How Nottingham cut cancelled operations

Last year we let down many patients and families from Nottingham and further afield because we cancelled their operations. This was due to sustained pressure on our emergency services over the winter. Our patients deserved a better experience. It was a low point for me and many of my colleagues.

All Nottingham University Hospitals Trust board members were absolutely determined that we would learn from what went wrong and make significant changes to ensure we and our patients never again found ourselves in that position. I publicly made this promise to patients.

I wrote a column for HSJ last year describing the difficulties we found ourselves in. I am pleased to report that, 12 months on, we have done what we said we would do. We have significantly reduced both on the day and prior to the day cancellations as a result of the hard work of many colleagues and teams across our hospitals.

Unforgettable encounter

Let me share details of a conversation that I will never forget. I met a cancer patient during this most difficult time in June 2012. It was a humbling experience as she and a family member described their distress to me, having experienced multiple cancellations. I put myself in their shoes; I asked myself how I would feel if this was me, my wife or a member of my family? The trust’s response − then and now − reflects what I believe is our spirit of openness, transparency and accountability.

Last year, our trust board requested a review of all cancelled operations. The review, published in September, concluded that there was no single reason for the cancellations − it was a result of an unforeseen and complex interaction of interrelated organisational and service changes. 

‘pull quote’

The report supported our safety and quality reasons for making these changes to the configuration of services across our hospitals. It also described that, notwithstanding the significant number of cancellations and the pressure experienced by our hospitals and staff, our clinical outcomes remained among the finest in the country.

The report described how we made changes to patient flow in a system, which was already stressed. Although bed numbers remained the same at Queen’s Medical Centre in the run-up to winter 2011-12, the types of bed changed.

Fewer elective beds (for planned operations and procedures) were readily available for emergency use when there were peaks in demand. Our system was less able to cope with extreme day-to-day variations in demand, and we took much longer to recover from very busy days than in previous years. In the first weeks of January 2012, Queen’s became over-full with emergency patients and we had no reasonable alternative than to cancel many operations.

cross head

As all other NHS trusts are required to do, we publish our on the day cancellations. However, we made a decision very early to go further. We are the first and, I believe, only trust in the country to publish total cancellations and reasons for these − which means not only on the day cancellations, but every single cancellation, irrespective of when it occurs.

We do so mindful of the effect every cancelled operation has on our patients and those close to them. This provides a clear statement of our progress and it ensures patients receive the care and relevant information they are entitled to. We publish this information monthly on our website.

‘pull quote’

We carried out over 125,000 operations and procedures at our hospitals last year. Our total cancellation rate from January to March 2012 was 10 per cent (2,313 operations), compared to 2.77 per cent (609 cancelled operations) from January to March this year. Importantly, we achieved the national standard for on the day cancellations in January.  

Our challenge and determination now is to achieve this consistently, month on month. Our emergency and elective patients had better experiences this winter, receiving more timely and safer treatment in our care.

What we did differently

We have made significant improvements by:

• Opening extra beds (109 extra medical beds at the Queen’s Medical Centre) in 2012-13 to meet the demand on our services, as well as four additional level-two critical care beds for patients requiring intensive care.
• Reducing our elective activity in our busiest winter months at Queen’s and Nottingham City Hospital to create extra capacity and safe care for emergency patients during winter. We commissioned additional capacity in the private sector to ensure that access for our elective patients was not compromised.
• Working with clinical colleagues to review the theatre scheduling process.
• Implementing a new escalation policy to ensure senior managerial and clinical input before any operation is cancelled.
• Investigating the cause of all cancellations.
• Purchasing additional theatre equipment to reduce any delays in turnaround time (for equipment to go through the sterile process).
• Creating an ordering system that will ensure all equipment is prepared and in theatre the night before the operation, to minimise disruption to theatre lists.
• Commencing work to align our elective theatre timetable with our critical care availability.
• Ensuring our chief executive’s team reviews all cancellations weekly and the trust board does so monthly so progress is closely monitored (we publish our cancellation rates). Our integrated performance report, published monthly on our website, includes details of patients who have had more than one cancellation so that the board can closely monitor and scrutinise such cancellations.

The results

Between January and March 2012, 242 (53.3 per cent) of our on the day cancellations were due to lack of available ward beds. In the same period this year, we cancelled 24 (12.8 per cent) operations on the day for this reason.

While much has been achieved, we will continue to do everything that we can to further improve patient care. One of our biggest reasons for cancellations is the clinical priority of other patients. One of our next pieces of work will be to look at individual surgeon list levels to reduce cancellations further across each specialty. Only by drilling down to this level of detail will we be able to take our performance to the next phase.

We will continue to focus on improved scheduling, booking processes and sterile services provision. I look forward to reporting in 12 months yet more improvements to the care we provide patients and their loved ones. 

Peter Homa is chief executive at Nottingham University Hospitals Trust