This article appears as part of the Inside the NHS newsletter.

It is fairly obvious that clearing the elective waiting list backlog depends on ramping up the number of patients getting into operating theatres for surgery.

Yet the results of a new workforce survey, published today, highlight that a lack of available theatre spaces is (alongside stress and burnout) the number one gripe for the nation's surgeons.

Indeed, the most recent available data for Scotland illustrates just how much patient turnover continues to lag behind pre-pandemic levels.

As of November 2023, a total of 25,922 operations were scheduled for theatre in NHS Scotland and, ultimately, 23,645 took place (the remainder were cancelled for reasons ranging from a lack of beds or staff to patients being too ill).

This means that elective activity was nearly 13% lower than it had been back in November 2019, when a total of 27,060 operations were carried out.

That drop in productivity is a major headache given that there are currently 151,000 people in Scotland waiting for some kind of inpatient or day case procedure, compared to 80,000 at the end of 2019.

Theatre space

A report by the UK's royal colleges of surgery – including the Royal College of Surgeons Edinburgh and the Royal College of Physicians and Surgeons Glasgow – found that 60% of those working in Scotland consider access to theatre to be the main challenge facing the profession. This compared to 56% of those working in England, and 62% for those based in Wales or Northern Ireland.

UK-wide, 41% of consultant surgeons were averaging just two scheduled operating sessions per week.

Part of the problem is the infrastructure itself, with the NHS estate grappling with an ever-increasing maintenance backlog. The Herald has heard complaints from surgeons that planned operating sessions have been derailed by everything from flooding and sewage leaks to broken equipment.

A lack of beds is another major problem. The UK entered the pandemic with fewer beds than comparable countries (2.4 per 1000 versus an OECD average of 4.3 per 1000), which had two effects: firstly, elective activity had to be curtailed much more drastically than in other countries to free up enough beds to prevent the NHS being overwhelmed by Covid admissions, resulting in larger backlogs; secondly, we now lack the capacity to ramp up elective activity to clear those backlogs as fast as other nations because so many beds end up occupied by unplanned, emergency admissions.

For that reason, the Colleges call for an increase in the number of beds being ringfenced for elective admissions.

The creation of more standalone surgical hubs such as Scotland’s National Treatment Centres (most of which are facing delays) will help too, but only they have enough staff to function.

Besides surgeons, a shortage of theatre nurses and anaesthetists is also holding back recovery.

The Herald:

Conflict

Surgical workloads are becoming "unsustainable" due to both rising referrals and an increase in the complexity of the patients requiring treatment.

This is not the only issue underpinning burnout and stress among surgeons, however.

In Scotland, nearly a quarter of respondents (23%) said they were grappling with "conflict in the surgical team", and 24% said issues with the workplace culture (for example, bullying and harassment) were a major challenge.

Two thirds of surgeons in Scotland said they "always" or "frequently" work beyond their contracted hours, and more than half (52%) complained about "conflict between clinical and managerial priorities" – the highest rate in the UK – pointing to high levels of discord between frontline medics and NHS managers.

Read more:

Innovation

The report concludes that "there is an urgent need to increase theatre capacity by ensuring that existing theatre spaces are utilised to their full potential".

This isn't impossible. One trust, Guys and St Thomas in London, has reportedly slashed its waiting lists through the rollout of a monthly High Intensity Theatre (HIT) list where two teams comprising six surgeons, four anaesthetists and 18 nurses, perform an entire week's worth of operations on a Saturday.

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The innovative model sees two operating theatres run side-by-side. As soon as one procedure is completed, the next patient – already under anaesthetic – is wheeled in. Instead of 40 minutes between cases, there are just two. The initiative has been used in areas such as gynaecological oncology to speed up diagnostic procedures in patients suspected of having cancer.

Could such a model be replicated in more hospitals? It has to be worth exploring.