Operating Theatres #1 – Setting the Scene

What makes a productive operating theatre? What constitutes quality in a theatres setting? How do we make theatres financially efficient? How can we improve safety in theatres?

In this series, I intend to explore each of these complex and inter-dependent questions. The ultimate purpose is to unravel them, to arrive at some conclusions regarding how to

    improve performance in theatres,
    and at the same time make theatres more efficient, and save money.

First, let’s set the scene.

Theatres are the single most expensive line item in an Acute Trust. There were about 12 million operations in England last year, in about 3200 theatres, in just a bit less than 150 Trusts. A little over half were day cases. About 2 million (a sixth) were emergencies. On average, it’s about 2 bed days per consultant episode.[1] Total expenditure on surgery in the NHS is more than 4% of the total NHS budget, or about £5 billion. Trusts had around 7.5 cancellations per 100 procedures[2]

It works out to an arithmetical average of 40,000 theatre cases in main surgery per year. That’s high for a district general hospital, which might be between 20-30,000, and low for a big University hospital in a large city (perhaps 50-60,000). The cost – and PbR revenue – to the hospital will vary equally, but on average will be somewhere in the range of £25-£30,000,000 per year per Trust.

These are big numbers!

Attention to this single area of hospital operations (excuse the pun) will pay off better than any other area of acute Trust improvement.

We’ve seen analyses of recent trends. A briefing by the Royal College of Surgeons (RCS) indicated that “orthopaedic activity in particular has witnessed an increase, with a 4.7% rise in the number of hip replacement procedures and a 3.26% increase in the number of knee replacement operations. There were further increases for amputations, tonsillectomies, and interventions for varicose veins.”

Some other recent trends indicate that financial pressures and policy decisions are leading to restrictions on care – bluntly, rationing policies – that disproportionately affect planned (elective) surgery. This includes operations such as hip and knee replacements or even heart and brain surgery. Another RCS briefing said “we have seen even harsher examples of arbitrary rationing. These broadly fall under four types of restrictions: ‘financial’ rationing; ‘lifestyle’ rationing; ‘pain threshold’ rationing; and individual funding requests. ”

More than one in three clinical commissioning groups (CCGs) in England are delaying or denying routine surgery – such as hip and knee replacements – to smokers and overweight patients, in contravention of national clinical guidance. For example, North, East and West Devon CCG imposed a number of restrictions on access to elective surgical procedures. These restrictions included requiring patients with a BMI over 35 to lose 5% of their weight prior to surgery and also requiring smokers to quit at least eight weeks before their operation.

Well, that’s the scene set. In the next article, I will explore the four key dimensions of Quality as it relates to Operating Theatres.

Donna Kelly
Healthcare Director

[1] NHS England, NHS Digital. Hospital Episode Statistics and other public data.
[2] NHS Providers. 2013 Operating Theatre benchmarking project.

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