The Use of Operating Theatres

The extent to which operating theatres are used and managed efficiently and effectively is a key issue in the overall use of hospital resources in Northern Ireland. Decisions relating to the use of the Services' 102 operating theatres in 21 hospitals are directly related to the availability of staff and beds, and to the volume and nature of emergency cases. The Audit Office found that some 37 per cent of available weekday theatre capacity was not used. This has to be viewed in the context of Northern Ireland's waiting lists and waiting times for treatment, which are currently the worst in the United Kingdom. Using operating theatres to their optimum could directly contribute to the reduction in waiting lists and the length of time which patients have to wait for treatment.

A report published today by John Dowdall, the Comptroller and Auditor General for Northern Ireland, examines the extent and the efficiency with which operating theatres are being used. It makes a number of recommendations which should be a timely contribution to current initiatives by the Department of Health, Social Services and Public Safety to reduce waiting lists and times, and to improve overall efficiency at local hospital level.

Main Findings

On Theatre Management and Control

The most vital element in the improvement of operating theatre efficiency is the development of an effective theatre services management structure and the establishment and implementation of a theatre policy and guidelines. Computerised data collection systems also play an important role, providing information for theatre management and operational requirements.

The report welcomes the recent developments in theatre management that have taken place (paragraph 2.82). However, the Audit Office found that there is considerable scope for further improvements and restructuring of operating theatre management in hospitals (paragraph 2.82). For example, while recognising that there is an effective theatre management structure in 15 of the theatres in the Royal Victoria Hospital we have recommended that management structures and functions be integrated throughout the 20 theatres (paragraph 2.50). We also found that:

the number of patients undergoing cardiac surgery is increasing again, including some receiving treatment outside Northern Ireland. However, while additional resources have been invested and clinical advances have increased pressure on the service, we are disappointed that action taken by the Department and other bodies has not been sufficient to ensure that the number of procedures which had been assessed and recognised as necessary over many years, has been achieved (paragraph 2.42). In this regard, the high incidence of cancelled sessions was noted (paragraph 4.16);

theatre users committees exist in most hospitals, but their key role in ensuring that theatres are used efficiently and effectively is in much need of development and the report contains recommendations on the action that should be taken by each acute hospital Trust (paragraph 2.84);

systems for the planning and monitoring of theatre activity in most acute hospitals were found to be basic, paper-based, labour intensive, and limited in their capacity; for example, Antrim Hospital (paragraph 2.81). The data collection and reporting on theatre use from these systems is therefore vulnerable to error; for example, Belfast City Hospital (paragraph 2.53). The introduction of new systems needs to be set in the context of existing budgets (paragraph 2.87). The report, however, welcomes the action being taken at some hospitals to introduce new systems; for example, Altnagelvin Hospital (paragraph 2.74);-

theatre costing facilities are not developed within hospitals' existing theatre management information systems and the Audit Office was unable to make any unit cost comparisons with hospitals elsewhere (paragraph 2.86).

On Planning and Organisation of Theatre Sessions

Consultant surgeons and anaesthetists, and theatre nursing and support staff need to function as a team to ensure that theatre services are provided in the most efficient and effective manner. The report urges Trusts to promote collaboration, teamwork and open communication amongst all surgical and theatre services staff, and especially co-operation in the co-ordination of leave, which is essential in order to optimise theatre use. The Audit Office recommends a series of measures which need to be in place to deal with, among other things, the allocation and cancellation of theatre sessions (paragraphs 3.14 and 3.15).

The report commends the attempts that are being made at individual hospitals to minimise the impact of higher priority, unplanned emergency procedures on planned elective surgery by introducing units dedicated to elective surgery and we welcome the Department's recent proposals to extend this further (paragraph 3.25).

On Measuring and Monitoring Theatre Utilisation

The extent of spare weekday theatre capacity must take account of, not only planned staff leave entitlement, but also time that has to be set aside for cleaning, maintenance, audit and training. To staff and resource all possible sessions within a hospital's available physical theatre capacity, would have significant implications that may not be cost effective or practicable in resource terms. However, sizeable spare theatre capacity of 37 per cent is a key issue. Subject to the availability of staff and other resources, there is spare, physical theatre capacity to accommodate initiatives to reduce waiting lists (paragraph 4.13).

It is important that Trusts are able to compare their performance against other Trusts, but without timely and reliable data this will not be possible. Data recorded by theatre nursing staff must be capable of being relied upon by the Department if it is to comprehensively fulfil its monitoring and planning roles. However, the Audit Office found evidence of some hospitals not using standardised definitions correctly, and of inconsistency throughout the health service, leading to concern about the validity of some of the theatre utilisation data published annually by the Department. Although we were advised of an on-going audit strategy and of a stringent validation process, there is a strong need for clearer guidance to be provided by the Department and for it to monitor the quality of data received from Trusts more closely before it is published (paragraphs 4.22 to 4.24).

Constant overruns of theatre lists by individual surgeons can result in the cancellation of operations. Theatre session start and finish times, and session under- and over-runs are monitored, but most hospitals do not yet monitor this at individual consultant level. Neither is any remedial action taken (paragraph 4.47). The incidence and reasons for constant overruns of theatre lists by individual surgeons, including when surgeons arrive late or do not turn up at all, need to be monitored closely by each hospital's clinical management. Many of these overruns will be unavoidable. However, the report recommends that, where there is good evidence that an individual consultant regularly under- or over-runs sessions, the Theatre Director should consider re-allocating theatre sessions (paragraph 4.49). The Department should also keep under review the impact of practices introduced elsewhere, for example the review of individual consultants' performance against targets, to see whether these have a beneficial effect which could then be usefully introduced in Trusts (paragraphs 4.50 and 4.53).

On Theatre Resources

Bed availability and bed management, and the availability of consultant and theatre nursing staff are major issues which affect the running of theatres.

The health services cannot operate efficiently and effectively without appropriately qualified and graded staff in post. The current level of consultant and theatre nursing under-staffing is, therefore, of concern (paragraphs 5.18 and 5.32). We welcome the action that the Department has taken to set out a definitive strategy for meeting its overall workforce commitments in the future. In view of the great importance which it rightly puts on getting appropriately qualified and trained staff in place where and when they are required, the Department needs to ensure that progress on this front is monitored and pressure maintained at the highest level, to prevent slippage and to provide support in pressing for appropriate funding (paragraphs 5.45 to 5.47).