“We’re doing everything that is needed. Thanks for your interest. Goodbye.”

James Gubb, 19 July 2007

A theatre on Broadway. A Hollywood actor starring at a blockbuster show. Demand is high and a waiting list is building up. But there it seems there aren’t enough ushers to put on a matinée performance, so the cast go and put on the show in a private members’ club instead – those who can’t afford to join are forced to wait, and wait…and, yes, wait, until they finally get to see the evening show on Broadway. Now think of the NHS…sound a familiar story?
John Petri, an orthopaedic surgeon, formerly under the employment of James Paget NHS Foundation Trust, is adamant that NHS waiting lists can, and should, be eliminated. But the problem is that no-one is asking the obvious question: why do we have waiting lists? It’s surely the lack of resources and the lack of doctors and nurses, right? Wrong.

According to Mr. Petri, the average orthopaedic team in the NHS has twice the number of surgeons, twice the number of anaesthetists and three times the number of operating staff as an equivalent team in France, yet performs less than half the number of operations. A feasibility study he produced showed the real problem is not a lack of staff, as been assumed by the DH, rather a lack of operating theatres.
He sent this study to Frank Dobson, the then Secretary of State for Health. Three months later he received a very nicely worded reply, which, he gruffly says could have been written in three, short and sweet sentences: “We’re doing everything that is needed. Thanks for your interest. Goodbye.”
But luckily Mr. Petri is a determined man. Not to be perturbed, he, and his CEO, pushed ahead anyway and, after 3 years of crossing the necessary ‘t’s’ and dotting those oh-so-essential ‘i’s’ to get things done in the NHS, the extra operating theatre was built. Mr. Petri could then apply his ‘dual-surgery’ technique – which was later to win him the Medical Futures Innovation Award in 2005. In essence it involves this: he’s operating in one theatre, while in the other the anaesthetist is preparing his next patient. Five or so minutes before he’s finished, the next patient is anaesthetised. When finished, Mr. Petri scrubs up, walks across the hallway to the other operating theatre and gets going.
In the old system, he would have sat drinking coffee for 40 minutes or so while the new patient was prepared for the same theatre his old patient has just come out of. But now Mr. Petri can spend 95% of his working time operating, rather than 50%. The result? He does 10 to12 operations in a day, rather than six. His waiting list? Zero.
Yet Mr. Petri himself is the first to admit that his ‘new’ technique is hardly revolutionary; more like making the most of one’s time – they already do it in France. As the Streets song runs: “Common sense, simple common sense”. And neither is it dangerous – a claim frequently raised by his colleagues who felt threatened by his ‘new’ ways of working – many more complicated operations than orthopaedics run beyond 3 hours. His take between 25 and 50 minutes each, and you don’t need the same numbers of support staff.
So, you may well ask, why’s no-one else doing this? Mr. Petri had a meeting with Tony Blair in 2005 – Mr Blair empathised with him, said the system is the Bain of his life and all that, and promised to send someone from the DH to have a look and spread best practice. Someone from the DH turned up at his hospital, but it was 6 months later and then…nothing.
This is the system’s level failing. There’s a department called the DH that even a recent Cabinet Office report describes as completely lacking direction, and a body formerly known as the NHS Modernisation Agency, now known as the NHS Institute for Innovation and Improvement, that should have been all over this. Karen Taylor, Director of Value for Money Studies in health at the NAO, says this is a huge problem, which runs deep into the heart of NHS organisations. There is such rigidity, such a culture of compliance, that finding examples of the dissemination and uptake of best practice is very much the exception rather than the rule.
But equally problematic according to Mr. Petri, are the consultants themselves – none of his colleagues, even at in his own Foundation Trust, were interested in taking up his new technique. For one, there’s no real means of making them change. Consultants work in parallel to each other, there’s no-one really managing them and there’s no common goal. A genuine partnership between management, consultants, and nurses is urgently needed.
But the real issue is they don’t want to change – and here’s where a taboo has to be broken. The patient’s interest in having their operation done as fast as possible, is not necessarily the consultant’s –at least on the NHS. Consultants have earned huge sums of money out of waiting list inefficiencies, through patients that are willing and able to pay the money to go private – and they pay 4 or 5 times as much as in France according to Mr. Petri. If waiting lists (and times) are cut, then this lucrative stream of income for consultants is also cut – indeed Mr. Petri reports that his private income has been chopped in half by the fact his ‘dual-surgery’ technique has eliminated his waiting lists. Clearly there’s a massive conflict of interests.
So what do you do? We have to accept that consultants are not all-singing, all-dancing, benevolent spirits, they are rational human beings who are, as much as the rest of us, at least slightly motivated by money. Incentive structures have to be put in place to make them want to change – make them want to cut waiting times and make them want to take up initiatives such as Mr. Petri’s ‘dual-surgery’ technique. This does not mean forcing them, which will only cause huge resentment and grind the system into even more of a paralysis than it is now. They have to want to change of their own accord.
In a sense these incentives are already being produced at a macro level through the advent of patient choice. Currently patients requiring elective surgery are guaranteed a choice of at least four hospitals, of which one can be private so long as they have the DH’s approval, they meet independent regulatory standards and can meet the NHS tariff for that particular operation. As of next year patients should, in theory, be allowed to choose from any. Bupa, in particular, are already advertising for NHS patients. Laing and Buisson calculate that if patients choose them, private hospitals could probably accommodate some 250,000 to 300,000 NHS treatments a year, including some diagnostic procedures (FT). This is significant, because so long as the choice is a genuine one, rather than one that is ‘managed’ (for example in favour of local NHS hospitals), then it should help to eliminate the public-private divide that is at the source of so much of the conflict of interest. Waiting lists should naturally be eased somewhat by private hospitals being paid the NHS tariff to take up the slack in NHS, thereby removing some of the lucrative patients that consultants earn so much out of under private fees.
The other side of the coin is the consultant contract, which represents a massive opportunity to give consultants the very incentive to change that we are talking about, but which, according to Karen Taylor, has largely been wasted. Consultants are now at least nominally paid by ‘performance activities’, but these are basically half-day blocks – little or no account is taken of what is actually done in them. A lot of coffee-drinking if Mr. Petri is to be believed. Instead, consultants could be paid per operation they carry out, or, even better, per operation weighted for the clinical effectiveness of their work (though adequate information systems would obviously have to be developed for this). Then, so long as the tariff paid per operation is not dramatically below that of private practice, waiting lists should really begin to tumble as consultants have the real incentive to operate on more NHS patients.
But will this be enough? Not necessarily, according to Care UK and Lodestone Patient Care (both of whom operate ISTCs), who employ bonus structures for their consultants, but not payment by activity. What matters as much, if not more than this, is the work culture, the professional ethos, making consultants feel valued such that they have little qualms about working, and working more efficiently at that. Both have found that NHS surgeons seconded to them are less efficient than there own – if these consultants work slightly over the programmed activity, they want to call the Royal Colleges in. What is more, Lodestone Patient Care reports that consultants employed by them complain of their productivity dropping when they are seconded to the NHS. Mr. Petri could sympathise with this – he explains how NHS consultants would be used to operating sessions in the NHS that are few, and short, typically running from 9.30am-12.30pm and 2.00pm-5.30pm and with a prevailing attitude that if you’re due to start at 4.30pm, and the computer says you normally take 1 hour 10 mins, you can’t start.
So, like everything, matters are more complex than they seem. The NHS ethos is far from productive at the moment – and this as much, if not more, the government’s fault than the hospitals and consultants that have failed to increase efficiency to cut waiting lists and improve patient care. The government’s obsession with top-down control and targets has ripped the heart out of ability of NHS organisations to innovate and drive efficiency changes. But, if the government could just keep its hands off (which is a big ‘if’) and restrain its role to advising on best practice, let the dynamic of the market work and allow hospitals more flexibility over consultant contracts, there is perhaps some hope that Mr. Petri’s vision of an NHS without waiting lists could be realised.
Unfortunately, however, his patience has worn out and he is off to work in Switzerland.
This commentary is based on a seminar given by John Petri at Civitas on 18/07/07.