Session 2007/2008

Eleventh Report

PUBLIC ACCOUNTS COMMITTEE

Further Report on the Use of Operating Theatres in the
Northern Ireland Health and Personal Social Services

TOGETHER WITH THE MINUTES OF PROCEEDINGS OF THE COMMITTEE
RELATING TO THE REPORT AND THE MINUTES OF EVIDENCE

Ordered by The Public Accounts Committee to be printed 13 March 2008

Report: 25/07/08R Public Accounts Committee

This document is available in a range of alternative formats.
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Public Accounts Committee
Membership and Powers

The Public Accounts Committee is a Standing Committee established in accordance with Standing Orders under Section 60(3) of the Northern Ireland Act 1998. It is the statutory function of the Public Accounts Committee to consider the accounts and reports of the Comptroller and Auditor General laid before the Assembly.

The Public Accounts Committee is appointed under Assembly Standing Order No. 51 of the Standing Orders for the Northern Ireland Assembly. It has the power to send for persons, papers and records and to report from time to time. Neither the Chairperson nor Deputy Chairperson of the Committee shall be a member of the same political party as the Minister of Finance and Personnel or of any junior minister appointed to the Department of Finance and Personnel.

The Committee has 11 members including a Chairperson and Deputy Chairperson and a quorum of 5.

The membership of the Committee since 9 May 2007 has been as follows:

Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)

Mr Jonathan Craig Mr Ian McCrea*
Mr John Dallat Mr Thomas Burns**
Mr Simon Hamilton Mr Mitchel McLaughlin
Mr David Hilditch Ms Dawn Purvis
Mr Trevor Lunn

* Mr Mickey Brady replaced Mr Willie Clarke on 1 October 2007
* Mr Ian McCrea replaced Mr Mickey Brady on 21 January 2008
** Mr Thomas Burns replaced Mr Patsy McGlone on 4 March 2008

Table of Contents

Report

Executive Summary

Summary of Recommendations

Introduction

Waiting Lists and Waiting Times

The Spare Capacity in Hospital Operating Theatres

The Cancellation of Operations

Computerised Theatre Management Information System

Appendix 1:

Extract from Northern Ireland Department of Finance and Personnel Memorandum
on the 7th and 8th Reports from the Public Accounts Committee Session 2005/2006

Appendix 2:

Minutes of Proceedings

Appendix 3:

Minutes of Evidence

Appendix 4:

Chairperson’s letter of 6 July 2007 to Dr Andrew McCormick, Accounting Officer,
Department of Health, Social Services and Public Safety

Correspondence of 20 August 2007 from Dr Andrew McCormick, Accounting Officer,
Department of Health, Social Services and Public Safety

Chairperson’s letter of 21 September 2007 to Dr Andrew McCormick, Accounting Officer,
Department of Health, Social Services and Public Safety

Chairperson’s letter of 5 February 2008 to Dr Andrew McCormick, Accounting Officer,
Department of Health, Social Services and Public Safety

Correspondence of 22 February 2008 from Dr Andrew McCormick, Accounting Officer,
Department of Health, Social Services and Public Safety

Appendix 5:

List of Witnesses

List of Abbreviations used in the Report

The Department	Department of Health, Social Services and Public Safety
Trust(s)	Health and Social Care Trust(s)

Executive Summary

Introduction

1. This report follows up the Memorandum of Response[1] to the Westminster Committee of Public Accounts’ Report on The Use of Operating Theatres[2]. It draws on written evidence which this Committee requested from the Department of Health, Social Services and Public Safety (the Department) and oral evidence taken from the Accounting Officer on 31 January 2008.

Waiting Lists and Waiting Times

2. In 2005, when the original report of the Westminster Committee of Public Accounts was published, the times that patients had to wait for their operations were very high. The Committee welcomes the significant improvement in waiting times, which has been brought about by a range of measures, including robust monitoring and performance management arrangements and the introduction of sanctions for poor performance.

The Spare Capacity in Hospital Operating Theatres

3. Operating theatre capacity is programmed for 64% use each week and over 95% of these sessions are used. While there has been some use of theatres in the evening and at weekends, principally through the use of contracts with the private sector to help reduce waiting lists, providers are still not maximising the use of the facilities.

The Cancellation of Operations

4. The Department has required Trusts to reduce the rate of cancellation of operations to 5% or less, and this has been achieved through a range of measures, including minimum notice for taking leave, the introduction of partial booking systems and the greater use of preoperative assessments. However, in 2005-06, the cancellation rate of 4.5% is estimated to have cost the health service £6.4 million of resources which were wasted or not used to best effect.

Computerised Theatre Management Information Systems

5. A new computerised management information system was planned to be in place by the end of 2006. However, although it is in place in some areas, it is not expected to be fully implemented until the end of 2008. The Committee believes that this should have been completed earlier.

Summary of Recommendations

1. The Committee welcomes the significant reductions in the size of waiting lists and waiting times for surgical procedures, but it notes that planned theatre sessions still only account for 64% of actual theatre capacity. The Committee recommends that the Department and providers strive to reduce the extent of this downtime and thereby to reduce waiting to its absolute minimum. With 36% of unused capacity, there is still room for further improvement (see paragraph 5).

2. The Committee believes that, where organisations can be motivated to make improvements, this is always better than using sanctions. Nevertheless, the “alternative offer system” is a good example of a sanction which has had the desired effect. In cases where improvement has proved difficult to achieve, or where problems are intractable, the Committee recommends that the Department considers introducing financial or other penalties. (see paragraph 8).

3. The Committee notes the Department’s assertions about the success of its sanctions policy. It should ensure that it keeps appropriate records to enable it to measure the success or otherwise of each occasion these are brought into use, so that the most effective measures are used (see paragraph 9).

4. It is evident to the Committee that, by arranging a sessional programme during the week which only uses 64% of operating theatre capacity, providers are not maximising the use of the facilities, which clearly can be brought into use when additional resources are provided for private sector assistance to clear backlogs. The Committee recommends that the Department and providers re-examine the resources applied to carrying out surgical procedures to ensure that waiting lists and access times continue to fall and that they are kept at a low level (see paragraph 12).

5. Whilst the Department’s willingness to consider alternative ways of addressing its very high waiting lists is to be commended, it must ensure that the use of operating theatres and theatre staff by any consultant acting in a private capacity, whether engaged by a patient, or engaged by the provider to reduce waiting lists, is fully costed and that such activity is subsidised by the public sector only to the extent that it is covered by negotiated contracts. When consultants undertake private work, not under contract with the health service, but using health service facilities and staff, the Committee recommends that Trusts should ensure that, at least, the full cost recovery is in place (see paragraph 13).

6. The Committee recommends that the Department ensures Trusts take all measures to minimise the number of cancelled operations. It is accepted that cancellations are unavoidable, but £6.4 million of resources are wasted or not used to best effect. The Department needs to systematically reduce its target from its current 5% and the Committee will be monitoring its success in doing so (see paragraph 17).

7. The Committee recommends that the Department prioritises the rolling out of the Computerised Theatre Management Information System. It is accepted that such a system is essential to improve theatre management and it should therefore be brought into play as a matter of urgency (see paragraph 19).

Introduction

1. The extent to which hospital operating theatres are used and managed efficiently and effectively is a key issue in the overall use of hospital resources in Northern Ireland. Decisions relating to the use of operating theatres are directly related to the availability of hospital staff and beds, and to the volume and nature of emergency cases.

2. On the basis of a report in April 2003 by the Comptroller and Auditor General[3], the Committee of Public Accounts at Westminster reported on this subject in July 2005[4]. Following this report a Memorandum of Response was published in December 2005[5].

3. This Committee is determined to ensure that the Westminster Committee’s recommendations are followed up and to monitor departments’ progress on their undertakings. In July 2007, the Committee wrote to the Department of Health, Social Services and Public Safety (the Department) asking for an update on progress against responses it had made in the Memorandum. The Department replied on 20 August 2007, and on 21 September 2007 the Committee wrote to the Department advising that it would request a further update on the Memorandum when the Accounting Officer next appeared before it. The Committee session on 31 January 2008 provided this opportunity.

Waiting Lists and Waiting Times

4. In 2005, the Westminster Committee had expressed its surprise at the extent of underutilisation of operating theatres in Northern Ireland, particularly at a time when the length of waiting lists for inpatient procedures and the times that patients had to wait for their operations, were very high. This Committee recognises that there have been significant reductions over recent years in both list sizes and waiting times. The Department told the Committee that its target for access to inpatient and day case surgery procedures is that by 31 March 2008, no one will wait more than 21 weeks. All providers were on course to deliver the target, this success having been achieved during a period of fundamental reorganisation of the health sector. It said that the main factor that affects progress is staff resources and the extent to which staff are available to undertake procedures and to make use of theatres.

Recommendation 1

5. The Committee welcomes the significant reductions in the size of waiting lists and waiting times for surgical procedures, but it notes that planned theatre sessions still only account for 64% of actual theatre capacity. The Committee recommends that the Department and providers strive to reduce the extent of this downtime and thereby to reduce waiting to its absolute minimum. With 36% of unused capacity, there is still room for further improvement.

6. The Department told the Committee that the reductions in the total numbers of patients waiting for their operations and the length of time they have to wait, have been brought about by a range of measures, including robust monitoring and performance management arrangements and the introduction of sanctions for poor performance. For sanctions, it gave the example of the introduction of the alternative offer system, whereby, if a Trust could not meet an access time target, it is obliged to incur the financial penalty of having to pay for the patient to be treated elsewhere. Approximately 100 patients had been transferred under this scheme in 2005-06, but the threat of this sanction had worked and it had not been necessary to apply it since then. The Accounting Officer made the point that when there was a possibility of a sanction being applied, the teams responded and found ways to deliver the target.

7. The Department told the Committee that if an organisation is not on track to deliver its targets, the Department had an escalation policy leading to representatives from the organisation being held to account at a higher level in the Department and, if necessary, the matter would be drawn to the Minister’s attention, though this had not often been necessary.

Recommendation 2

8. The Committee believes that, where organisations can be motivated to make improvements, this is always better than using sanctions. Nevertheless, the “alternative offer system” is a good example of a sanction which has had the desired effect. In cases where improvement has proved difficult to achieve, or where problems are intractable, the Committee recommends that the Department considers introducing financial or other penalties.

Recommendation 3

9. The Committee notes the Department’s assertions about the success of its sanctions policy. It should ensure that it keeps appropriate records to enable it to measure the success or otherwise of each occasion these are brought into use, so that the most effective measures are used.

The Spare Capacity in
Hospital Operating Theatres

10. The Department told the Committee that, of surgery sessions planned since 2005-06, over 95% of sessions had been used. However, the Committee views this against the 36% of unused theatre capacity and against the Westminster Committee’s recommendation that the Department should negotiate with consultants, within the terms of the new consultants’ contract, to work on weekday evenings and at the weekends. As the Department had advised the Committee that it could consider granting some flexibility to the terms of the consultants’ contract, the Committee asked about the rate of uptake of evening and weekend working. The Department said that there had been some uptake by consultants.

11. The main success in improving access times has been a direct result of the organisation and development of in-house provision, which, to some extent, had involved extended hours. It also said that some of the work on clearing backlogs had been undertaken through independent-sector contracts which allowed providers from that sector to use hospital operating theatres, often in the evenings and at weekends. The Department emphasised that this was not private practice in the sense of a service that is paid for by patients, but one which is paid from the public purse, as a way of addressing waiting list problems. The Committee sought further details on the percentage of private services used to reduce waiting lists and was told that 5,353 inpatient and day case procedures (3%) were carried out in 2006-07 at a cost of £16.6 million. During the same period, 43,319 (10%) outpatient assessments were carried out.

Recommendation 4

12. It is evident to the Committee that, by arranging a sessional programme during the week which only uses 64% of operating theatre capacity, providers are not maximising the use of the facilities, which clearly can be brought into use when additional resources are provided for private sector assistance to clear backlogs. The Committee recommends that the Department and providers re-examine the resources applied to carrying out surgical procedures to ensure that waiting lists and access times continue to fall and that they are kept at a low level.

Recommendation 5

13. Whilst the Department’s willingness to consider alternative ways of addressing its very high waiting lists is to be commended, it must ensure that the use of operating theatres and theatre staff by any consultant acting in a private capacity, whether engaged by a patient, or engaged by the provider to reduce waiting lists, is fully costed and that such activity is subsidised by the public sector only to the extent that it is covered by negotiated contracts. When consultants undertake private work, not under contract with the health service, but using health service facilities and staff, the Committee recommends that Trusts should ensure that, at least, the full cost recovery is in place.

The Cancellation of Operations

14. The Westminster Committee expressed concern at the reasons for the last minute cancellation of operations. These included annual leave taken at the last minute by consultants, patients not turning up or being found to be unfit for surgery, constant overruns of theatre lists by individual surgeons, and beds becoming unavailable due to the delayed discharge of patients from hospital. It recommended that the Department measure the rate and reasons for cancelled operations, and the introduction of remedial action to reduce the incidence of cancellations, particularly those which are avoidable.

15. The Department told this Committee that it had subsequently imposed a requirement on Trusts to reduce the cancellation rate of scheduled sessions to 5% or less. In both 2005-06 and 2006-07, this rate was 4.5%. It also told the Committee that the Department had imposed a requirement on Trusts to ensure that all staff give at least six weeks’ notice of planned annual or study leave. Compliance with this policy is monitored by the Trusts. Preoperative assessments had been introduced as a standard procedure, and partial booking has been introduced for all inpatient/day case procedures.

16. The Committee asked about the cost of cancelling a session in an operating theatre and was told, in a subsequent letter to the Committee, that the average cost of a cancelled session was approximately £3,860 in 2005-06. As 1,664 sessions were cancelled that year, this results in a total cost of operations cancelled to be approximately £6.4 million. The Accounting Officer told us that this estimate does not represent the true extent of any loss of resource to the health service. It assumes that none of the hospital staff and other resources involved can be diverted into other productive activities, whereas in practice, this happens. However, the Department was unable to quantify this. It is clear to the Committee that, in many cases, there is a very substantial wastage of resources, and whilst it welcomes the action taken by the Department to reduce cancellations, it is concerned at the continuing relatively high level and disruption to patients’ healthcare and recovery.

Recommendation 6

17. The Committee recommends that the Department ensures Trusts take all measures to minimise the number of cancelled operations. It is accepted that cancellations are unavoidable, but £6.4 million of resources are wasted or not used to best effect. The Department needs to systematically reduce its target from its current 5% and the Committee will be monitoring its success in doing so.

Computerised Theatre Management Information System

18. In 2004, the Department told the Westminster Committee that a new computerised theatre management information system would be in place by the end of 2006, yet in its reply in August 2007, it advised this Committee that this is not now expected to be in place until the end of 2008. The Department accepted that the project had not moved as rapidly as had been hoped and planned. The Committee believes that this project should have been brought to a conclusion earlier. Although the new system is now in place in some areas, the Committee regrets that full implementation is still not expected before the end of 2008.

Recommendation 7

19. The Committee recommends the Department prioritises the rolling out of the Computerised Theatre Management Information System. It is accepted that such a system is essential to improve theatre management and it should therefore be brought into play as a matter of urgency.

[1] Northern Ireland Department of Finance and Personnel Memorandum on the 7th and 8th Reports from the Committee of Public Accounts session 2005-06; 2 December 2005; CM 6699

[2] The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services: House of Commons Committee of Public Accounts, 18 July 2005; 7th Report of Session 2005-06; HC 414

[3] The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services: NIAO 10 April 2003; NIA 111/02, HC 552

[4] ditto: House of Commons Committee of Public Accounts 18 July 2005; 7th Report of Session 2005-06; HC 414

[5] Northern Ireland Department of Finance and Personnel Memorandum on the 7th and 8th Reports from the Public Accounts Committee Session 2005-06; 2 December 2005; CM 6699

Appendix 1

Extract from Northern Ireland Department of Finance and Personnel Memorandum on the 7th
and 8th Reports from the Public Accounts Committee Session 2005/2006

Northern Ireland
Department of Finance and Personnel
Memorandum on the
7th and 8th Reports from the
Public Accounts Committee Session
2005/2006

Presented to The House of Commons by the
Secretary of State for Northern Ireland by
Command of her Majesty

2 December 2005

CM 6699 LONDON: THE STATIONERY OFFICE LTD.

Department of Health, Social Services and Public Safety:
The use of operating theatres in the Northern Ireland Health and Personal Social services

Department of Culture, Arts and Leisure:
The Navan Centre

Glossary of Abbreviations

C&AG	Comptroller and Auditor General
DFP	Department of Finance and Personnel
DHSSPS	Department of Health, Social Services and Public Safety
HPSS	Health and Personal Social Services
HSS	Health and Social Services
IT	Information Technology
NIAO	Northern Ireland Audit Office
PFI	Private Finance Initiative
UK	United Kingdom

Department of Finance
and Personnel Memorandum
Dated 2 December 2005 on the 7th and
8th Reports from the Committee of
Public Accounts Session 2005-2006

Seventh Report
Department of Health, Social Services and Public Safety
The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services

The Committee’s main conclusions
There is no convincing explanation as to why Northern Ireland, with the highest level of funding in the UK (apart from Scotland) does not get the return on the use of its theatres which is obtainable in other parts of the UK. Relatively high per capita funding, significant idle theatre capacity and deprivation and morbidity levels that are no higher than some other areas in the UK are hard to reconcile with waiting list and waiting time performance that is the worst in the UK. This is even more inexplicable given the Department’s assertion that the current pattern of use of theatres in Northern Ireland matches the pattern of use in the rest of the UK.

The Department of Health, Social Services and Public Safety (“the Department”) notes the Committee’s comments and shares its concerns regarding the need to maximise theatre utilisation in order to reduce waiting lists and times. It is taking a range of steps to address the situation to ensure a more effective and efficient use of resources and improved patient care. The initiatives being undertaken by the Department are described in response to the Committee’s subsequent conclusions.

These include:

introduction of new management structures including a Theatre Managers’ Forum and Theatre Users’ Committees;
introduction of pre-operative assessment to reduce cancellations through patients unfit for surgery;
introduction by Trusts of more flexible working arrangements to increase the use of theatres in the evenings and at weekends to facilitate additional activity to address waiting lists; and
implementation of a Regional Theatre Management IT System to support better planning of theatre sessions and accurate monitoring of performance in theatre usage across all Trusts.

The Department is confident that the roll out of these initiatives will ensure a more efficient use of theatres and a significant reduction in waiting lists and waiting time performance in the near future.

A major element in improving operating theatre efficiency is the development of an effective theatre services management structure, and the establishment of a theatre policy and guidelines, together with computerised data collection systems. It is clear to this Committee that there were deficiencies in the management and control of operating theatres in Northern Ireland and that there is considerable scope for improvements and restructuring of operating theatre management in hospitals.

The Department notes the Committee’s comments. The issues raised by the Committee are addressed in response to Conclusions 4 and 5.

We are alarmed at the incidence of operations cancelled at the last minute for a variety of reasons, for example, patients failing to attend for surgery, patients unfit for surgery, session overruns, delayed discharge from hospital. Some of these are perfectly avoidable. Reasons given for some others are inexcusable (for example, the persistent taking of annual leave at the last minute by consultants). They result in an unnecessary waste of theatre resources, which is totally unacceptable, given that Northern Ireland has the worst waiting list performance in the United Kingdom. We expect the Department, with Trust co-operation, to measure and monitor the rate and reasons for last minute cancellations, set targets for their reduction, and invoke sanctions on staff when necessary. Proper theatre management systems must be introduced throughout the HPSS to facilitate this.

The Department notes the Committee’s comments. The issues raised by the Committee are addressed in response to Conclusions 6 and 7.

The current level of consultant and theatre nursing under-staffing and the limited availability of beds in Northern Ireland’s acute hospitals is a matter of great concern to the Committee.

The Department notes the Committee’s comments. The issues raised by the Committee are addressed in response to Conclusion 9.

The Department of Health, Social Services and Public Safety has accepted and told us that it has implemented all of the C&AG’s 43 recommendations. Measures are being taken to improve the management of theatres, including the creation of more effective theatre utilisation committees, the deployment of theatre managers with appropriate authority, and the introduction of a new theatre management information system, which will be a common computerised system across all trusts. The Department is monitoring the theatre utilisation performance of each and every trust and their implementation of the C&AG’s recommendations. While the actual use of theatre capacity has increased slightly since the C&AG’s Report, from 63% to 64%, the Department would see improving that ratio to 70% as a reasonable intermediate aspiration. We welcome this positive response but we expect the Department to ensure that more progress is made and maintained. We will be monitoring progress closely.

The Department can assure the Committee that it will ensure that further progress in relation to the utilisation of operating theatres in the Northern Ireland Health and Personal Social Services (HPSS) is made and maintained. The other issues raised by the Committee are addressed in response to Conclusions 4 and 5.

The sizeable spare capacity in hospital operating theatres that is not being utilised and its impact on patients waiting for operations

PAC Conclusions 1 & 2

Theatres are scheduled to open seven hours (i.e. two sessions) each day for five days a week. There is, therefore, significant spare capacity in the evenings and at the weekends that could potentially be used, but for the most part is not. Even within the scheduled weekday use, theatres are, on average, idle almost 40% of the time.

More use should be made of theatres during weekdays, in the evenings and at the weekends to reduce waiting lists and waiting times that currently are at an unacceptably high level compared to the rest of the UK. Patients can suffer and their health can deteriorate while waiting for hospital treatment.

The Department notes the Committee’s comments and agrees that, with waiting lists at an unacceptably high level, theatre capacity and other resources need to be used as efficiently as possible in order to make significant reductions in waiting times.

In relation to the use of the theatres in evenings and at weekends, operating theatres are routinely used for emergency surgery and, increasingly, to facilitate additional sessions for waiting list initiatives to reduce waiting times. For instance, theatres at the Tyrone County hospital have recently been used by a team of visiting surgeons to carry out an additional 200 cataract procedures over a single weekend, thereby significantly reducing waiting times for this procedure. There are similar initiatives involving local surgeons, for example, surgeons in Greenpark Trust have been routinely using theatres at weekends in recent years to carry out additional orthopaedic procedures to ensure the achievement of waiting list targets.

Following its roll out, the new regional theatre management system will facilitate the monitoring of evening and weekend working. The Department will continue to monitor operating theatre utilisation quarterly. Areas of poor performance will be raised with relevant Trusts.

The Department views the reduction of waiting lists and waiting times as a top priority and recognises that the efficient use of operating theatres is integral to this. The Minister for Health announced a major programme of elective care reform in July 2005. As a first step, a target has been set to ensure that no patient is waiting more than twelve months for inpatient or day case treatment at 31 March 2006, with maximum waiting times for major joint replacement (nine months), cardiac surgery (six months) and cataract surgery (six months). It is clear from internal weekly monitoring of waiting list performance that this reform programme has already resulted in significant improvements in inpatient and day case waiting times.

PAC Conclusion 3

We recommend that the Department review current theatre utilisation patterns at individual hospitals with a view to their maximisation, and negotiate with consultants, within the terms of the new consultant’s contract, to work on weekday evenings and at the weekends.

The Department accepts fully the need to maximise theatre utilisation in individual hospitals and will continue to review current utilisation patterns with a view to their maximisation. In relation to the use of current planned sessions, performance in Northern Ireland for 2004-2005 now stands at 95 per cent, thereby exceeding the target contained in the Bevan report[1], and highlighted in the C&AG’s report, which recommended that hospitals should aim to use 90 per cent of planned theatre time. The Department will continue to monitor and intervene where appropriate to ensure remedial action is taken when poor performance is identified.

The new regional theatre management system will also make more detailed information available on a regular basis, enabling the Department to monitor closely and benchmark theatre utilisation with a view to making maximum use of this resource.

In the context of achieving the agreed waiting list targets for 2005-2006, Trusts have been required by the Department to negotiate with consultants to maximise elective activity, including securing additional sessions for evening and weekend working. A number of such arrangements have already been introduced and this is reflected in significant improvements in waiting list performance. The Department now meets with all Trusts on a weekly basis to monitor performance towards the agreed waiting list targets.

The scope for better theatre management and control

PAC Conclusion 4

The Department has told us that it has implemented all 43 recommendations made in the C&AG’s Report, including those on theatre management and control. It has been working with Trusts to ensure that they take all the recommended measures that are needed. This is commendable, but it is important that action is sustained and we have asked the NIAO to keep progress under review.

The Department appreciates the Committee’s recognition of the progress it has made in implementing the C&AG’s recommendations. All of the recommendations relating to theatre management and control have been fully implemented, and all Trusts now have a theatre manager of the appropriate grade, a Theatre Users’ Committee made up of senior Trust staff from a range of disciplines, and have theatre policies and procedures in place. The Department has required Trusts to establish Theatre Users’ Committees that fully perform the roles and responsibilities recommended in the C&AG’s Report.

The Department is however fully committed to sustaining progress and is progressing towards resolution of any outstanding issues in relation to full implementation of all of the agreed C&AG report recommendations within the shortest possible timeframe. The NIAO has agreed that all but one of the report recommendations have been fully implemented. The final one relates to cardiac surgery and is being addressed. Cardiac surgery fast tracking has been implemented to the extent that the relevant Trust has put in place several measures to maximise throughput, such as developing and implementing protocols with regard to nurse-led procedures, including extubation and discharge. As a consequence, waiting lists for cardiac surgery have reduced by 50percent over the last year and the Department is confident that no-one will be waiting more than six months for cardiac surgery by 31 March 2006.

PAC Conclusion 5

A new common computerised theatre management information system, to be introduced in 2005 throughout the HPSS, will facilitate improved theatre management and control, giving a common, consistent information base on which to compare the performance of each and every Trust. The Department needs to ensure that the existing computerised theatre management systems developed within some Trusts are compatible with this new system and that consultants co-operate fully in managing and using the new system.

The Department notes the Committee’s comments. A new computerised regional theatre management system is in the final stages of procurement, with a supplier contract expected to be awarded early in 2006 and is expected to be fully operational by the end of 2006. The new system will facilitate improved theatre scheduling and will provide theatre managers, Theatre Users’ Committees and the Department with significantly improved information for monitoring and control purposes.

The system is being introduced in all but two Trusts, Greenpark, which has it’s own system more suited to it’s specialised needs than the regional project, and the Royal, which is procuring a new theatre management information system as part of a much wider PFI project. The Department agrees with the Committee’s recommendation that the systems in these Trusts must be fully compatible with the new system, including the production of consistent information, and has required the Trusts concerned to co-operate with the regional project to ensure that this is the case. The Greenpark and Royal Hospital Trusts are involved in the project management structures that have been established and the Department is content that their systems will produce information consistent with the new system.

A change management programme is to be introduced to ensure the full cooperation of consultants and other staff in the use of the new system. Theatre Users’ Committees will review the extent to which consultants are managing and using the new system fully and the Department will meet regularly with the Trusts, to ensure that the new system is being fully utilised.

The scope for improving the planning and organisation of theatre sessions and the need to improve the measurement and monitoring of theatre utilisation

PAC Conclusions 6 & 7

Many of the reasons given for the last minute cancellation of operations are indicators of poor management, where the planning and organisation of theatre sessions could be improved. They include annual leave taken at the last minute by consultants; patients not turning up for surgery; patients found to be unfit for surgery; constant overruns of theatre lists by individual surgeons, and beds becoming unavailable due to the delayed discharge of patients from hospital.

With appropriate management such cancellations are avoidable. The Department must view the consequences of last minute cancellation of operations, in terms of a waste of resources and nugatory cost. The rate and reasons for cancelled operations need to be systematically measured and monitored by Trusts and the Department, and remedial action taken to reduce the incidence of cancellations, particularly those which are avoidable. The Department needs to set targets for reducing cancellation rates, and performance against these targets must be measured and closely monitored.

The Department notes the Committee’s comments and shares its concerns regarding the late cancellation of operations, particularly for avoidable reasons. The Department accepts that management needs to be improved. All of the NIAO’s recommendations relating to the planning and organisation of theatre sessions have been fully implemented. In particular, theatre staff, including consultants, are now required to give at least six weeks notice of annual leave, study leave or other known commitments and this is monitored by Theatre Users’ Committees.

The Department also recognises that patients found to be unfit for surgery can result in the late cancellation of operations. It has therefore required all Trusts to introduce pre-operative assessment as a standard procedure, with theatre time not allocated to individual patients until this has taken place. In relation to patients not attending for surgery, the Department has also required Trusts to introduce partial booking (i.e. where patients are given a choice between available booking times) of all patients to minimise the incidence of cancelled operations. The Department requires all Trusts to implement these procedures as soon as possible and at the latest to be fully compliant with these measures by September 2006. It will monitor closely their impact on the level of cancellations and the reduction of waiting times.

The Department can assure the Committee that it recognises the importance of the proper management of this issue and will ensure that progress is maintained. The new Theatre Management System will facilitate the robust monitoring of the level of and reasons for cancellations. In the meantime, in the context of achieving the agreed waiting list targets, the Department will ensure the relevant information is collected and monitored. It will require Trusts to take whatever remedial action is necessary to ensure that the incidence of cancellations, particularly those that are avoidable, is minimised.

The Department will set a target for those Trusts that have not already reduced their cancellation rate of scheduled sessions to 5 per cent or less, to achieve this target level in a phased manner, dependent on an assessment of Trusts’ current performance. Different timescales for achievement of the target are necessary because of the significant variation between Trusts in the baseline cancellation rate of scheduled sessions.

PAC Conclusion 8

There was evidence of incorrect and inconsistent disclosure of utilisation data by Trusts, raising concerns about the validity of the annually published theatre utilisation data. Trusts must have timely and reliable data to compare their performance against that of other Trusts, and theatre utilisation data has to be reliable if the Department is to fulfil its monitoring and planning roles. The new common computerised theatre management systems to be introduced in 2005 throughout the acute hospital sector should facilitate this.

The Department accepts the Committee’s concerns about weaknesses in the accuracy of utilisation data provided by Trusts. The Department fully realises the importance of its need for timely and reliable data in order to fulfil its planning and monitoring roles. As a result, measures are currently being taken forward to address the current deficiencies including the revision of existing guidance where this was found to be ambiguous in relation to data definitions and developing new validation systems to verify the quality of the information provided by Trusts. This should be fully operational by 31 March 2006.

Since the Committee’s hearing a comprehensive theatre audit has been completed and standardised minimum data requirements and associated definitions for use by all Trusts are being developed. These have been included in the technical specification for the new common computerised theatre management system.

The shortage of theatre staff and the limited availability of beds

PAC Conclusion 9

The level of consultant and theatre nursing under-staffing and the limited availability of beds is a matter of great concern and it is clear to this Committee that workforce planning and management, and better bed management is needed by both Department and Trusts. The Department told us it has now set out a definitive strategy for meeting its overall future workforce commitments, but pressure needs to be maintained by the Department to prevent slippage. It also needs to look to best practice on bed management, and to increase the volume and range of day surgery procedures to release hard-pressed inpatient surgical beds.

The Department shares the Committee’s concerns regarding the need to have sufficient numbers of consultant and theatre nurse staff in place as well as beds for patients requiring surgery. The actions taken by the Department have ensured that staffing levels in the delivery of front line healthcare services in Northern Ireland compare favourably with those in the rest of the UK, as do the numbers of beds available. However, in line with international trends, greater numbers of healthcare staff will be required in the coming years.

In order to meet this challenge the Department and Trusts have significantly revised their workforce planning procedures and put in place a strategy to ensure that there is a better match between the supply and demand of appropriately trained staff to meet service needs, and prevent slippage in this area. The workforce planning cycle comprises a major review every three years, with annual update reviews. These are carried out for each clinical professional group in the HPSS, and a number of supporting groups.

Since 2000 the number of consultant surgeons has increased by 11 per cent, whilst the number of trainee surgeons has increased by 18 per cent. The benefits of this increase in trainee surgeons will be reflected in consultant numbers from 2006 onwards. Similarly, since 2000 there has been a 10 per cent increase in consultant anaesthetists, coupled with 60 per cent more trainee anaesthetists.

Regarding the nursing workforce there has again been significant investment in staff recruitment and training, with the numbers of pre-registration nurse training places having increased by 30 per cent between 2000 and 2004.

The Department also accepts the Committee’s comments in relation to best practice on bed management, and the need to increase the volume and range of day surgery procedures. In relation to bed management, the Department has required Trusts to develop plans detailing actions to be taken to facilitate the earlier discharge of patients and to reduce the average length of stay consistent with best practice elsewhere in the UK. A target has been set to reduce delayed discharges in 2005-2006 by 15 per cent compared to 2003-2004 levels. In addition, the Department also requires Trusts to develop plans to increase the proportion of surgery carried out as day cases, and in doing so to compare current day case rate performance with best practice rates. The proportion of surgery carried out as day cases has increased by 4.8 percentage points over the last five years to 31.1 per cent.

[EXTRACT]

[1] The Management and Utilisation of Operating Departments, Professor Bevan, for NHS Management Executive, 1989.

Appendix 2

Minutes of Proceedings
of the Committee Relating to the Report

Thursday, 31 January 2007
Senate Chamber, Parliament Buildings

Present: Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Jonathan Craig
Mr Simon Hamilton
Mr David Hilditch
Mr Trevor Lunn
Mr Ian McCrea
Mr Mitchel McLaughlin
Ms Dawn Purvis

In Attendance: Mrs Debbie Pritchard (Principal Clerk)
Mr Jim Beatty (Assembly Clerk)
Mrs Gillian Lewis (Assistant Assembly Clerk)
Mrs Nicola Shephard (Clerical Supervisor)
Mr Ricky Shek (Clerical Officer)

Apologies: Mr Patsy McGlone

The meeting opened at 2.00pm in public session.

3.50pm Mr McLaughlin left the meeting.

5. Evidence on the Memorandum of Response: The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services.

The Committee took oral evidence on the Memorandum of Response: the Use of Operating Theatres in the Northern Ireland Health and Personal Social Services from Dr Andrew McCormick, Accounting Officer, Department of Health, Social Services and Public Safety (DHSSPS), Mr Andrew Hamilton, Deputy Secretary, Healthcare Policy Group, DHSSPS, and Mr Dean Sullivan, Director of Planning and Performance, DHSSPS. The witnesses answered a number of questions put by the Committee.

Members requested that the witnesses should provide additional information on some issues raised during the evidence session to the Clerk.

4.05pm The evidence session finished and the witnesses left the meeting.

[EXTRACT]

Thursday, 13 March 2008
Room 144, Parliament Buildings

Present: Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Jonathan Craig
Mr John Dallat
Mr David Hilditch
Mr Trevor Lunn
Mr Ian McCrea
Ms Dawn Purvis

In Attendance: Mr Jim Beatty (Assembly Clerk)
Mrs Gillian Lewis (Assistant Assembly Clerk)
Mrs Nicola Shephard (Clerical Supervisor)
Mr Ricky Shek (Clerical Officer)

Apologies: Mr Thomas Burns
Mr Simon Hamilton
Mr Mitchel McLaughlin

The meeting opened at 2.05pm in public session.

2.06pm Mr Hilditch joined the meeting.

2.07pm The meeting went into closed session.

2.08pm Mr Dallat joined the meeting.

2.14pm Ms Purvis joined the meeting.

5. Consideration of the Committee’s Draft Further Report on The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services.

Members considered the draft report paragraph by paragraph. The witnesses attending were Mr Kieran Donnelly, Deputy C&AG, Mr Terry Woodhouse, Director of Value for Money, and Mr Joe Campbell, Audit Manager, NIAO.

The Committee considered the main body of the report.

Paragraphs 1 - 4 read and agreed.

Paragraph 5 read, amended and agreed.

Paragraphs 6 and 7 read and agreed.

Paragraph 8 read, amended and agreed.

Paragraph 9 read and agreed.

Paragraphs 10 and 11 read, amended and agreed.

Paragraph 12 read and agreed.

Paragraph 13 read, amended and agreed.

Paragraphs 14 and 15 read and agreed.

Paragraphs 16 – 19 read, amended and agreed.

The Committee considered the Executive Summary of the report.

Paragraphs 1- 5 read and agreed.

Agreed: Members agreed to write to the Accounting Officer, Department of Health, Social Services and Public Safety to seek clarification on the cost of cancelling an operating theatre session.

Agreed: Members ordered the report to be printed.

Agreed: Members agreed that the Chairperson’s letters to the Accounting Officer, Department of Health, Social Services and Public Safety (DHSSPS), and the responses from the Accounting Officer, DHSSPS, would be included in the Committee’s report.

Agreed: Members agreed to embargo the report until 00.01am on 24 April 2008, when the report would be officially released.

Agreed: Members agreed that they would not hold a press conference.

2.58pm The witnesses left the meeting.

[EXTRACT]

Appendix 3

Minutes of Evidence

31 January 2008

Members present for all or part of the proceedings:
Mr John O’Dowd (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Jonathan Craig
Mr Simon Hamilton
Mr David Hilditch
Mr Trevor Lunn
Mr Ian McCrea
Mr Mitchel McLaughlin
Ms Dawn Purvis

Witnesses:

Mr Andrew Hamilton
Dr Andrew McCormick
Mr Dean Sullivan

Department of Health, Social Services and Public Safety

Also in attendance:

Mr John Dowdall CB		Comptroller and Auditor General
Mr Ciaran Doran		Deputy Treasury Officer of Accounts

1. The Chairperson (Mr O’Dowd): The second part of the session is something of an innovation for the Committee. The Committee is determined to see that the Westminster Public Accounts Committee’s recommendations are followed up and to monitor Departments’ progress on their undertakings to us. Therefore, for the first time, we will hear evidence from an accounting officer on a report published in July 2005, ‘The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services’.

2. Dr McCormick, last August you gave the Committee a highly detailed response to this Committee on the Westminster Public Accounts Committee’s report on the underutilisation of operating theatres here. The efficiency of operating theatres has made a major impact on the service offered to patients and on public confidence in being treated within a reasonable time.

3. The Committee is keen to hear about the progress that has been made since your predecessor appeared before the Westminster Public Accounts Committee in November 2004. We are aware of a sizeable reduction over recent years in the length of waiting lists and in the time that patients must wait for operations. Before I open the floor to members, what plans have you to reduce further the waiting lists? Some people have had to wait far too long for operations. To what extent does the underutilisation of operating theatres have an adverse effect on your ability to effect reductions?

4. Dr McCormick: That is an important aspect of what the Department is trying to achieve. I have good news to report on reducing access times. Any member who is not present today will want to be informed about what I am about to say because the Department monitors access times carefully.

5. The target for access to inpatient and day-case surgery procedures is that by March 2008 no one will wait more than 21 weeks, and all providers are on course to deliver that highly significant improvement. At the time of the Westminster Public Accounts Committee’s report, some 12,000 people were waiting more than six months; by March 2007, no one was waiting more than six months. The target is to reduce the wait to 21 weeks by March 2008.

6. That reduction is the result of the major successes of clinicians and managers across the trusts. It is important to pay tribute to the chief executives, the management teams and the clinicians who have delivered that target. It is a remarkable turnaround. We have been undergoing fundamental reorganisation, which has made the task all the more difficult.

7. We are now using 95% of theatres. The main factor that affects progress is staff resources, consultants, specialist nurses, and so on. What matters is the extent to which staff are available to undertake procedures and to make use of theatres. It is not that limitations on theatre utilisation have been inhibiting progress on waiting lists; on the contrary, that problem is diminishing rapidly. There has been major progress on improving access times, and we want to pay tribute to the system for the success that has been achieved.

8. The Chairperson: I welcome Dean Sullivan. Two members will ask questions on behalf of the Committee; after that, we will open up the floor for questions.

9. Mr Hilditch: The departmental response states that if there are poor waiting times, sanctions may be used. What is the nature of those sanctions, and have they been used?

10. Dr McCormick: There are several dimensions to that. In the past few years, an important innovation on our approach to waiting list management has been to introduce the alternative offer system: if a trust says that it cannot meet an access time target, it is obliged to pay for the patient to be treated elsewhere. Therefore the target is meant for the individual, but the sanction on the provider is that they pay for something that they have not provided, so it is a financial penalty. That has not been used extensively. I am not even sure whether it has been necessary to apply it, because the trusts have succeeded and they have been meeting their targets. When there was a possibility of a sanction being applied, the teams responded and found ways to deliver the target.

11. The second aspect relates to our approach to performance management arrangements. If the information shows that an organisation is not on track to deliver its targets, we have an escalation policy, so the routine monitoring is handled by the service delivery unit and the team. If there is a problem or a breach, representatives from the organisation are required to attend meetings or they are held to account at a higher level in the Department. Following that, it may be drawn to the Minister’s attention if necessary; although that has not often been necessary.

12. Our ultimate message is that the role of organisations is to deliver targets; that is their purpose. People recognise their value, and they want to achieve certain standards. Clinicians and the whole team are committed to doing better. There has been a strong willingness to engage with the process, even in the context of financial constraints and equality and safety issues. The performance has been strong, and it is important to recognise that and pay tribute to those who have delivered it.

13. Mr Hilditch: Has the threat of sanctions been sufficient?

14. Dr McCormick: Yes.

15. Mr Dean Sullivan (Department of Health, Social Services and Public Safety): Approximately 100 patients were transferred under the alternative offer scheme in 2005-06. That is a drop in the ocean compared to the number that was treated that year. Since then, there has been little or no need to use sanctions because the fact that they exist at all has meant that the trusts have known that we would seek to use them when appropriate. Their very existence has meant that we have not had to use them.

16. Mr Hilditch: The Department told the Westminster Committee that a new information-management system would be implemented by the end of 2006. A departmental response, which was sent in August 2007, stated that the new system was not expected to be in place until the end of 2008. The Public Accounts Committee is therefore concerned about the two-year delay in its implementation.

17. Dr McCormick: The project did not move as rapidly as we had hoped and planned. Again, it was necessary to implement a proper procedure that would allow us to ensure that the system was the correct one, that it was understood correctly, and that the professionals and managers who would use it would buy in to it. Time was taken to do that, and we think that that was a worthwhile exercise. Obviously, it would have been desirable to have had the system implemented sooner. Nevertheless, it is now in place in some areas, and last month’s foresights stated clearly that by June this year, it will be in at least one site in each trust. It will be implemented fully in all trusts by the end of the year.

18. There was also some disappointment on our part that implementation had been slower than we had hoped. However, we are determined to see the project through and to secure the value from it. The best way in which to guarantee that people will use and get the full value of it is to take the time to draw them together and to make sure that they have an input into its development.

19. Mr Hilditch: Has there been any further slippage on the date?

20. Dr McCormick: No, the project is on track.

21. Mr Hilditch: The Department reported that the overall utilisation of operating theatres was 95·5% in 2005-06, which exceeded the target that was set in the Bevan Report. Has that rate been maintained since then, and have all hospitals met that target?

22. Dr McCormick: Yes, we have been advised that that continues to be the up-to-date figure.

23. Mr Sullivan: The figure was 95·5% in 2006-07 and 95·8% in the first six months of 2007-08.

24. Mr Lunn: The Department said that it would consider granting some limited flexibility to allow consultants to work in the evenings and at weekends where there was a risk to the achievement of waiting-time targets. What has been the rate of uptake on that?

25. Dr McCormick: There has been some uptake. The main success in improving access times has, primarily, been a direct result of the organisation and development of in-house provision. To some extent, that has involved extended hours. Given that part of the problem was dealing with backlogs rather than long-term capacity, it has been possible to undertake some of that work through independent-sector contracts that allow providers from that sector to use our theatres. That has happened regularly, and a lot of work through those contacts has been done in the evenings and at weekends. That has played a large part in clearing the backlogs, particularly where some specialities are concerned. Therefore, we have made sure that we have made the best possible use of all available resources to allow us to deliver the targets and to ensure that we are making the right progress.

26. Mr Lunn: Did you say that a great deal of private work is being done in the evenings and at weekends?

27. Dr McCormick: Work was being done at those times when we needed to contract with an independent or private-sector provider to allow trusts to devise a procedure — or a suite of operations — to deliver a target. It is not private practice in the sense of a service that is paid for by the patients: it is paid from the public purse, as a way of addressing waiting list problems.

28. Mr Lunn: Are consultants willing to embrace the opportunity?

29. Dr McCormick: Yes. It has worked in practice. There is no way that we would have made progress without the clinicians’ commitment.

30. Mr Lunn: The Department has told us that during 2005-06, 4·5% of operations were cancelled against a target of 5%. That was a good achievement. What was the target — and the outcome — for 2006-07?

31. Dr McCormick: My understanding is that it was 4·5% in 2006-07.

32. Mr Lunn: What is the cost of cancelling a session in an operating theatre?

33. Mr Sullivan: It is difficult to determine the precise cost. The Department believes that cancellation costs potentially around £1 million for each percentage point. The Department tends to take account of the level at which those last percentage points can be brought towards 100% of the planned and funded theatre capacity, rather than the level of individual sessions. The Department is happy to provide the Committee with an indication of the cost of the cancellation of an individual session.

34. Mr Lunn: You have almost given us the figure — £4·5 million per annum.

35. Mr Sullivan: If it were possible to totally eliminate all cancellations, that would be correct.

36. The Chairperson: No other members have indicated that they wish to ask a question. Can you provide the Committee with the percentage of private services that are being used to reduce waiting lists?

37. Dr McCormick: Yes.

38. The Chairperson: Thank you for that additional information on the use of operating theatres. The Committee will consider your evidence in due course and may make further recommendations.

39. Before you go, I must mention that Mr Dallat would have liked to have asked several questions on domiciliary care, and the Committee shall forward those to you. I believe that you will provide the Committee with more information on the UK Homecare Association. We do not usually encourage the submission of written evidence, but I appreciate that the paper was tabled late and that it was, therefore, difficult for you to garner all the evidence.

40. Thank you for your co-operation. Your presentation has proved useful.

Appendix 4

Correspondence

Chairperson’s letter of 6 July 2007 to Dr Andrew McCormick

NIA Logo (Black).ai

Public Accounts Committee
Parliament Buildings
Room 371
Stormont
BELFAST
BT4 3XX

Tel: (028) 9052 1208
Fax: (028) 9052 0366

PUBLIC ACCOUNTS COMMITTEE

Date: 06 July 2007

Dr Andrew McCormick
Accounting Officer
Department of Health, Social Services & Public Safety
Room C5.11
Castle Buildings
Stormont
Belfast
BT4 3SQ

Dear Andrew

Memorandum of Response: The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services

The Committee has requested that I write to you for an update on the progress against the Department’s responses to the Committees conclusions, including the main conclusions, of the House of Commons Committee of Public Accounts report ‘The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services’.

I would be grateful if we could have your response by Wednesday, 22 August 2007.

Yours sincerely

John O’Dowd
Chairperson

Correspondence of 20 August 2007 from Dr Andrew McCormick

From the Permanent Secretary
and HSC Chief Executive
Dr Andrew McCormick

20 August 2007

John O’Dowd
Chairperson
Public Accounts Committee
Parliament Buildings
Room 371
Stormont
Belfast
BT4 3XX

Dear John

Memorandum of Response: The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services

Your letter of 6 July sought an update on the progress against the Department’s responses to the Committee conclusions of the House of Commons Committee of Public Accounts report ‘The Use of Operating Theatres in the NI HPSS’.

Please find attached at Annex 1 to this letter the conclusions and updated responses as requested.

Andrew McCormick

Annex 1

The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services

August 2007: Updated DHSSPS responses to the main conclusions of the House of Commons Committee of Public Accounts report of 2 December 2005

There is no convincing explanation as to why Northern Ireland, with the highest level of funding in the UK (apart from Scotland) does not get the return on the use of its theatres which is obtainable in other parts of the UK. Relatively high per capita funding, significant idle theatre capacity and deprivation and morbidity levels that are no higher than some other areas in the UK are hard to reconcile with waiting list and waiting time performance that is the worst in the UK. This is even more inexplicable given the Department’s assertion that the current pattern of use of theatres in Northern Ireland matches the pattern of use in the rest of the UK.

At the time of the Westminster Committee of Public Accounts report in December 2005, the Department confirmed that it shared the Committee’s concerns regarding the need to maximise theatre utilisation in order to reduce waiting lists and times. In its response the Department outlined a number of steps being taken to ensure a more effective and efficient use of resources and improved patient care. These included the introduction of new theatre management structures, pre-operative assessment services, more flexible working arrangements within Trusts to facilitate additional evening and weekend activity, and the implementation of a regional Theatre Management System to ensure better planning and monitoring of theatre usage across all Trusts.

Since the Committee published its report there have been significant improvements in waiting times for surgery. At the quarter ending September 2005, there were almost 47,000 people waiting for inpatient or daycase treatment. Of these, almost 12,000 were waiting more than six months, 2,500 more than twelve months, and 300 were waiting in excess of two years.

Since then, both the total numbers waiting and the length of time patients wait have fallen significantly. At the quarter ending March 2007, 38,000 people were waiting for inpatient or daycase treatment and no-one was waiting more than six months. By March 2008, we expect to see the maximum waiting time for inpatient or daycase treatment reduce to 21 weeks.

These reductions have been brought about by a range of measures, including robust monitoring and performance management arrangements and the introduction of sanctions for poor performance. These measures have acted as incentives to Trusts to improve performance and ensure that they are making the most efficient use of resources, including theatres, to achieve the maximum waiting time targets.

As confirmed in the Department’s response to the Westminster Committee’s report, theatre managers and Theatre Users Committees, comprising senior staff from a range of disciplines, are in place across all trusts. Theatre policies and procedures are also in place.

The Department advised the Westminster Committee that it was in the process of procuring a regional, computerised theatre management system, expected then to be fully operational by the end of 2006. This new system would facilitate improved theatre scheduling and provide theatre managers, Theatre Users’ Committees and the Department with significantly improved information for monitoring and control purposes.

Due to difficulties experienced with the procurement process, the roll-out of this new system was delayed. However, procurement is now complete and the system was piloted in Belfast City Hospital in April 2007. The system is now in place across the Belfast City Hospital site and has been deployed in the main theatres at Causeway Hospital. A timetable for full implementation is currently being finalised with Trusts and it is expected that the regional theatre management system will be in place across all Trusts by the end of 2008.

Around the time of publication of the Westminster Committee’s report, the Department wrote to all Trusts in November 2005 outlining the key actions for Trusts arising from the report. This letter required Trusts to collect and monitor information on the rate and reasons for cancellations and to aim to reduce the cancellation rate of scheduled sessions to 5% or less.

With regard to sessions cancelled as a result of consultant leave, the Department requires Trusts to ensure that all staff give at least six weeks’ notice of planned annual or study leave. All Trusts have confirmed that this is the case and compliance with this policy is monitored by Theatre Users’ Committees.

With regard to operations cancelled at the last minute because patients are found to be unfit for surgery, the Department has required all Trusts to introduce pre-operative assessment as a standard procedure. This will ensure that theatre time is only allocated once patients have been assessed as medically fit and have confirmed that they are willing to undergo surgery. The Department’s Service Delivery Unit has recently issued further guidance on effective pre-operative assessment, and is working closely with Trusts to ensure that it is fully applied by March 2008.

In order to minimise the level of cancelled operations, the Department has also required Trusts to introduce partial booking for all inpatient/ daycase procedures. This will ensure that patients have an opportunity to agree a suitable date and time for their surgery, thereby reducing the likelihood that they will cancel at the last minute. The Department has established that more work is required to ensure that effective partial booking is in place for all inpatient and daycase specialties and we are working very closely with Trusts to ensure this is achieved.

The current level of consultant and theatre nursing under-staffing and the limited availability of beds in Northern Ireland’s acute hospitals is a matter of great concern to the Committee.

The Department continues to recognise the importance of ensuring that sufficient suitably qualified staff are available to meet the needs of the health service. A comprehensive programme of workforce planning reviews is in place to establish information on the supply and demand of staff in the main clinical professions and in a number of supporting groups in the Health and Social Care (HSC) services. These reviews also ensure that the Department is fully aware of the issues impacting on recruitment and retention and career progression. The workforce planning cycle comprises a major review of each group every three years, supported by annual update reviews. The purpose of the annual update reviews is to maintain current workforce information and identify any new issues impacting on the workforce group thereby enabling any necessary action to be taken at an early stage.

In recent years there have been further significant increases in the number of consultant and nursing staff. Between September 2003 and March 2006, the number of consultants increased by 13% and the number of qualified nurses increased by 8%. In addition, between 2000/01 and 2005/06, the number of commissioned student nurse places increased by 750 per annum.

With regard to improved bed management, new targets have been set to reduce the number of delayed discharges from acute hospital beds. By March 2008, all patients with complex care needs must be discharged from an acute hospital setting within 72 hours. All other discharges must take place within six hours. We are working very closely with Trusts to support the achievement of this target. In addition, the targets that have been set to reduce the length of time patients wait for surgery require Trusts to make the most efficient and appropriate use of available beds. For example, more patients are now having their treatment in one day - between 2000/01 and 2005/06, the number of patients treated as day cases increased by 28%.

Since the publication of the Westminster PAC report in December 2005 the NI Audit Office view on implementation of the original NIAO report recommendations has been further clarified. The NIAO has accepted that all but one of the 43 recommendations contained in their original report have been fully implemented. The one recommendation not yet fully implemented relates to cardiac surgery fast tracking. However, it is no longer considered that fast tracking of cardiac surgery patients is in all cases an appropriate approach from a clinical standpoint. In any case, waiting times for cardiac surgery have been significantly reduced since the time of the Committee’s report and a dedicated workstream has been set up within the Department to focus on improving access to cardiac surgery, including the implementation of good practice measures where appropriate.

Theatre utilisation rates continue to be monitored closely and the Department now measures theatre utilisation rates based on the number of sessions actually planned. Using this widely accepted methodology, utilisation rates in 2001/02 were 94% and have increased to 95.5% in 2005/06, the last year for which information is available.

This exceeds the target contained in the Bevan report[1] , and highlighted in the original NIAO report, which recommended that hospitals should aim to use 90% of planned theatre time.

The sizeable spare capacity in hospital operating theatres that is not being utilised and its impact on patients waiting for operations

PAC Conclusions 1 & 2

Achieving these reduced waiting times has required Trusts to ensure that they make the most efficient use of operating theatres. This has included increased use of theatres for evening and weekend sessions. The roll-out of the regional theatre management system will allow the Department and Trusts to monitor more closely the extent to which evening and weekend capacity is being used.

PAC Conclusion 3

The Department wrote to Trusts following the Committee hearing, requiring them to negotiate with consultants to maximise elective activity, including securing additional sessions for evening and weekend work. Where Trusts consider there are significant risks to the achievement of waiting time targets, the Department can consider granting some limited flexibility to the terms of the consultant contract.

The scope for better theatre management and control

PAC Conclusion 4

Since the publication of the Westminster PAC report in December 2005 the NI Audit Office view on implementation of the original NIAO report recommendations has been further clarified. The NIAO has accepted that all but one of the 43 recommendations contained in their original report have been fully implemented. The one recommendation not yet fully implemented relates to cardiac surgery fast tracking. However, as noted above, it is no longer considered that fast tracking of cardiac surgery patients is in all cases an appropriate approach from a clinical standpoint. The Department remains committed to ensuring that the improvements arising from implementation of all recommendations are sustained.

PAC Conclusion 5

As detailed above, due to difficulties experienced with the procurement process, the roll-out of the regional theatre management system has been delayed. It is expected that the system will now be in place across all Trusts by the end of 2008.

A dedicated project team has been set up within the Department’s Service Delivery Unit to manage the implementation of this new system across all Trusts and to ensure that systems already in place are fully compatible with the regional system.

The scope for improving the planning and organisation of theatre sessions and the need to improve the measurement and monitoring of theatre utilisation

PAC Conclusions 6 & 7

At the time of publication of the Westminster Committee’s report in November 2005, the Department wrote to all Trusts. This letter required Trusts to reduce the cancellation rate of scheduled sessions to 5% or less. The Department monitors cancellation rates on a regular basis and, in 2005/06, 4.5% of scheduled operations were cancelled.

The Department continues to take a number of measures to reduce the levels of cancelled operations.

PAC Conclusion 8

In our response to the Committee, we indicated that existing data definitions and guidance were being revised and that minimum data requirements and associated definitions were being developed for use by all Trusts. This work has now been completed and standard reports using key utilisation indicators will be available for use in conjunction with the regional theatre management system.

The shortage of theatre staff and the limited availability of beds

PAC Conclusion 9

The Department recognises the importance of ensuring that sufficient suitably qualified staff are available to meet the needs of the health service. A comprehensive programme of workforce planning reviews is in place to establish information on the supply and demand of staff in the main clinical professions and in a number of supporting groups in the Health and Social Care services. These reviews also ensure that the Department is fully aware of the issues impacting on recruitment and retention and career progression. The workforce planning cycle comprises a major review of each group every three years, supported by annual update reviews. The purpose of the annual update reviews is to maintain current workforce information and identify any new issues impacting on the workforce group thereby enabling any necessary action to be taken at an early stage.

With regard to improved bed management, the targets that have been set to reduce the length of time patients wait for surgery oblige Trusts to make the most efficient and appropriate use of available beds. More patients are now having their treatment in one day - between 2000/01 and 2005/06, the number of patients treated as day cases increased by 28%. New targets have also been set to reduce the number of delayed discharges from acute hospital beds. By March 2008, all patients with complex care needs must be discharged from an acute hospital setting within 72 hours. All other discharges must take place within six hours.

[1] The Management and Utilisation of Operating Departments, Professor Bevan, for NHS Management Executive, 1989

Chairperson’s letter of 21 September 2007 to Dr Andrew McCormick

Public Accounts Committee
Parliament Buildings
Room 371
Stormont Estate
BELFAST
BT4 3XX

NIA Logo (Black).ai

Tel: (028) 9052 1208
Fax: (028) 9052 0366
Email: cathie.white@niassembly.gov.uk

Dr Andrew McCormick,
Accounting Officer,
Department of Health,
Social Services and Public Safety
Room C5.11
Castle Buildings
Stormont
Belfast
BT4 3SQ

Date: 21 September 2007

Dear Andrew

Re NIAO Report on ‘The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services’

The Committee at the meeting on 20 September has considered your response to the Memorandum of Response on the ‘Report on The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services’.

The Committee noted the update on progress on the undertakings given by the Department in the Memorandum of Response. The Committee will request a further update when you next appear before the Committee.

Yours sincerely

John O’Dowd

Chairperson

Chairperson’s letter of 5 February 2008 to
Dr Andrew McCormick

Public Accounts Committee
Parliament Buildings
Room 371
Stormont Estate
BELFAST
BT4 3XX

NIA Logo (Black).ai

Tel: (028) 9052 1208
Fax: (028) 9052 0366
Email: jim.beatty@niassembly.gov.uk

Dr Andrew McCormick
Accounting Officer
Department of Health, Social Services & Public Safety
Room C5.11
Castle Buildings
Stormont
Belfast
BT4 3SQ Date:

5 February 2008

Dear Andrew

Re: Public Accounts Committee Evidence Session on 31 January 2008

Further to the evidence session at the Public Accounts Committee meeting yesterday, please provide the following additional information which members requested at the meeting:

Memorandum of Response: The Use of Operating Theatres in the NI Health and Personal Social Services

1 Please inform the Committee of the cost of cancelling an operating theatre session.

2 Please provide details of the percentage of private services being used to reduce waiting lists for operations, e.g. costs and numbers.

I should be obliged for a response by Monday, 18 February 2008.

Yours sincerely

John O’Dowd
Chairperson
Public Accounts Committee

Correspondence of 22 February 2008 from
Dr Andrew McCormick

amcc1548.pdf

Memorandum of Response: The Use of Operating Theatres in the NI Health and Personal Social Services

1 Please inform the Committee of the cost of cancelling an operating theatre session.

DHSSPS Response: The latest cost information available is in respect of 2005/06. During that year there were 35,081 operating theatre sessions held and 1,664 sessions cancelled, representing a theatre session cancellation rate of 4.5%.

The total (unaudited) cost of operating theatres reported by Trusts for 2005/06 was £141.8m. In arriving at this, costing guidance tells Trusts to absorb a share of overheads across theatres costs but to exclude all capital-related costs.

On the basis of the above the estimated average cost of an operating theatre session (including a cancelled session) was approximately £3,860 in 2005/06.

Please note that this estimate does not represent the true extent of any loss of resource to the health service arising from the cancellation of a theatre session, since it assumes that none of the hospital staff and other resources involved can be diverted into other productive activities. In practice much of the staff and other resources would be redeployed on other health service activity, although it is not possible to quantify this precisely.

2 Please provide details of the percentage of private services being used to reduce waiting lists for operations, e.g. costs and numbers.

DHSSPS Response: During 2006/07 a total of 181,549 inpatient and daycase procedures were carried out in Northern Ireland. Of these, some 3% (5,353) were carried out by independent sector providers at a cost of £16.6m.

In relation to outpatient assessments, during the same period, 2006/07, a total of 478,537 outpatient assessments were carried out in Northern Ireland. Of these, some 10% (43,319) were carried out by independent sector providers at a cost of £6.3m.

Independent sector activity represents a small proportion of all activity. The Department considers the use of independent sector providers as an effective short-term measure to reduce waiting times for patients by supplementing health service capacity.

Appendix 5

List of Witnesses Who Gave Oral Evidence to the Committee

1. Dr Andrew McCormick, Accounting Officer, Department of Health, Social Services and Public Safety.

2. Mr Andrew Hamilton, Deputy Secretary, Department of Health, Social Services and Public Safety.

3. Mr Dean Sullivan, Director of Planning and Performance, Department of Health, Social Services and Public Safety.

4. Mr John Dowdall CB, Comptroller and Auditor General.

5. Mr Ciaran Doran, Deputy Treasury Officer of Accounts.

Session 2007/2008

Eleventh Report

PUBLIC ACCOUNTS COMMITTEE

Further Report on the Use of Operating Theatres in the Northern Ireland Health and Personal Social Services

TOGETHER WITH THE MINUTES OF PROCEEDINGS OF THE COMMITTEE RELATING TO THE REPORT AND THE MINUTES OF EVIDENCE

Public Accounts Committee Membership and Powers

Report

Appendix 1:

Appendix 2:

Appendix 3:

Appendix 4:

Appendix 5:

List of Abbreviations used in the Report

Executive Summary

Introduction

Waiting Lists and Waiting Times

The Spare Capacity in Hospital Operating Theatres

The Cancellation of Operations

Computerised Theatre Management Information Systems

Summary of Recommendations

Introduction

Waiting Lists and Waiting Times

Recommendation 1

Recommendation 2

Recommendation 3

The Spare Capacity in Hospital Operating Theatres

Recommendation 4

Recommendation 5

The Cancellation of Operations

Recommendation 6

Computerised Theatre Management Information System

Recommendation 7

Appendix 1

Extract from Northern Ireland Department of Finance and Personnel Memorandum on the 7th and 8th Reports from the Public Accounts Committee Session 2005/2006

Northern Ireland Department of Finance and Personnel Memorandum on the 7th and 8th Reports from the Public Accounts Committee Session 2005/2006

CM 6699 LONDON: THE STATIONERY OFFICE LTD.

Contents

Glossary of Abbreviations

Department of Finance and Personnel Memorandum Dated 2 December 2005 on the 7th and 8th Reports from the Committee of Public Accounts Session 2005-2006

Seventh Report Department of Health, Social Services and Public Safety The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services

The sizeable spare capacity in hospital operating theatres that is not being utilised and its impact on patients waiting for operations

PAC Conclusions 1 & 2

PAC Conclusion 3

The scope for better theatre management and control

PAC Conclusion 4

PAC Conclusion 5

PAC Conclusions 6 & 7

PAC Conclusion 8

The shortage of theatre staff and the limited availability of beds

PAC Conclusion 9

Appendix 2

Minutes of Proceedings of the Committee Relating to the Report

Thursday, 31 January 2007 Senate Chamber, Parliament Buildings

Thursday, 13 March 2008 Room 144, Parliament Buildings

Appendix 3

Minutes of Evidence

31 January 2008

Appendix 4

Correspondence

Chairperson’s letter of 6 July 2007 to Dr Andrew McCormick

PUBLIC ACCOUNTS COMMITTEE

Memorandum of Response: The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services

Correspondence of 20 August 2007 from Dr Andrew McCormick

Memorandum of Response: The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services

Annex 1

The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services

The sizeable spare capacity in hospital operating theatres that is not being utilised and its impact on patients waiting for operations

PAC Conclusions 1 & 2

PAC Conclusion 3

The scope for better theatre management and control

PAC Conclusion 4

PAC Conclusion 5

The scope for improving the planning and organisation of theatre sessions and the need to improve the measurement and monitoring of theatre utilisation

PAC Conclusions 6 & 7

PAC Conclusion 8

The shortage of theatre staff and the limited availability of beds

PAC Conclusion 9

Chairperson’s letter of 21 September 2007 to Dr Andrew McCormick

Re NIAO Report on ‘The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services’

Chairperson’s letter of 5 February 2008 to Dr Andrew McCormick

Further Report on the Use of Operating Theatres in the
Northern Ireland Health and Personal Social Services

TOGETHER WITH THE MINUTES OF PROCEEDINGS OF THE COMMITTEE
RELATING TO THE REPORT AND THE MINUTES OF EVIDENCE

Public Accounts Committee
Membership and Powers

The Spare Capacity in
Hospital Operating Theatres

Extract from Northern Ireland Department of Finance and Personnel Memorandum on the 7th
and 8th Reports from the Public Accounts Committee Session 2005/2006

Northern Ireland
Department of Finance and Personnel
Memorandum on the
7th and 8th Reports from the
Public Accounts Committee Session
2005/2006

Department of Finance
and Personnel Memorandum
Dated 2 December 2005 on the 7th and
8th Reports from the Committee of
Public Accounts Session 2005-2006

Seventh Report
Department of Health, Social Services and Public Safety
The Use of Operating Theatres in the Northern Ireland Health and Personal Social Services

Minutes of Proceedings
of the Committee Relating to the Report

Thursday, 31 January 2007
Senate Chamber, Parliament Buildings

Thursday, 13 March 2008
Room 144, Parliament Buildings

Chairperson’s letter of 5 February 2008 to
Dr Andrew McCormick

Correspondence of 22 February 2008 from
Dr Andrew McCormick