On the road to shorter waiting lists

Health Secretary, Andy Burnham, recently disclosed that new “entitlements” for patients are to include a right to an operation within 18 weeks of patients first seeing their GP. Primary care Trusts will be forced to send patients to a hospital in another area or, in extreme cases, for private treatment if they cannot deliver this entitlement in NHS facilities.1 In fact, the latest figures (May 2009) show that 93.7% of admitted patients and 97.8% of non-admitted patients completed their referral to treatment pathway within 18 weeks2 – but should we be setting our expectations much higher? Vanguard’s chief executive, Ian Gillespie argues that patients and clinicians in the UK should expect faster referral-to-treatment times than the current target dictates. He believes that creative use of mobile healthcare services could become part of the solution and also help the NHS to reduce its costs. He explained that he had previously worked in the US, before returning to the UK to join Vanguard, which has had a significant influence on his views on healthcare delivery. “I had concerns about the American healthcare delivery model, but what the US does well is to ensure that patients receive rapid treatment. My reason for joining the company, initially, was the belief that Vanguard could make a difference to healthcare delivery. For example, the NHS has fixed infrastructure but can use mobile theatres to control surgery costs when reacting to unexpected surges in demand,” he commented. Vanguard provides equipped mobile healthcare facilities to meet the need for extra capacity (with or without clinical staff) – including mobile operating theatres, day surgery units, endoscopy suites, recovery wards and clinics. The company already has a significant client base of Trusts throughout the UK, but is now setting its sights on further growth, not just as a provider to the NHS, but also as a supplier of services to healthcare organisations overseas. To pursue these ambitions for expansion, the management of Vanguard decided it was necessary to secure independence from parent company Nuffield – a notfor- profit, private healthcare provider. “Vanguard benefited from significant investment from Nuffield, enabling the mobile fleet to increase to 36 – the largest such fleet in the world. However, the aim of the management buy out (MBO) was to enable the company to explore additional areas of commercial activity, including international markets,” Ian Gillespie commented. “Key to the company’s strategy is to ensure it is the largest independent sector provider to the NHS, but Nuffield’s private healthcare interests and charity status presented some complexities that needed to be addressed in order to grow the business further,” he explained, adding that it was apparent that Vanguard was no longer a “strategic fit” with Nuffield’s changing aspirations. The MBO was initiated to enable the company to build and strengthen its relationships with the NHS, therefore. “We are now an independent company, once again, and have achieved stability in terms of retaining our core team – so there is continuity for our NHS customers. The original founders of the business have re-joined the management in order to strengthen and support the team,” he continued.

Capacity management

One of the ways in which Vanguard is supporting the NHS, to achieve greater flexibility, is by maintaining capacity during refurbishment – not just for operating theatres but also for endoscopy units upgrading under the National Endoscopy Programme. “Vanguard can provide inexpensive infrastructure to ensure waiting times are not increased while work is carried out. Therefore, NHS managers who are able to plan multi-site refurbishments, for example, can make big cost savings and continue with ‘business as usual’,” said Ian Gillespie. The NHS also requires flexible capacity to meet spikes in demand, which can also be provided through the use of mobile theatres. Peaks in demand may be due to seasonal influences or the fact that emergency cases take precedent over planned surgery. “These factors mean that often patients do not know when they will be treated,” commented Ian Gillespie. “I was appalled, when I returned to the UK, that people thought that ‘18 weeks’ is a success story. In most parts of the world, patients would be outraged if they had to wait this long for surgery. Why can’t patients be treated next week or even next day? You would not expect to wait this long for service in any other industry, so why healthcare?” He added that he believed that the application of lean manufacturing principles in the NHS could have the potential reduce waiting lists to zero. “To get to this point, the NHS needs to use modern tools and management techniques, as well as to ensure flexible capacity,” he asserted. “However, the NHS infrastructure has not been designed to be flexible – if you could start over, hospitals would be built very differently; there would be different process flow with different configurations so that you could extend theatre space and increase or decrease bed space. This would be coupled with lean strategies to increase throughput during demand spikes.” Some architects are starting to attempt to address this through modular designs and the concept of “health ports”, he explained. Potentially, these ports – or “docking stations” – could be built onto every community hospital or doctor’s surgery, when being designed or refurbished, allowing a mobile unit to be attached, while providing a seamless appearance to the patient. “Meeting the 18-week target is not a case of ‘we have achieved our goal and can now sit back and relax’; efforts need to be continued, and increased, to maintain the waiting time at 18 weeks and decrease it further – there can be no room for complacency. The reality of waiting targets, whatever the goal, is that the NHS will continue to need flexible capacity,” he continued. An example where extra capacity was managed using mobile theatres was at Barking, Havering and Redbridge Hospitals NHS Trust. The Trust is one of the biggest and busiest in the country and admits between 1,200 and 1,400 people every week from the waiting list for surgical operations or investigations. Towards the end of 2002, it needed to carry out an additional 4,000 operations in the following year to help reduce the length of time people were waiting for operations and the number of people on its waiting list. With its existing operating theatres already heavily used, it needed an option to quickly expand operating theatre capacity. As part of the Trust’s research to resource safe, productive and affordable additional theatre capacity, Stephen Walsh, director of elective services for the Trust went to Hinchingbrooke Hospital in Cambridge to see a Vanguard Healthcare mobile operating theatre in action and make an assessment. The Trust subsequently installed a mobile operating theatre – including some theatre nursing/ODP staff from Vanguard – at Harold Wood Hospital in Romford. At the time of the installation, Stephen Walsh told the BBC: “I was impressed by the technology and the speed with which it could be brought to the hospital – it was up and running within the space of three hours.” Consultant general surgeon, Dr Mrinal Sahary, added: “The theatre has enabled us to reduce our waiting lists and also change some of our practices to allow us to carry out more procedures as day cases. This is not only better for the patients, as they avoid an unnecessary stay in hospital, but also allows us to make better use of our resources and treat more patients.” In fact, the modular theatre helped the Trust to reduce waiting times for patients by more than half across many procedures and was used for a range of operations – including hernias, gall bladder removal, cataract removal and gynaecology operations. In 2005, the Trust installed a further mobile operating theatre at Harold Wood Hospital – complete with a specialised nursing support team from Vanguard to assist the Trust’s own surgeons and nurses.