The story of one NHS operation

“WHAT WOULD you like to see?” asks the scrub nurse as a surgeon beside her feeds a wire through a patient’s urethra. It is a Friday afternoon in Theatre 2 at Huddersfield Royal Infirmary in West Yorkshire, and the surgical team is showing your correspondent their equipment. There are tweezers “to take out the specimen”; sponge rollers to soak up the blood. There is the resectoscope, an electrified half-moon wire to burn through bad bladder tissue. “But obviously you can’t see it because it’s in the patient,” she says.

That patient—call him Mr Jones—can count himself comparatively lucky to live where he does. Calderdale and Huddersfield Trust has climbed the ladder for hospital waiting lists in recent years: 72% of patients are seen within the target time of 18 weeks compared with 59% in England overall. Mr Jones’s path through the system shows how the National Health Service (NHS) could use its resources better.

Wonks and politicians alike agree that productivity—the ratio of treatment the NHS provides to its inputs, such as labour, equipment and drugs—is a pressing problem. Hospitals have more staff than ever (see chart), yet they are doing less than they were before the pandemic. Between 2019 and 2023, the amount of surgery carried out by each surgeon decreased by 12%; the numbers are almost as bad for outpatient appointments and significantly worse for emergency care.

A paper published for an NHS England board meeting in May identified some reasons for this. Chief among them was industrial action, which since late 2022 has led to the cancellation of more than 1.4m appointments and operations. Other factors included an increased use of agency staff, longer hospital stays, maintenance backlogs and rising prices of new branded medicines and technology. That still left a mysterious productivity gap whose likely cause, the authors concluded, was a lack of “discretionary effort” from staff. Some of this may be temporary: the new Labour government has settled pay disputes with some NHS workers, for example. But many problems pre-date the pandemic.

To understand more, rewind to before Mr Jones reaches the operating table. His first interaction with a doctor would have been when he went to his general practitioner (GP), complaining of weight loss and bleeding from his rectum. It may well have taken Mr Jones a while to get an appointment: Britain has almost 16% fewer fully qualified GPs per person than other rich countries. But those symptoms were enough for his GP to refer him to hospital.

In the NHS in England only 57% of patients start urology treatment within the target time of 18 weeks (it is 69% for Huddersfield’s trust). One problem is a lack of diagnostic capacity. Britain’s number of CT scanners is among the lowest in the OECD, a club of mostly rich countries. The NHS also has a measly number of radiologists. And trusts need to be able to track and triage thousands of patients. This should be “100% automated”, says Tim Ferris, who until recently oversaw digital transformation in the NHS. But some trusts still rely on “lots of people filling out spreadsheets”. In the year to March an estimated 20,000 operations were cancelled on the day because of administrative errors.

Mr Jones is, on both counts, relatively lucky. A timely CT scan showed a thickening of the lining of his bladder; a separate test, a colonoscopy, also found polyps in his rectum. Huddersfield’s analytics are some of the most advanced in Europe: clinicians use speech-to-text software to dictate their notes, freeing more time to spend with patients. After consultation it was determined that both procedures could be done together—“front and back”, as Jonathan Cowley, a colorectal surgeon, puts it. That means a quicker recovery, too.

Around three to four weeks before the operation comes a pre-assessment with a nurse. This appointment should help reduce the risk of complications, which happen in 10-15% of operations. If a patient has diabetes, for instance, a surgeon cannot operate until it is properly controlled. Yet an estimated 1m adults in England who live with the condition have not been diagnosed. The Calderdale and Huddersfield trust works with local GPs to identify and control cases of diabetes; across the NHS, such collaboration remains rare.

Non-clinical reasons cause the last-minute cancellation of 80,000 NHS operations each year. One problem is a shortage of beds, particularly in winter. Huddersfield has got round this by ring-fencing beds for elective procedures, says Tom Strickland, the trust’s director of operations. Equipment failures are another constant headache. In a corridor a man wearing scrubs and a badge reading “theatre co-ordinator” explains that there is a slight delay in Theatre 2, caused by a problem with the ventilation system. On average, issues caused by the crumbling NHS estate disrupted services in 13 hospitals a day in the year to March 2023. Clearing the NHS’s overall maintenance backlog would cost £11.6bn ($15.2bn), about 6% of the NHS’s annual budget.

A lot of the time “you’re sitting in tea rooms, not operating”, says one former NHS surgeon who now works in the private sector. This is particularly wasteful since, with outpatient clinics, on-call duties and administrative tasks, most surgeons are actually in theatre for only one day a week. More capital investment would help, but so would better management. There are 24% fewer managers per NHS employee than 15 years ago; doctors are often not predisposed to listen to those that remain. Huddersfield’s answer is for a clinician to focus solely on theatre productivity.

Back in Theatre 2 the ventilation system has been fixed, and Mr Jones is unconscious. The lights darken. Someone runs through a final checklist on a touchscreen: “Antibiotics given? Hair removal? Is he diabetic?...” Once it is complete, the procedure can finally begin. Next door, in Theatre 1, the surgical team is using a Cambridge-made robot; its upfront costs are a cool £1.2m, but urologists already do twice as many nephrectomies as before.

After his surgery Mr Jones will be wheeled into the post-op recovery room. During the covid-19 pandemic, all elective procedures were stopped so this bay could be converted to a spillover intensive-care unit. In Huddersfield, as elsewhere, this was when the trust’s productivity plummeted. A lot of the staff redeployed to covid wards ended up taking sick leave for issues such as burnout, says Saran Ahmed, the theatre’s day-to-day manager. To get through the resulting backlogs, Huddersfield now runs theatre lists on Saturdays, paying staff a fixed cost per case to incentivise them. But “it’s a marginal gain, not a silver bullet”, says Mr Strickland.

It does not help that patients are staying longer in hospitals than they used to. That may be because less experienced managers are still learning the ropes of discharge planning. But it is also because of problems in social care. In Huddersfield 120 beds are filled by people with no one to look after them when they leave. A shortage of district nurses and physiotherapists makes it more likely that patients like Mr Jones will be readmitted.

With investments in tech, a focus on efficiency and partnerships in community care, Huddersfield has done well since the pandemic. Between March 2021 and July 2024 it leapt from the bottom quartile of trusts for patients waiting more than a year for treatment into the top. But there is still room for improvement. Getting a patient through all the steps in a surgical pathway is “like a relay”, says Mr Strickland. “There are so many hand-offs…it’s all about making sure they come together.” ■

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