Cutting waiting lists depends on high levels of overtime by operating theatre staff, but this is no long-term solution to persistent shortages. Jonathan Edgar and colleagues report on a survey

The government's pledge to reduce waiting lists and times is beginning to show some positive results. But while the short-term picture indicates that waiting lists are falling, a survey we conducted of 34 acute trusts in England suggests that achieving the government's targets will be hard hit by staff shortages and other problems in the labour market.

Unlike previous waiting list initiatives, where funds were provided as a one-off payment, a proportion of the funding for this initiative is set to become recurrent. Health secretary Frank Dobson has stated that the waiting list initiative is to be a long-term solution to a continuing problem. But most of the measures put in place to increase capacity have, on the whole, been short-term. Achievement of the waiting list targets so far has been largely due to the willingness of operating theatre staff to work overtime.

If there is to be a longer-term gain from the waiting list initiative, current working practices and the use of theatre staff should be examined to ensure that where waiting list funding is used, it is as effective as possible. Without this, trusts may have difficulty in sustaining the government's objectives.

In June this year, the health and social care management group at PricewaterhouseCoopers sent a postal questionnaire to 100 trusts, asking about staffing levels in operating theatres, vacancies, difficulties in recruiting, and local pay incentives. We contacted chief executives, directors of personnel and theatre managers. There were 34 valid replies.

The survey found that trusts were experiencing major difficulties in recruiting suitably qualified theatre staff. Reasons given included a shortage of suitable staff, local competition, high staff turnover and poaching by other hospitals. Trusts reported that they were already under the required staffing levels for their existing capacity, and that even with active recruitment campaigns they had been unable to secure a sufficient number of applicants to meet their shortfall.

The long-term solution to containing waiting lists is extremely complex. Managers acknowledge that the use of overtime and extra hours cannot be maintained indefinitely to increase activity. The detrimental effects of long-term use of such policies are well known. High levels of overtime frequently lead to increased sickness, higher levels of stress and lower morale.

The logistical implications of weekend and evening operating affect the day-to-day running of hospital services. And the cost of these arrangements has an impact on trust efficiencies. Many of the trusts surveyed were instigating local pay policies, paying double time or employing staff to a higher grade in an effort to secure the staff they needed.

The NHS has a responsibility to adopt a more strategic approach in responding to the waiting list initiative. Our experience of reviewing strategic and operational theatre management has highlighted a number of key areas worthy of exploration when looking for opportunities to sustain increased theatre capacity.

Staffing mix

Hospitals need to develop staff patterns based on flexible skill-mix rather than the traditional grade mix. The grading structure set out in Whitley terms and conditions hinders the use of a flexible skill-mix. Many trusts have moved to new local terms and conditions allowing greater flexibility, and are now beginning to see the benefits in terms of staff deployment.

The guidelines for the use of skill-mix in operating theatres, drawn up by the National Association of Theatre Nurses, concentrates on grade- mix and not skill-mix.1

Flexible contracts

Hospitals should also consider implementing staffing levels and contracts that reflect fluctuations in the workload.

Our experience has shown that trusts frequently operate rigid and routine staffing timetables that fail to take into account the variations in the length, number and complexity of operations.

Most trusts use historical 'five-day' working contracts without considering the benefits of fewer, but longer, days, which more appropriately mirror activity levels.

Rotation programmes between specialties

Trusts should also devise rotation programmes for junior theatre staff to enable working across all theatres. Operating department assistants and nursing staff are invariably assigned to a specific area or theatre. Structured rotation of junior grades allows greater opportunity to gain a grounding in several areas while increasing deployment potential.

Reducing absence

Managers should address long-term and repeat sickness with support from the human resources department. Where trusts have developed local sickness and absence policies, rates of absence have dropped considerably.

The government believes that a 1 per cent reduction in absence rates would save the NHS£140m annually.

Recruitment incentives

Our studies suggest that while pay is a significant factor when deciding about employment, opportunities for job sharing, training and flexible hours are seen as clear attractions. Managed career breaks and refresher courses designed to assist re-entry of nurses to employment by maintaining and updating their skills could also help recruitment.

The government's human resources strategy, Working Together - securing a quality workforce for the NHS, unveiled at the end of September, will require all NHS employers to be able to show an improvement in retention rates, and to conduct annual staff surveys.

Hospitals should consider improving recruitment of operating department assistants by holding theatre open days. They should also develop theatre co-ordination groups within specialties.

Our research suggests that specialties which routinely undertake multidisciplinary meetings have fewer communication breakdowns.

Given the difficulties in recruitment and staffing highlighted by our survey, the government's waiting list initiative holds significant implications for theatre management throughout the country.

The use of high levels of overtime cannot be sustained indefinitely. In adopting a more strategic approach to reducing waiting lists and investing a proportion of the recurrent funding in long-term resource strategies, the NHS would be in a stronger position to sustain any increase in theatre capacity.