3 The scope for improving the planning
and organisation of theatre sessions and the need to improve the
measurement and monitoring of theatre utilisation
14. Many of the reasons given by acute hospitals
for the last minute cancellation of operations are indicators
of poor management, where the planning and organisation of theatre
sessions could be improved. They include annual leave taken at
the last minute by consultants; patients not turning up for surgery;
patients found to be unfit for surgery; constant overruns of theatre
lists by individual surgeons, and beds becoming unavailable due
to the delayed discharge of patients from hospital.[22]
The Department added that principally, and increasingly over recent
years, it has been the use and availability of intensive care
and critical care capacity.[23]
15. There is a need for advance notice of planned
leave by surgeons and nurses to facilitate proper planning and
organisation of theatre lists. The C&AG's Report cited instances
in one particular hospital where planned theatre sessions had
to be cancelled because some consultant surgeons were persistently
taking leave at the last minute leaving no time for redeployment
of scheduled anaesthetic cover, and resulting in a waste of resources.[24]
We find this to be totally unacceptable.
16. The Department told us that, under new theatre
management arrangements introduced since the C&AG's Report,
such practice should not, and could not, arise and would be penalised
within current arrangements.[25]
The theatre managers and theatre user committees that are now
in place in every hospital have powers to take whatever action
is appropriate. Doctors who persistently go on leave without giving
enough notice would be in breach of contract and could face disciplinary
procedures. Offending surgeons could lose their operating time
which could then be allocated to somebody else.[26]
However, the Department has advised us that there have been no
cases where a Trust has had to initiate disciplinary proceedings
against any doctor for failing to fulfil their contractual commitments
as a consequence of persistent non-compliance with local protocols
for the notification of attendance at operating sessions.[27]
17. The most common reason for operations being cancelled
at the last minute was that the patient did not turn up for surgery.[28]
At 30%, this is much too high and we would expect the Department
to try to identify the reasons for this and, where clinically
acceptable, to be proactive in introducing appropriate measures
to lessen what is clearly a waste of valuable clinical effort
and of other resources.
18. In the NHS in England, if an operation is cancelled
by a hospital at the last minute for non-clinical reasons there
is a guarantee that offers another binding operation date within
28 days. We find it outrageous that there is no similar guarantee
in Northern Ireland and, although we have heard the Department's
comments about the shortage of funds, we strongly recommend that
it should strive to introduce such a target as soon as possible.[29]
19. A National Booked Admissions Programme is being
implemented in the NHS in England which has resulted in improvements
in the rate for patients not attending for surgery.[30]
The implementation of this national programme in Northern Ireland
should enable the Department to save on the costs of non-attenders
which the Department has calculated for 2003-04 at some £2.5
million (based on an estimated average cost of £2,500 per
operating session). The Department have told us that they are
currently exploring partial booking arrangements.[31]
Booking arrangements should be actively pursued by the Department
to minimise the cost of underutilised theatre capacity, and we
shall be monitoring closely progress by the Department in implementing
such arrangements.
20. Operations can be cancelled at the last minute
because patients are found to be unfit for surgery, yet it seems
that little use was made of pre-admission assessment clinics in
hospitals.[32] We welcome
the Department's assurance that most specialties in hospitals
are now doing a pre-assessment.[33]
We think that, unless there are prevailing clinical reasons for
not doing so, pre-assessment should be a standard procedure in
all acute hospitals in order to reduce the incidence of last minute
cancellations due to patients not being fit for planned treatment
and we recommend that the Department promotes such activity.
21. A significant cause of the last minute cancellation
of operations is where beds become unavailable due to the delayed
discharge of patients. Such bed blocking is also a big problem
in the NHS, but we cannot understand why this should be replicated
in Northern Ireland where the funding and organisation of health
and social services are integrated and should therefore present
less of a problem than elsewhere in the United Kingdom, where
the two services are separate.
22. We cannot accept that the problem is due primarily
to the unavailability of funds to enable patients to transfer
to residential or nursing accommodation or to domiciliary care,
given that the health service in Northern Ireland has some of
the highest funding in the United Kingdom. We are, therefore,
not convinced of this funding excuse for the high incidence of
last minute cancellations due to delayed discharges. The Department
must take the necessary measures, offered by good practice elsewhere
in the NHS, to improve the management of the discharging process
after treatment. This may require them to push for a greater influence
with the private sector, for example, on the siting of residential
and nursing homes.[34]
23. The Department also needs to view the consequences
of last minute cancellation of operations, for whatever reasons,
in terms of the waste of resources and nugatory cost. The rate
of, and reasons for, cancelled operations need to be systematically
measured and monitored by Trusts and the Department, and remedial
action taken to reduce, where possible, the incidence of avoidable
cancellations. Targets should be set for a reduction in cancellation
rates, and performance against these targets measured and closely
monitored.[35] We expect
to see the Department produce and monitor, a measurable monetary
reduction in the level of wasted resources arising from avoidable
cancellations.
22 C&AG's Report, Appendix 3; Q 119 Back
23
Q 14 Back
24
C&AG's Report, para 3.11 Back
25
Qq 73-74 Back
26
Qq 155-157, 194-198 Back
27
Ev 19 Back
28
C&AG's Report, para 4.25, Appendix 3, Q 120 Back
29
C&AG's Report, para 4.28; Qq 74-75 Back
30
C&AG's Report, paras 4.32-4.33 Back
31
Qq 183-185; Ev 20 Back
32
C&AG's Report, paras 4.37, 4.43 Back
33
Q 118 Back
34
C&AG's Report, para 5.11, Appendix 3; Qq 168-175 Back
35
Qq 163-166 Back
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