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Orthopaedic Surgery

4.42 pm

Mr. Bob Blizzard (Waveney) (Lab): Most debates in this Chamber take the form of an hon. Member identifying a problem and asking a Minister to tackle it. Unusually, that is not what I want to do today. I want to tell, and share with my hon. Friend the Minister, a remarkable success story at my local hospital and to show how the whole national health service can benefit.

Our NHS has two distinctive features. First, it is free at the point of delivery, regardless of ability to pay, which is why it commands overwhelming public support. That is a principle that must never be abandoned. The second feature is not good: the wait for treatment. That is the worst feature of the NHS and is what most people want changed. The Government undertook a massive public consultation on the NHS in 2000 and waiting was by far the main concern of the millions of people who responded; that is the same today.

One of the largest contributors to overall waiting lists is orthopaedic surgery, such as elective work on hips and knees, which also has some of the longest waits. As people live longer and medical health improves, the demand for replacement of worn-out joints continues and will continue to increase. National figures and those that I have seen for my local hospital show that, over the years, those on orthopaedic waiting lists comprise at least one quarter of the total of all those waiting up to six months for treatment. On average, they have comprised those waiting six to nine months and form the vast bulk of those who have had to wait more than nine months.

The Government's record on reducing waiting lists by around 300,000 and getting waiting times down from 18 months or more under the previous Government to a maximum of nine months last year and a maximum of six months by the end of this year is one of their best achievements. They have increased resources and set targets. However, the Department of Health has said:

In January 2004, the national orthopaedic project had to be set up, in the words of the then Health Minister, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton),

With effort and drive, our aim is that by the end of December this year, no one will wait more than six months. Any objective observer would conclude that that represents huge progress since 1997. However, the wait is still six months and to an individual patient, that seems a long time, especially if he is in pain. As people forget the old 18-month waits, they will feel that the NHS is not what it should be if they have to wait for six months or even 18 weeks. As things stand, waiting is still set to be part of the NHS.

I can tell the Chamber, however, that at my local hospital, the James Paget health care trust, patients of orthopaedic surgeon Mr. John Petri do not wait for six months or 18 weeks. Mr. Petri, as I told the Prime Minister this afternoon, has no waiting list at all. Let me explain how that remarkable achievement came about.
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John Petri used to work in France. When he arrived at the James Paget, he could not understand why we had long waiting lists. The hospital at which he had worked in France was of a similar size, serving a similar size of population with fewer resources, but with no waiting lists; they were unheard of. At James Paget, there were twice as many orthopaedic surgeons and twice as many anaesthetists as in his hospital in France, but they worked in a different way, in different hours, and performed fewer operations.

In France, it was normal for a surgeon to work with two teams in two theatres, moving, after scrubbing up, straight from an operation in one theatre to another in a second. Here, he found that after an operation it was normal for a surgeon to sit around drinking tea and waiting for his one team to prepare the next patient for the same theatre. That is what is wrong with the surgery system in our hospitals. In a typical three-and-a-half-hour operating session, only two hours of a surgeon's time may actually be spent operating. As Mr. Petri put it, if we were running a factory, we would not allow our most important and expensive machine to stand idle for that length of time. I would suggest that the same is true of a surgeon in a hospital.

There was another key difference. The French hospital had three theatres, compared with two at James Paget. We have the wrong balance of resources between surgeons and theatres. In about 2000, when Mr. Petri saw more resources coming in to the NHS, he put a proposal to the management of the hospital to introduce the dual operating system there. That was when I first met him. He felt that orthopaedic patients were being let down by the NHS; there was something seriously wrong and they deserved better. Sadly, the other surgeons at that hospital did not wish to change. They said that dual operating would not work and so, at that time, did the Royal College of Surgeons. However, the chief executive of the hospital, David Hill, and his managers backed John Petri.

In 2001, Mr. Petri began a pilot scheme of one dual operating session a week, and his team visited France to see the system in operation. Quickly, his waiting list for hip operations reduced from one year to three weeks. The system worked, but more theatre space was needed for it to continue. A business case was put to the strategic health authority, and it supported it with £2 million for a new theatre, which was opened in 2003. Dual operating was phased in as additional theatre and ward staff were recruited, additional beds opened and the process was refined.

Dual operating has been running fully in 2005. Mr. Petri performs two such sessions a week in addition to one conventional session. It involves his being allocated two theatres for five hours instead of the conventional three and a half hours. Both theatres are fully staffed, and he operates on one patient while the next is prepared in a second theatre. He then moves on to the second patient, leaving a support doctor to complete the first operation by stitching up and such like. By the time he has finished in the second theatre, a third patient is waiting for him in the original theatre, and so on. He can perform two or three major operations and four or five minor ones in a five-hour session, compared with one major and a couple of minors in the conventional way. There is more flexibility and there are fewer cancellations.
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Trial figures show that in 50 operating sessions, John Petri performed 270 operations. Two colleagues, in 50 sessions each using single theatres, totalled 225 operations. That is why John Petri now has no waiting list. Not only is he maintaining that position, he is now taking patients off his colleagues' lists, reducing waiting times across the hospital.

Mr. Anthony Wright (Great Yarmouth) (Lab): My constituents in Great Yarmouth share the hospital with those of my hon. Friend. Is not the lesson to be learned from the example of that particular surgeon, that the issue is not just the resources that go into the hospitals? Millions of pounds of investment have been made in our hospital in Great Yarmouth, but does my hon. Friend not agree that his example proves the point that it is about the working practices, not just of the surgeons, but of the rest of the staff? If there is a trend towards looking at other practices across the UK and Europe and throughout the world, we can learn a lot and benefit our constituents, whom we are here to serve.

Mr. Blizzard : My hon. Friend is absolutely right. The change could not have happened without the £2 million investment from the NHS, but it would not have happened without the innovative and brave stance taken by Mr. Petri. It raises some questions—as I will go on to show—about the way in which surgeons work. I hope that there are some lessons to be learned.

Mr. Petri said to me:

He said that he feels energised by what he is doing, and that he felt sleepier under the old system, with long breaks between the operations. He has been nominated for the 2005 medical futures innovation award, and we will know tomorrow night whether he has won. He deserves to win, because he is a hero of the NHS.

Full credit, however, must also be given to the James Paget hospital, its management led by David Hill, and its board led by John Hemming. It is a top-performing three-star hospital with no deficit, which has always met all its targets and which will move to foundation status in April. The hospital backed John Petri and, as a quality organisation, managed the necessary changes. Those changes could not have been made without such management and the investment that the Government have made in the NHS.

John Petri is an innovator, but what is being achieved is also a team effort involving the support of anaesthetists, theatre staff, ward staff, sterile services staff and porters. On behalf of my constituents and those of my hon. Friend, I should like to thank all those staff who have signed up to dual operating.

Sadly, the other orthopaedic surgeons have not signed up to it. Even though dual operating has been proven to work, the other orthopaedic surgeons at the James Paget hospital will not change over to it. The historic compromise made at the birth of the NHS means that they are contracted to the hospital, not employed by it, and so the hospital management cannot require them to change.

I asked the Royal College of Surgeons to comment. I would not say that it was completely negative, but it was not yet convinced. It said that the system needed
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trialling—I pointed out that it had been going on for the best part of a year—and that it wanted to look at it more carefully. I had thought that it would be more welcoming of the idea, and would ask what we needed to do to make it work, rather than being sceptical about it. However, to be fair, the president and vice-president of the royal college will visit James Paget hospital in a couple of weeks.

I asked why other surgeons would not take up that innovation. Habit and lack of motivation must be part of the answer. The new contract for consultants seems to give them no incentive to do so; in that respect it was a missed opportunity. One should also ask whether those at the top of the NHS—those who manage the NHS—really understand what is going on down below, and whether those down below really make the effort to alert those at the top. The system of tea drinking never seems to have been challenged either from within or outside the NHS.

If surgeons do not want to change, one should also ask whether there is really a full commitment to the NHS. Are they really worried that if they have no waiting list, there will be no private patients? Do they have a vested interest in maintaining some waiting lists? Mr. Petri's private income has fallen by 10 per cent. in the past year, and he expects it to fall further. However, he said to me:

Where are the other surgeons who think like that?

Why have we got the wrong ratio of surgeons to theatres? Has the Department of Health studied the number of operations performed in relation to the number of surgeons employed over the years? Have we had the corresponding rise in the number of operations from the increased numbers of surgeons?

The number could be going down because of changes in anaesthetics. In the UK, we have traditionally made quite heavy use of general anaesthetic compared with other countries, and that entails certain dangers. As we rightly move towards more use of local anaesthetics, I am told that that will increase the pre-operative preparation time, resulting in more tea drinking for surgeons unless we change the system.

I also asked Mr. Petri whether dual operating had wider application to surgery beyond orthopaedics. "No doubt", he said. It is not applicable for longer operations but, for operations of between one hour and one and a half hours, he said that we "Could do it easily". In the light of that, on behalf of patients in my constituency and that of my hon. Friend the Member for Great Yarmouth (Mr. Wright) and patients all over the country, I must lay down a challenge to surgeons: please have a good look at Mr. Petri's example and please follow it. I ask my hon. Friend the Minister to take this matter further and to encourage the surgeons to follow that route.

"Contestability" is the new word in the national health service. Let us contest the working practices of surgeons. Our aim as a Government is to get down to a maximum wait of 18 weeks. To do that, we are reorganising primary care trusts, introducing GP-based
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commissioning, shaking up local providers and giving patients a choice of four treatment centres. I wonder whether following Mr. Petri's innovation might be a simpler way of bringing down the waiting times, but we are going down that road. Dual operating needs to be part of the new system. If it is, we might be able to exceed the 18 week target by a long way.

I am convinced that it is right to have a patient-led NHS, but patients rarely challenge doctors. They usually see them as some kind of God who can do no wrong and they tend to blame politicians for the shortcomings of the NHS. Given Mr. Petri's innovation and the reluctance or unwillingness of surgeons to adopt it, the public must ask questions of their consultant surgeons. They must challenge why their consultant is not doing dual operating and achieving a waiting list of zero.

I am not criticising surgeons' expertise, commitment to the job or care. I was admitted to the James Paget hospital with a broken hip; it was an emergency. Those who operated on me and subsequently looked after me as an out-patient were first class. I know that when I go back next year to have all the metalwork in my hip removed, I will receive excellent treatment, despite making this speech.

For a long time in this country, there has been an acceptance of waiting lists. People have never really asked why they exist; they might assume that the NHS needs more funding. None of them know about the tea drinking. How can they when they are on the operating trolley? John Petri told me of the looks on his patients' faces when he tells them that they do not have to wait at all. This should be the norm.

I hope that my hon. Friend the Minister will, as a result of this debate, undertake to examine how dual operating can be introduced in all our hospitals. After all, we know the benefits of dual operating in Westminster Hall; this debate would not have taken place at the same time as the one in the main Chamber if we did not have dual operating.

4.58 pm

The Parliamentary Under-Secretary of State for Health (Caroline Flint) : May I say to both my hon. Friends the Members for Waveney (Mr. Blizzard) and for Great Yarmouth (Mr. Wright) how grateful I am that they have had the opportunity of this Adjournment debate to discuss this issue? Undoubtedly, there are issues about resources in the NHS and I will explore them in more detail. Resources are needed, but this is not just about them; it is about thinking outside the normal framework and the traditional way in which things have always been done.

One pleasing aspect of this Adjournment debate, secured by my hon. Friend the Member for Waveney, is that it seems that in his hospital, in which my hon. Friend the Member for Great Yarmouth also shares an interest, there is a culture of opportunities for staff to raise issues and ideas. Management will then try to pay heed to those and consider where they can be introduced and supported to make a difference to the patients in Waveney and Great Yarmouth.

There has been a view, which I am glad to say is changing, that the NHS is characterised by long waits in accident and emergency, long waits to see a GP and very
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long waits to see a hospital consultant. Many patients were waiting more than 18 months for an operation. To be honest, when we came to power in 1997 the situation was out of control. It was particularly bad for patients waiting for orthopaedic operations, who would often be in pain and have restricted mobility that could affect their work and other aspects of their lives, thereby having a knock-on effect on their families.

Against that background, the changes that we have brought in, with the help of dedicated staff, have been astonishing. Gone are the days of 18-month-plus waiting times. Now nobody should wait more than nine months, and that will be down to six months by the end of the year. In 1998, the average waiting time for an orthopaedic operation was more than 19 weeks; it is now down to just 12 weeks, and it is still falling.It is our ambition that by 2008 we will have brought down the entire time from GP referral to the start of treatment to a maximum of 18 weeks.

What is heartening about today's debate is that it highlights that as well as what we are doing, we can explore problems and achieve innovation in the way that Mr. Petri has shown. It is important to examine the practices that exist and how they can work better. As my hon. Friend the Member for Waveney pointed out, not only has Mr. Petri led in this area, based on his experience of working in France, but he has convinced the team that he works with that what he has pioneered can make a difference to the patients. I am sure that that must lead to more job satisfaction—for example, from the look on the faces of patients who are told, "There are no waiting lists, so we can see you as soon as possible." That makes a welcome change from the long waits that people are often used to. I am glad to see that that, and what people expect from the NHS, is changing.

We have made a huge investment in the NHS. We have increased the budget from £34 billion in 1997–98 to £70 billion this year, and that figure will top £90 billion in 2007–08. In orthopaedics, we have increased the number of consultant doctors by more than 40 per cent., and I understand that there have been similar increases in the numbers of physiotherapists, occupational therapists, specialist nurses and theatre staff.

I read in a newspaper a call from the Royal College of Surgeons for more theatres and more staff. Clearly, in Mr. Petri's hospital there was an understanding that in order to initiate reform and shorten the waiting lists there had to be investment, and it is my understanding that that was attended to in respect of both theatre facilities and staff. We have to challenge those who say, "It's just a question of more money," by asking them, "How are you using the facilities and the staff that you already have in your hospitals?" It is always possible to come up with a thousand reasons why systems of working cannot change, but it would be nice if people occasionally looked at the example of what is happening in Great Yarmouth under the leadership of John Petri—and with the support of other hospital staff—and if they said, "If they can do it there, why can't we do it here?"

That is an issue for a patient-led NHS. Patients often accept that what they are being told is what they can expect; it is what they are used to. I hope that the recent publicity might make more trusts question how they operate. I hope, too, that patients will have read the story and will ask questions of their GPs and others. I would also like the patient representatives who are
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involved in our local patient forums, and those who are on the boards of PCTs and trusts, to say, "Well, hang on; it might not be simple to do the same thing in our community, but can we at least explore why it can't happen here as well as in Great Yarmouth?"

Orthopaedics presents particular challenges in respect of getting waiting times down. That is why we set up the national orthopaedics project. The project team built support among clinicians, and provided management support where it was most needed, and the results so far have been impressive. The number of patients waiting longer than six months has fallen from 57,000 to just over 15,000. Moreover, as I said, we are also on track to achieve our target that by the end of the year no one will wait longer than six months for an operation.

In seeking to sustain these gains and to tackle waiting times by treating people within 18 weeks of their GP referral, it is clear that resources alone will not work. Resources and reform have to go hand in hand. We need to search for innovative new ways to drive up standards. That is why we have talked about selective use of the independent sector, and that is why we are introducing greater patient choice, extending the number of foundation trusts and setting a national tariff for NHS services. These fundamental changes are part of a coherent package to revolutionise patient care, abolish the second best and reward good and popular services.

However, we need to build on that by considering what is being done in the NHS. Today we have heard about a good example of what an NHS hospital with NHS staff can achieve. I noticed the quotes from Mr. John Petri in the article in The Sunday Times. He said:

I shall take the idea of dual operating back to the Department and we shall consider it further. I know that Mr. Petri is up for an award tomorrow and I wish him all the very best. Whether he gets that award or not, he should be congratulated on not only talking the talk but walking the walk by providing the services that people need.

Innovation such as the dual-surgery approach pioneered by Mr. Petri is to be welcomed, and we need to consider further how we can complete a framework for treating people with muscular-skeletal conditions so that they can be given the most appropriate treatment as soon as possible. We have also considered how we can prevent people with such problems having falls, which lead to hospital treatment. Furthermore, we have considered how to make sure that there are packages that prevent people, particularly the elderly, coming back to our hospitals after treatment because of another, preventable, fall. Some excellent work is going on between PCTs and hospitals to put together a care package for that.

I was interested by something my hon. Friend said earlier, when we were discussing this issue, about the number of cases referred to orthopaedic surgery that do not necessarily need surgery. That is another area that can be considered; other professionals can work with GPs to ascertain whether time is being wasted on referring people to surgeons when they do not need surgery. We can look at a number of areas to reduce the waiting times for hospital care, particularly orthopaedic care.
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With unprecedented investment, the NHS has the money and staff to deliver the standard of care that all patients deserve. We have created a strong NHS and tried to reduce the influence from Whitehall. The combination of investment, support and reform can work. Average waiting times have come down by 40 per cent., but we can do more. We need to look to innovation and share best practice in professional exchange, so that the public know what they can expect and should demand from their local services. Only by doing that will we truly have a patient-led NHS that best serves patients' interests and, importantly, maintains its good reputation as an organisation that does not stand still, but can move with the times and be a health service fit for the 21st century.

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