- Scarlett McNally, professor
- scarlettmcnally{at}cantab.net
Follow Scarlett on X @scarlettmcnally
The new plan to improve NHS elective care includes creating and expanding surgical hubs.1 As a surgeon, I feel conflicted. It’s positive if patients with treatable conditions can move forward from the waiting list. But we need to do this with great care to avoid negatively affecting the rest of the NHS, especially for patients deemed ineligible or due to the diversion of staff, training capacity, and funding from existing NHS sites.2
We already have over 100 surgical hubs, some delivering 11-20% more efficiency.3 Hubs tend to take patients with few other conditions and relatively low operative risk, whereas patients with more underlying medical conditions and higher risk must wait for a site with medical back-up for their operation. It’s important to consider that half of the patients having procedures are over 604— of whom 63% have multiple comorbidities5 and 32% have obesity.5 We must be careful to avoid surgical hubs widening existing health inequalities.
Models include hubs within a hospital and standalone hubs.2 Standalone elective hubs without senior doctors on call overnight will rightly reject patients deemed at higher risk—a considerable proportion. Staff at one hub told me that they have a contract with a private ambulance for emergency transfers. Hubs within hospitals have the best chance of reducing excessive waiting lists6 without excluding high risk patients, who may need onsite medical care. This is reminiscent of debates suggesting that midwife led units co-located with obstetric units may be safer than standalone midwife led units, since there’s a 20% rate of transfer in labour.7
To tackle the waiting list for elective surgery, we need ringfenced beds within hospitals and clinical leadership. I’ve seen complex workarounds to reduce cancellations of elective operations due to ward beds or intensive care beds being filled with emergency patients. One orthopaedic unit had a doorway deliberately too narrow for an emergency bed, another had couches instead of beds, and in orthopaedics we’re often grateful for MRSA screening requirements that limit emergency admissions so that we’re ready for elective patients.
Clear pathways
I studied queuing theory and wrote a dissertation about converting randomly occurring events, including injuries and emergencies, into pathways such as day case trauma surgery to reduce admissions. But this approach needs senior surgeons in “hot clinics”8—where patients return for assessment, investigation, and consultant led decision making as outpatients. This model doesn’t work if surgeons are taken away for shifts in a surgical hub.
We’re short of key staff, including an urgent need for 1900 anaesthetists.9 If we fail to develop future leaders we’ll leave overstretched resident doctors doing administrative work for increasingly inactive, complex emergency patients. We need senior staff and the elective service to model shared decision making10 in clinics, preoperative preparation, day case operating, and early mobilisation. This would help the one third of older people having surgery who come as an emergency, as well as future patients.5
Hubs are necessary but aren’t sufficient alone. Having standalone hubs can increase the bureaucracy and administrative steps that occur between systems and in assessing suitability. The Getting It Right First Time programme by NHS England has been given funding and a remit to deliver surgical hubs. But this programme should follow the principles, pathways, and resources11 developed by the Centre for Perioperative Care, such as supporting preparation for surgery,12 creating clear pathways, and making shared decisions with patients.9 Northern Ireland13 and Wales14 have programmes for planned care that have the right intentions. But we really need to create a better future where all perioperative pathways are streamlined. This needs teams who know each other and work well together. We can’t afford to lose more staff and funding to standalone surgical hubs.
We should construct surgical hubs within hospitals to improve care, including care for patients deemed unfit for surgical hubs and those having emergency surgery. This could also include adjacent services such as weekend physiotherapy, to help patients get mobile and free up emergency beds.15 The detail about the next wave of hubs—places, people, pathways, and patient centredness—could be critical for the future of surgery in the NHS.
Footnotes
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Competing interests: Scarlett McNally is a consultant orthopaedic surgeon, president of the Medical Women’s Federation, and deputy director of the Centre for Perioperative Care.
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Provenance and peer review: Commissioned; not externally peer reviewed.
