Cancellation of Planned Operations in the NHS

Mark Cheetham consider=ultranationalist colorectal and general surgeon Shrewsbury Telford Shropshire Midlands
Cancelled operations

The problem

Clare Marx (President of the Royal College of Surgeons) and Chris Hopson (CEO of NHS Providers) has rightly pointed out the problem of planned operation being cancelled due to lack of beds (see Sunday Times Letters 12/2/17). From the patients’ perspective, to have surgery cancelled at short notice is extremely frustrating and at worst leads to ongoing pain and deterioration, ultimately with a poorer outcome. When planned operations are cancelled, our surgical trainees sit idle when they should be honing their skills to become the next generation of consultant surgeons. Financially, NHS hospitals are hit with a double whammy; they incur the costs of laying on elective theatre sessions without the income to support them and then later in the year many will lay on additional sessions at extra cost to clear the waiting list.

What can we do then?

There is another way. Of course, we need to fund health and social care adequately. We also need to reconsider how we deliver planned surgical care within the NHS. Over the last three years, we have developed a programme to reshape the delivery of healthcare in Shropshire. This programme (called Future Fit) will see one of our two hospitals specialise in providing planned care and the other becoming a specialist Emergency Centre. The vast majority of planned surgical operations can be safely performed in a hospital which does not take emergency admissions. Separating planned surgery from emergency admissions has clear advantages including a greatly reduced risk of cancellation of surgery, better patient experience and better outcomes. A small number of specialist hospitals in the United Kingdom have, for many years, provided a high quality of surgical care with a low risk of cancellation of operations specifically because they are insulated from the pressures of emergency admissions; it is time that such services are available to the whole population.

Why healthcare in Shropshire (and the UK) needs to change

I’ve just been interviewed on Radio 5 live about plans to change health services in Shropshire. The interview was promoted by articles in the HSJ  and The Telegraph about the NHS England STPs. You can read the article here.

So here’s my take on changes in the Shropshire health system;

Background

In November 2013 members of the public, local councillors and healthcare professional met in Telford at meeting called A Call to Action. Here we discussed problems with the local healthcare system and the likely impact of changes in out local population. After this meeting the Future Fit programme has spent 3 years developing a new clinically led model of care and developing options for the future delivery of hospital care.

So what are the problems with the system now?

At the moment we deliver emergency and planned care from two district general hospitals in Telford and Shrewsbury. This way of working developed in the 1980s when the Princess Royal Hospital opened in Telford. Over the years this has worked reasonably well but recently this model has begun to show signs of failure. Since the 1980s there have been many changes in healthcare which mean that the model of small district general hospitals providing all services is no longer sustainable.

Rising demand

People in the UK are living longer than ever, which is good news, however they are living longer with ill health which us causing increasing demands on the health system. This is particularly true in Shropshire which has a higher proportion of older people than most counties. Improvements in medicine mean that we can provide  treatments that would not be possible before. So we now have a sizeable group of older people many of whom are living with several long term conditions.

Improving standards

Patients and their relatives are increasingly (and rightly) expecting a higher  standard of care when they come into hospital. This is mirrored in national guidance and how hospitals are inspected by the CQC. These higher standards can only be met by more care being delivered directly by fully trained consultants (rather  by doctors in training as is often the case now).

Specialisation

In the 1980s doctors were much less specialised than now, this meant that a surgeon or a physician could  deal with pretty much all emergencies. Nowadays diagnosis and treatment is more complicated – this means that more specialists are needed to deal with emergencies. For example, in the 1980s a district general hospital, like the Royal Shrewsbury Hospital, would have about 4 general surgeons; we now have specialist teams in vascular, colorectal, upper gastrointestinal and breast surgery.

On-call

In order to have access to a specialist 24 hours a day, there need to be enough of them to staff an on call-rota. If there are too few people on a rota, it will be hard work and it may be more difficult to recruit doctors. Often larger specialist hospitals will be able to support more doctors and therefore each doctor has to work fewer weekends and nights- this makes these hospitals easier to staff.

Recruitment

Some specialities are particularly difficult to recruit to, because there are national shortages of people trained in this area. There are particular shortages on doctors who specialise in accident and emergency and intensive care.  Currently we need two groups of these doctors to staff bipoth our sites. This duplication makes the staffing issues worse and is more expensive.

Technology

Modern emergency medicine relies on the ability to perform urgent scans (particular a CT scan) any time day or night. Each CT scanner needs a specialist doctor and radiographer available around the clock to perform and report the scans. Currently we need to have a scanner available 24 hours a day in both our hospitals. Similar arguments apply to equipment in operating theatres, endoscopy and cardiology.

 

Clinical  links

When someone ill is admitted to hospital, it may not be obvious what is wrong with them and which specialists they need. Currently we do not have all specialities in either of our hospitals. For example, we only have emergency surgery in Shrewsbury and paediatrics in Telford. This means it’s really difficult to look after children who need emergency surgery.

Conclusion

I have written here about some of the main issues facing hospital services in Shropshire. I will blog later about some of the plans to improve local health care.

Mark Cheetham