Let’s start the new year with a positive message about what the NHS can improve

By Steve Black

Innovative surgical practices can significantly enhance NHS efficiency and productivity, but entrenched resistance and systemic challenges hinder widespread adoption. Overcoming obstacles is crucial for lasting improvement, writes Steve Black

I’m normally the one to say pessimistic things about NHS performance so I thought I could start the new year by talking about a positive story showing how innovative thinking could improve something.

The positive story was told in The Times in December . The headline read “London hospital cuts waiting lists with innovative system”. And this sure sounds like a positive story that big improvements are possible. Woot!

But my short bout of optimism was tempered by many of the responses to the story by NHS-related people on social media. To sort the wheat of the story from the social media chaff (and perhaps recover some kernel of optimism) I need to explain some of the details.

The essential idea is to rethink the normal way surgery operates to minimise surgeon and theatre downtime. One of the medics who developed the process:

“…compares it to a Formula One pit stop. They’ve got one person doing the rear right wheel, one person doing the front left wheel. It’s the same thing. The operating theatre is effectively like that.”

A key idea is to use larger teams to operate two theatres in parallel enabling surgeons and anaesthetists to be far more highly utilised because they spend far less time waiting for other things to happen. This also increases the theatre’s productivity. Overall, the team claims to have more than doubled their overall productivity by carefully analysing the causes of delay and waste, and minimising them by process redesign and better operational planning.

That sounds great. But instead of welcoming the improvement, many commentators challenged the idea, and some claimed it didn’t make any real difference to productivity (despite many misreading the detail in the article to challenge the team’s claims).

Roy Lilley summarised some of this well (and, unusually, provided an evidence source for his position, though one that was unconvincing given what we know about operational management).

Other commentators didn’t believe the team’s claims of major productivity improvement (some challenging the calculations using the incomplete numbers given in The Times article). Some alleged the idea was inherently unsafe.

Some argued the parallel operating was unstable given things like unpredictable delays in patient or staff arrival. This last objection is particularly odd given the emphasis the team placed on far better coordination and planning which minimises the causes of those–all too common–problems in more conventional NHS practice.

Too many objections sound like “that’s not how we normally work, working differently would be disruptive, we can’t avoid the major causes of inefficiency in the current system”.

One reason why I thought those objections to be irrelevant is that the world is full of examples where major causes of delays in processes can be eliminated by good analysis of the details of the operational process and causes of problems followed by process redesign to minimise them. More significantly, the details of such redesigns have been described before inside the NHS. My favourite example is from 2007 and is described in this piece from the British Medical Journal .

The author explained the situation in the NHS when he arrived:

“The operating sessions were short and few, only three and a half hours twice a week. Then half of that time was taken up with ‘sending for the patient,’ anaesthetising, positioning, and cleaning the theatre between operations. Sometimes something would get in the way of even this slow routine, and the reasons to cancel operations were innumerable: unavailable instruments, unavailable porter, lack of beds, and unexpected medical problems. I spent more time in the coffee room than in theatre.

“The most amazing aspect of all this was that nobody was talking about the causes of waiting lists. If I asked, people looked at me condescendingly as if I were deluded. If pressed, they would mention ‘lack of surgeons’ as the cause. How could it be ‘lack of surgeons’ if I was doing half as many operations as when I was in France?”

He explained how operational redesign could safely reduce the causes of waste and delay. And he demonstrated that his changes could work by implementing them in his hospital, achieving a near doubling of system productivity and overall output.

But the–apparently positive–ideas didn’t spread and were unpopular with his colleagues. One reason being that an orthopaedic surgeon with a very short waiting list can see their private income halved with no counteracting incentive from the NHS despite a large improvement in NHS productivity.

While orthopaedics may be an outlier as far as incentives go, other objections to such changes are common. The disruption caused by new methods of work is an objection for many.

Perhaps even more importantly, many medics resist ideas from operational management that might mean they have to subject themselves to far better planning and coordination. And the hospital might have to employ more operational managers to design or implement the new process. And more managers is obviously bad, right?

I still regard these stories as providing a ray of optimism in a dysfunctional NHS. Improvement, even big improvement, is possible with the will and competence to achieve it.

But the NHS is still far too dominated by spurious objections to the possibility of improvement and far too short of the right skills to design or implement such improvements widely. And the system lacks both clarity about the need for improvement and any consistent incentives to drive it.

But, despite my reputation for pessimism, I remain optimistic because those are fixable problems.