces the period lost through consultants taking annual leave at short notice, which can ruin schedules.
Heaven forbid the suggestion they are taking time off for golf, or private-sector operations. But it is not uncommon for one in six timetabled sessions to be cancelled, often due to short-notice annual leave.Days off for sickness or annual leave by nursing staff are not such a problem, as they can usually be covered by others.
'Most consultants are working very hard, ' says Mr Brough, refusing to be drawn on what they might do on their days off. l Operating Theatres: a bulletin for health bodies .
Audit Commission. www. district-audit. gov. uk