OP E R ATING THEATR E S
and skills within the NASA team – without bringing in “Russian experts” from outside – to bring the crew safely back down to earth. According to Dr. Rasburn, this is how the NHS needs to need to tackle the backlog and ultimately avert disaster. Productivity will be one of the most
important tools, he commented: “It’s the only thing we have left. We know that we have extra funding from the Government, but we don’t have any extra staff coming from anywhere, so how can we get more patients through, safely, with the resources we already have?” Dr. Rasburn highlighted the ‘Glanso Model’, whereby everyone in the surgical team (surgeon, anaesthetist, ODP, scrub nurse, runner, recovery nurse, porter) is rewarded financially for safe and efficient care. Rather than a simple hourly rate, all members of the team are paid according to the high-quality work that has been done – including being rewarded for an increase in the volumes of cases performed. “We work with Trusts at weekends to really understand how we can supercharge the waiting list initiatives,” he explained. The pair went on to present data showing how surgery performed at the weekend, through ‘in-sourcing’, as part of the Glanso programme to reduce waiting lists, was associated with much shorter length of stays than ‘normal’ surgery carried out during the rest of the week. Capacity has also significantly increased, despite the pressures, by using existing staff at the hospital. “Since we started working at North
Devon, the length of stay [hips] has gone from 4.2 days (2012) to 1.4 days (Oct 2020),” Dr. Matthew Molyneux revealed. There have also been year-on-year productivity gains and a massive increase in patient throughput (up 200%). This has involved ‘Getting It Right First
Time’, theatre planning optimisation, and ensuring the patient selection is correct. Luke Brunton, an orthopaedic consultant at the Northern Devon Healthcare NHS
Trust, observed that the support had “helped break through the barriers that traditionally prevent positive change”, while the Rapid Recovery Programme “surpassed expectations” and established the Trust as an exemplar site. Dr. Rasburn explained how, in 2017, Bristol wanted to run a pilot of payment per case for the whole team to see what happened to efficiency. However, ‘Agenda for Change’ presented barriers to initiating the project, so they had to use UHB theatres when they were ‘fallow’ and set up a company to employ UHB staff and pay them. This was how ‘Glanso UK’ was first established.
The pilot ran for 12 months; the Trust kept 20%-30% of the tariff and 70%-80% was used for staff payment. For any patients that stayed in overnight, the Trust was paid £300. Dr. Molyneux explained that the approach eliminates inefficiencies in the pathway, with smaller intervals (typically 5 minutes) between patients on the list. As staff are rewarded for the work they do, instead of finishing early, extra cases can be added to the list.
“Instead of being ‘punished’ for being efficient, which is the normal NHS model, staff are incentivised to receive the extra work and they are paid extra…Throughput is increased by a third and pay is up by a third, so it is a ‘win-win’ all round,” said Dr. Rasburn. “Once the whole team are aligned on productivity, with a reward for being productive, the whole team works together. The porter is knocking on the door asking: ‘can I get the next bed?’” Dr. Molyneux added. During the 12-month pilot:
l Glanso averaged 7.3 patients per [upper GI] list compared to 2.1 for surgery carried as part of the ordinary working week and 4 patients for the Waiting List Initiative.
l The average tariff per list was £11,139 for Glanso, compared to £5,300 for the surgery carried as part of the ordinary working week, and £8,439 for the Waiting List Initiative.
If lists are inefficient, a lot of work is sent to the private sector. Patients may get their operations, but this means that, instead of paying the tariff price of around £5,500 for a hip replacement, the system is effectively paying twice – the true cost of THR then becomes around £11,000. This is not the best way of using
our resources or the tax-payer’s money. Professor Tim Briggs CBE, National Director for Clinical Quality and Efficiency, NHS.
JANUARY 2022
l The average tariff per patient was £1,536 for Glanso, vs £2,470 for surgery carried as part of the ordinary working week and £2,110 for the Waiting List Initiative.
l The Trust profit for the Waiting List Initiative was 8% compared to 13% for Glanso.
Based on the results, the Trust wanted to carry on the Glanso project and expand the initiative to other specialty areas, and the project has also been rolled out to other Trusts. The initiative has successfully helped to reduce waiting times, increased profits for Trusts and rewarded staff with better pay. A huge amount of work was also carried out during the pandemic, across a variety of specialties, helping to tackle mounting waiting lists for hospitals.
“Instead of outsourcing, the Glanso approach keeps the money within the Trust and within the NHS staff teams…We like to think of this as a symbiotic relationship,” Dr. Rasburn concluded.
Productivity and the environment John Dade, president of the Association for Perioperative Practice (AfPP), gave a presentation on ‘Increasing productivity – the ecological impact’. He pointed out that the health service is currently challenged with some ambitious targets around its carbon footprint. Although NHS England published ‘Delivering a net zero NHS’ in October 2020, a show of hands suggested that awareness and readership of this publication continues to remain poor among healthcare professionals on the frontline of care. The document includes the following ambitious targets: l For the emissions we control directly (i.e the NHS Carbon Footprint): the aim is to reach net zero by 2040, with an ambition to reach an 80% reduction by 2028 to 2032
l For the emissions we can influence [for example, manufacturing and the supply chain], referred to as ‘NHS Carbon Footprint Plus’: the aim is to reach net zero by 2045, with an ambition to reach an 80% reduction by 2036 to 2039.
“With all that we need to do in terms of recovering elective surgery, have we really bought into Delivering a net zero NHS in theatres? Moreover, have we been sold it?” commented Dade. He went on to discuss the challenges and issues. A barrier often cited for recycling items is the fact that the pre-recycle decontamination process is expensive for clinically used items. The counter argument to this is the cost of clinical incineration – the figures for which are “staggering”, Dade pointed out. Another issue is the fact that many single-use anaesthetic items (for example, supraglottic airway devices) are not made
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