The president of the Royal College of Surgeons of England talks about why an increase in consultants isn’t matched by an increase in the number of operating theatres.
In the current landscape of the NHS, the headlines are dominated by a recurring theme: a system under immense strain. While the elective recovery backlog remains a top priority for the government, the reality on the ground for surgical teams is one of many hurdles. From a crumbling estate and aging IT infrastructure to the critical shortage of intensive care beds, the path to the operating theatre has never felt more congested.
Tim Mitchell, president of the Royal College of Surgeons of England, speaks with Healthcare Today about the urgent need for capital investment, the shift toward preparation lists to keep patients fit for surgery, and the expanding role of robot-assisted technology in the modern operating theatre.
You can’t open a newspaper without being hit by issues of ward space, bed availability, theatre access and maintenance challenges of hospital theatres. How are they affecting surgical throughput at the moment?
It is a significant problem. We have recently conducted our second census of the surgical workforce, and it shows broadly similar findings to those from two years ago. Little has changed over that period. More than half of consultants and other staff report that one of their main frustrations is not being able to access operating theatres for a variety of reasons, some of which you have already mentioned.
One issue is simply the number of theatres available. The vast majority of consultant surgeons have two half-day operating lists or fewer in their weekly timetable. That is partly because, over the past 20 years, there has been a significant increase in the number of consultants without a matching increase in the number of operating theatres.
Even where facilities exist, there are staffing constraints. A fully functioning theatre requires a complete team – nurses, an anaesthetist and other theatre staff – as well as a hospital bed for the patient afterwards. Critical care and intensive care beds are a particular pressure point. Many colleagues experience the frustration of arriving at work expecting to operate on a patient they have assessed and prepared, only for the case to be cancelled if, for example, a required intensive care bed is unavailable. Those beds cannot always be ring-fenced for surgical cases because of emergency demand.
For the patient who has come to hospital expecting surgery, having prepared psychologically and made the necessary arrangements in their personal life, a last-minute cancellation is absolutely devastating. Sadly, this is not an uncommon story. It reflects a combination of pressures coming together across the system.
Surgical hubs – I think there are 123 in England at the moment – are seen as part of the solution to backlog challenges. Are they a sticking plaster or are they useful?
Surgical hubs are very useful and are part of the solution to this problem. The college has been advocating for them, particularly the concept of ring-fenced facilities for elective, planned surgery, which is considered very important.
One of the difficulties is that hospitals are often full of emergency cases. Ring-fenced facilities allow surgical activity to continue even when the wider system is very busy. Surgical hubs are particularly suited to high-volume, low-complexity cases because they enable a large throughput, but they are not limited to these.
Surgical hubs must not undermine existing capacity. They need to add capacity rather than substitute for it, with appropriate staffing, rostering and efficient use. It is also important that surgical hubs include training for the next generation of surgeons. The surgical census found that trainees are concerned about their opportunities to access the operating theatre. Without training the next generation, there will not be a future service, so training must be embedded within service expansion.
“A huge amount of public money is spent on the health service, and it needs to be used as efficiently as possible.”
The Royal College has suggested that waiting lists be thought of as “preparation lists”. What does this mean?
The concept is to avoid placing someone on a waiting list and then effectively forgetting about them until their turn for an operation arrives. Waiting times can be quite long, and this creates an opportunity to ensure patients are as fit as possible by the time they come in for surgery. That can include encouraging them to stop smoking, to exercise, and to improve their cardiovascular fitness.
The college contributes to the Centre for Perioperative Care (CPOC), alongside the Royal College of Physicians and a number of other organisations, with a focus on how to improve care in the perioperative period. A key element of that work is ensuring patients are in the best possible condition when they come in for surgery.
Experience after the COVID-19 pandemic illustrated the reverse situation, where the general health of patients deteriorated between being placed on a waiting list and eventually coming in for surgery. By the time they were called, their overall health was sometimes worse than when they were first listed.
This raises several considerations. An operation may no longer be appropriate, further tests may be needed to prepare for surgery, or treatment may be required for conditions such as high blood pressure or diabetes, which can delay surgery. The aim is to avoid putting people on a waiting list, calling them later, and finding that an opportunity has been lost either to improve their fitness for surgery or, if they are not in the right condition, to ensure surgery is safe at that point.
The Royal College has described the government’s waiting list pledge as “near impossible” to meet without urgent investment. What needs to happen now to make progress on waiting times? Is it just hard cash?
A huge amount of public money is spent on the health service, and it needs to be used as efficiently as possible. At the same time, there is a major problem with NHS estates. Some buildings are literally falling apart, including issues such as reinforced autoclaved aerated concrete, and there is a substantial maintenance backlog across NHS facilities, which has a significant impact.
IT systems are also not where they should be. Many clinicians find it frustrating that systems do not interact well with each other. There is a strong view that capital investment is needed in estates and IT to help address these problems.
Alongside that, services need to be used as efficiently as possible to maintain throughput, including through measures such as surgical hubs. Returning to the 92% 18-week target by the end of this parliament is seen as very ambitious, and there is a view among a number of organisations that it may be extremely difficult to achieve.
It is difficult to identify a single solution. The reasons for the current situation are multifactorial, and any solution therefore also has to be multifactorial. Investment in estates and IT is particularly important, especially when looking to the future.
Healthcare Today has written extensively about robotic-assisted surgery. Is it the Holy Grail that people think it is?
It is important to talk about robot-assisted surgery rather than robotic surgery, because there can be a public perception of an autonomous robot carrying out an operation on its own. That is not where things stand. In robot-assisted surgery, the surgeon remains in control.
In certain fields, it has been a major advance. It is well established in prostate and kidney surgery and is becoming increasingly established in bowel surgery. From a clinical perspective, establishing evidence of effectiveness is paramount. Patients need to receive treatments that are proven to be safe and effective. That evidence base exists for prostate and kidney surgery and is developing in bowel surgery.
There also needs to be suitable regulation and governance around how it is introduced. Systems should be introduced in a structured way, with each hospital having arrangements for oversight.
A key priority is equity of access – equal access for patients across the country and equal access to training for both current and future surgeons.
“We must recognise that our workforce is one of our strongest assets; we have a duty to protect and nurture them.”
We have tried to highlight the issue of burnout in the medical profession, and it is an issue that the recent workforce census highlights. How can surgical careers be made more sustainable?
Indeed, this is borne out by our surgical census report, and it is a point we continue to highlight. We must recognise that our workforce is one of our strongest assets; we have a duty to protect and nurture them. In my meetings with ministers, they have explicitly stated their intent to make the NHS the best employer in the country. That is the standard we should be aiming for, and there is now a genuine recognition of its importance.
The responsibility also lies with individual trusts in England and health boards across the devolved nations to acknowledge this and implement the necessary support. We have seen examples of exemplary practice; Northumbria, for instance, is often held up as a beacon because of the immense support it offers its staff. We witnessed this first-hand during a visit to their hospital, which was, of course, the trust formerly led by Jim Mackey [now chief executive of NHS England].
We must be honest: across the board, workforce morale is currently poor. The NHS has functioned on goodwill for a very long time. Doctors, nurses, and all members of staff arrive at work with the sole intention of providing the best possible care; it is only right that we look after them in return.
What are your expectations for the next census report? What will you be turning to when the results come in that you won’t see change the most?
By the time of the next report, we hope to see a marked improvement in our core metrics. We want to see fewer colleagues reporting high levels of stress and burnout. We also want to see clinicians spending more time in the operating theatre, and for our trainees to report better access to high-quality training opportunities. Ultimately, we expect these improvements to translate into the broader metrics by which the health service is measured: increased productivity and a sustained reduction in the elective recovery backlog.
