What are the benefits of a Vanguard mobile theatre, set up as an ‘Elective hub’?

Glen, Harkamal and Chris met for this discussion at Warwick Hospital, about a month after South Warwickshire University NHS Foundation Trust began orthopaedic procedures in a Vanguard mobile laminar flow operating theatre. You can watch the meeting here or read excerpts, below.

For greater insight, there is a case study, here

And for a different perspective of this project, you can watch a conversation between Chris and Tim Robertson, Consultant Orthopaedic Surgeon at Warwick Hospital, click here

Chris:

You're performing well on the RTT (Referral to Treatment Times) league table at the moment. I think top five is what we've heard, actually. So, what was the rationale behind looking to get in a Vanguard theatre?

Glen:

Well, firstly, we've got capacity to help the rest of the NHS. Whilst we're very focused on keeping waiting times down as much as we can locally, there's a huge opportunity to improve waiting times in a lot of organizations around us. There's a number of trusts that have got some really long waits and their patients could come here quite easily for surgery.

Harkamal:

When you talk about being top five, T&O (trauma and orthopaedics) is one of the best in the country. So, it does make sense, given our experience of offering mutual aid, that that's the area that we would continue to invest in.

Chris:

I understand this is a first, or one of the first times, when the surgical hub has been created on an A&E and trauma site. Is that creating any additional challenges for you?

Glen:

It does, but I think it's the right place to undertake surgery, particularly for the age profile of the patients that we have. You can never be too sure whether there might be a complication to the surgery. So, being on a site that's got physicians, and elderly care physicians, on it, is important. I also think it's really important for the NHS to utilize all of its theatre capacity, and probably 90% of theatres are on acute sites. So, if we kind of give up on being able to get productivity out of acute sites, we've got quite a bit of trouble.

Chris:

That productivity piece is really interesting. Having a situation where you're almost standardizing the activity, having a team that's dedicated, working on the unit as well, will, I'm assuming, just help with that efficiency and that throughput. Is that what you are finding?

Glen:

Yes, we use data to compare performance between members of the team, but also with the other top performing organizations. So, we're always looking for opportunities to improve. A lot of that is around length of stay, as well as what we actually do in theatres. But the other challenge alongside that is really just protecting the elective beds to make sure that you manage urgent care.

Harkamal 's philosophy is that we simply don't cancel elective activity on this site, and that's something that she's got a lot of disciplines around. And it's a mindset in the organization.

Chris:

What I found quite interesting was that you’ve situated the Vanguard theatre slightly away from your normal surgical block, to give it that dedicated team, dedicated resource, and then straight into elective beds. Can you talk us through that?

Harkamal:

We built a corridor right off the orthopaedic elective ward and it really does improve the patient journey. Patients can visualize where they're going, and that journey is just a lot more streamlined. Every micro gain that you can make in any kind of theatre pathway really adds to the productivity and the overall efficiency, so it's important. We've got the opportunity, so we might as well take it and that's why we've made the decision to put that there. And so far, we haven't lost a single joint. We don't overrun, so, the staff experience is much better. We start on time. That's obviously better for staff and patients. So, it makes sense to try and do as much close to the patient, as you can.

Chris:

I love the philosophy around not cancelling an elective patient or elective list. And I think it sounds like having a dedicated surgery for that elective list, even if a significant number of A & E or trauma patients come in, you've still got that facility.

Harkamal:

Absolutely, and that's regardless of which theatre that's in. We do not cancel electives for beds related pressures. So, we wouldn't put emergency patients into elective bed capacity. The only reason we would ever need to cancel is if the patient isn't fit or if, you know, there's an unexpected thing with equipment or something. But as a rule, we would never cancel electives and that's even when in winter. We just wouldn't do it and that's why it makes sense to put the Vanguard closer to the ward, because we know we're not going to be using it for anything else anyway.

Chris:

Talking to Tim (Tim Robertson, Consultant Orthopaedic Surgeon at Warwick Hospital), he told us earlier that a joint replacement seems to be increasingly day case and your length of stay consequently is coming down. Is that having an impact on freeing up beds or is it just better for patients overall?

Harkamal:

A little bit of both. It obviously is better for patients. As soon as you are operated on, you want to go home and start your rehab journey. We are looking to see what more we can do in terms of any additional cases and that's sort of starting to ramp up already because we know that we can create the bed capacity to bring more patients in, as and when appropriate. It’s about optimizing the pre-op bit and then the post rehab, and getting patients home is a really, very key part of that.

Chris:

How are you finding it, having a dedicated Vanguard team on there and a dedicated consultant team as well? Is that working well?

Harkamal:

Massively, yeah. I think we're very fortunate. A lot of the staff who have come with the Vanguard have worked here before. So, they remember a lot of the faces. They understand how we work here. So, that discipline around our scheduling and starting on time, we haven't had to bring anybody on board with that and it's been quite seamless.

The Vanguard team has been brilliant. They've integrated really well and because everyone knows each other and just having that environment where everyone sees each other so often, has made sure that that integration is seamless and fast. So, within a couple of days, really, it's become business as usual.

Chris:

Glenn, I understand that you're providing support for other hospitals as well. How is that working? Because that must add a level of complication, I would have thought, in terms of managing patient lists and…

Glen:

Yeah, it does, but it's been really rewarding. We started actually within The Foundation Group, with Wye Valley, in Hereford, which is a good one-and-a-half hours away. Originally, we wondered whether patients would take that offer, but because of the way we structured the pathway, because of the way we offered follow up by our teams into Herefordshire, that's been really well received.

It’s been great for the team to work with the Wye Valley team. As well as making sure that waiting times were shorter, they shared some of their learning with each other and improved both of the services as a consequence.

Chris:

Excellent. And I'm interested in that financial case, because obviously the Vanguard comes with a cost because you have additional staff and additional capacity. The activity-based funding changed, I think, within the NHS from April onwards. Has that helped? And, the fact that you're pulling from a wider catchment, does that also support the additional cost?

Glen:

Yeah. The return of Payment By Results has been an important element within our thinking on this, as has ensuring that we get good productivity levels from the theatre. I pushed for the return to PBR because I think it's a great way to motivate clinicians and I think as long as you can build into it the ability to invest in their services, then they're very willing to do that.

Chris:

It's that mentality, isn't it, around having a significant challenge ahead of you and then being rewarded for tackling that challenge? It’s quite a big incentive for you as a trust, but also, like you say, for the consultants as well.

Glen:

Yeah, the orthopaedic block here was built a few years ago based on the old PBR model. They were very productive. We set them a challenge of a high-level workload, they delivered on that, and we were able to invest in the service, and that's a good philosophy.

Chris:

You are clearly a trust that is investing in training and training that sort of future clinicians. I think you've had Acorn House for about a year now, as well. So, are you able to use the Vanguard facility for training the next generation of clinicians or how do you see that, moving forward?

Glen:

Yes, we've been very focused on both training and research. A lot of our clinicians, including our orthopaedic team, are really involved in delivering the next level of service and sharing that learning across the NHS. So, that in itself is an attraction to recruit future staff, but also training junior surgeons and ensuring that when they're with us that they're really busy and doing what they want to do as part of their training program. So, that productivity thing is important as well.

Chris:

It's really interesting listening to you because, ultimately, it feels like the NHS has got two significant challenges among many ahead of it. One around the waiting lists in that post-COVID environment, but then also having that next generation of clinicians and consultants coming through. It seems like you're using the Vanguard theatre to help on both counts but doing it in a really clever way.

Glen:

Yeah. We gained university status a year ago and that was based on both the experience of doctors in training, we work with Warwick Medical School predominantly, but also training other disciplines of staff. So, actually, one of the other considerations of the orthopaedic team has been the way that we've developed our therapy team. Within our South Warwickshire Accelerated Transfer Team, those roles have been extended. We've got advanced clinical practitioners as part of the team, as well. So, the theory that we have is making sure that every member of staff can reach their potential and work to the top of their license and to develop their skills, is why we developed the training centre and why we tried to create a bit of a magnet for recruitment.

Chris:

Can I just ask a question around the patient management and patient flow? Pulling from different trusts, as well as managing those PTLs (Patient Tracking Lists) in a way that gets a most efficient throughput… How are you managing that?

Harkamal:

It does add a degree of complexity, just in that you've got a separate subset of patients to manage but patient tracking has been going on forever, so as long as you stick to the same rules that you’re used to, and we just use our PTLs in the same way that we always have, that's the point. I'm really passionate about not reinventing the wheel, so I get frustrated when people suggest different lists for the same thing.

We're good at that here, you know, our trauma and orthopaedic booking team, for example, are excellent. They've been validating all the way down. We know exactly what's happening with our patients. We know when they are ready to be here. We know if they've got anything coming up that we need to work around, and that's really important and has been really key to us maximizing our lists.

We have had, in the last couple of weeks, patients not being very well but we have a whole group of patients who are ready to come in at short notice. We ring them in the morning and then they come in. So, we haven't lost a single opportunity to operate since the Vanguard has been in, and we've just adopted the same approach for patients that we offer mutual aid to. We add them to our list and we manage them in the exact same way that we would ordinarily.

Chris:

I hear that also you manage that preadmissions piece very well, as well, making sure the patients themselves are the right patients to be going through the Vanguard unit, to get the right length of stay, keeping it down and not having any potential post-surgical complications.

Harkamal:

Absolutely. Having the right patient in the right place is key to ensuring productivity, a good patient outcome and a good patient experience. And the Vanguard's no different to that. So, we've adopted the same philosophy with the Vanguard.

Chris:

We've just done a little piece of work around trying to quantify the social impact and social benefit of someone having a joint replacement and having it done sooner. Obviously, you've got a financial benefit from a trust, based on PBR, whereby you know what the joint is worth, and so you know that for 81 joints…

But also, you can then start to quantify through ‘quality of life years’ added for a patient, what that is worth to them. Also, to society as a whole.

It would be really interesting to come and have a conversation with you about that and let you have that data. Ultimately, you may turn around and say, well, the unit was ‘this amount’ in terms of costs, this is a financial value added to the trust and obviously commercially sensitive, but this is the value added to the patient.

Glen:

Yeah, I think there's also a relationship between shorter elective waits and urgent care, particularly in orthopaedics. So, if we can manage those individual patients, they're less likely to come in as an emergency, which is a bigger financial impact for the NHS and a bad outcome.

Chris:

Right. It's really quite interesting when you look at that patient benefit. Obviously, there's a benefit to them. They can return to work sooner, but also they don't require carers, necessarily. Their partners may be able to go back to work, but also they don't then come into A&E, or go back to the GP. So, there's a longer-term cost saving.

Glen:

Just being able to mobilize, so that, you know, they're able to live active, independent lives. As you say, the ongoing burden on the NHS when they're not, is really significant indeed.

Harkamal:

We have looked at it through a ‘health inequalities lens’. So, within Warwickshire, it’s 16.9 years I think for women and 19 years for men in terms of the average number of years that people live in ill-health and a lot of that does link to having to wait so long to get access to healthcare. So, if you can access earlier, you'll have fewer years living in ill-health, which will have an overall cost reduction to the NHS economy. It's very important.

Chris:

I think it's really interesting. Typically, when we talk about the success factors for having a Vanguard theatre in, people often talk more around the financial side of things. I think there is a danger we overlook the patient benefit as well and the value that they get out of it and can give back to society as well. So, really good to hear your view on what that could look like for a patient.

Harkamal:

From our perspective, obviously, patients get seen sooner, it's a great experience for them. We don't want patients to be waiting too long to get that treatment. But when you look at things through a health inequalities lens, that's when I think this conversation really comes to life. So, we know that patients can live between 16 and 20 years in ill-health in this area and that has a real cost and a real impact on our local economy. So, helping people get their operations sooner, get mobilized sooner, get back to work or get back to not needing quite so much support, feels really important, and trying to reduce time spent in ill-health is absolutely a driver for us, and understanding inequality and what that means for each individual feels quite important.

Chris:

It's really fascinating and I wish I could remember the statistic, but we all know that the average life expectancy has significantly increased over the last 50 years, but the additional time someone spends actually living a healthy life during that period is significantly less. It’s about three years, I think, in additional healthy life. So, all the additional activity, as you said, actually 19 to 20 years in some instances, of people just living in ill-health. So, they are living longer, but not really getting the value or the benefit of that life.

Harkamal:

Yeah, exactly. And when you think about health inequalities, it's quite easy to think about deprivation, and that's obviously very important, and we do try and consider that within our modelling and try to understand that demographic. But aging and being elderly is the single biggest determinant of health and health inequalities. It's really vital that we think about that.

And when you look at the breakdown of our trauma orthopaedics waiting list, you know, those patients are the older generation. And so, we know that they're likely to face health inequalities. So, it feels really important that we do tackle that group and do whatever we can to bring down those waiting times.

Chris:

Yes, and the risk that once they have had a fall, is that, potentially, it doesn’t always end well…

Harkamal:

Exactly. We don't want patients coming to us via A&E. We want them here on an elective waiting list, having received really, really good pre-op, healthy, fit, willing and able to receive the treatment, receive their treatment, and then go home as quickly as possible.

Chris:

Getting ahead of when there may be complications. Amazing. It's interesting because you're using this for orthopaedics and clearly, GIRFT (Getting It Right First Time) has been a big initiative in the NHS. How is this helping with your GIRFT performance?

Glen:

GIRFT has become a real currency for productivity and clinical outcomes, and over the years it's been built up by all the clinicians in each specialty. So, our team have been quite active on GIRFT for a little while, but this has allowed us to take it to another level of demonstrating that productivity and having the capacity to use all the surgeons we have. I chair the regional elective recovery board and we get Tim Briggs along, who always puts the data up there, and it's always nice to see when South Warwickshire is towards the top of that list.

Chris:

Glenn, how's it going?

Glen:

It's going really well. So, it's been great for the team to get behind the planning of this. We built a separate corridor that gives them access to the Vanguard theatre. What that means, actually, is that in the future, we are able to drop another theatre in, as and when we need it.

The way that the team works from a productivity perspective, as well, has been great. We've been agreeing with them to increase the number of patients on the list. That pre-op element of it, to make sure the right patients are on the list, is really important. The changeover between patients is also important. But, they just really love delivering care and reducing the waiting times.

Chris:

And I guess at the end of all this, you will look back and think, ‘did we achieve what we wanted to achieve?’ So, what would you see as your key measure of success?

Glen:

Obviously, it's about reducing NHS waiting times - that's a national priority, and doing that in a way that we're ensuring that those around us with longer waiting times are accessing this, and that it's a great experience for those patients. But also, that it’s working for the organization as well. It's delivering some income that's helping us against our cost improvement target. So, it's a win-win.

Chris:

(To Harkamal) Anything to add?

Harkamal:

No. I think Glen said it all! What more is there to say? People not waiting and having a nice time when they're here.