Some operating theatres are used only eight hours a week

Hospitals in England and Wales could cut waiting times for operations and outpatient appointments and have more free beds without any extra resources if they were better managed, says a report from the public spending watchdog, the Audit Commission.

The commission, which this week published four reviews as part of its acute hospital portfolio, found a common theme in the services it examined – huge variations among hospitals in the services they deliver, which could not be easily explained.  “The conclusion cannot be avoided that some trusts could improve the services they deliver significantly within their existing resources”, the report says.

On average about 6% of elective admissions are cancelled in the week before they are due to take place in acute hospitals across England and Wales, many after patients have been admitted.  The reasons for the cancellations can be non-clinical such as lack of a bed, theatre time, or staff.  Often, however, they are because patients are found to be unfit for surgery or have a last minute change of mind – both problems could be avoided with better preoperative assessment of patients and explanation about what will happen, says the report.

Auditors also found that operating theatres could be used more efficiently.  A well-used theatre would usually be used for more than 40 hours a week.  But the review found that they are used for an average of just 24 hours a week, with some used for as little as eight hours.  To get more out of each theatre, hospitals could reduce the number of sessions they leave clear for emergencies and keep them running after 5pm to increase capacity, says the commission.

Another weakness in acute hospitals is the number of outpatient appointments that get cancelled, which reaches a fifth or more in one in 10 units.  Many trusts will find it hard to meet the 2005 target for patients to wait no longer than 13 weeks for an appointment as set out in the NHS Plan unless they organise clinics more appropriately, predicts the commission.  A big problem is the short notice that staff give when they take leave, something that managers can easily address, it says.

Simply throwing more money at the services reviewed will not necessarily make them better, says the commission.  For services to improve, staff need to examine how they organise their work, it advises.  “This often requires a shift in attitudes or behaviour – not just from managers, but from everyone (and especially doctors),” it says.

Ref: Audit Commission

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PCT Self assessment tool finalised

Under-performing primary care trusts now have a valuable tool to help them draw up their performance improvement plans.

The National Primary and Care Trust (NatPaCT) development programme has released the final version of the development needs self assessment tool.  The tool is a key part of the PCT improvement programme and has been designed with the specific intention of helping PCTs, particularly those given a zero or one star rating by the Commission for Health Improvement, formulate strategies to bring their organisation up to three star standard.

The star-ratings system has caused no small amount of controversy in the public health sector – many professionals felt the system was too crude and that it did not take into account the long-term nature of public health interventions.

All PCTs will be able to use the self assessment tool to focus on areas of greatest concern and develop strategies for addressing them.  Users are led through a series of questions and prompts to a suggested improvement plan template.  Although use of the tool is voluntary, NaPaCT communications director John Callaghan expected that it would be valuable to many PCTs as it ‘allows for a top level self assessment of development needs’.

‘The tool is voluntary but, when it comes to drawing up the improvement plans, SHAs will want to see what processes the PCT has gone through to come up with that plan,’ Mr Callaghan said.  ‘As much as possible, we’ve tried to minimise the extra work for PCTs – the tool is very flexible in allowing the use of work that has already been done.

‘The tool also lets people from the whole organisation contribute their perspective on how well the organisation is doing in their areas.  The tool is not only useful for assessing how well the PCT is performing against national targets and indicators, but also how well they are preparing themselves for the new system reform agenda’.

Zero star PCTs will get additional support from the NHS Modernisation Agency’s performance development team to complete the self assessment process.  Dr Alexandra Tobin, performance development team associate director (primary care), said the team had been working with the 21 zero star trusts since the ratings were announced in July.

‘At the moment we are in the diagnostic phase, so we are purely dedicated to the self assessment process, and part of that work is to really get to know the organisation,’ Dr Tobin said.

‘That leads to us speaking to lots of different people, and not just senior managers,’ she continued.  ‘We may find some really good reasons as to why a particular trust may be struggling.  What we then need to do is take a balanced view and help everyone in that organisation understand what responsibilities they have.

‘The idea is that we work together to help each other understand what is required to ensure the improvement of an organisation’.  Each zero star PCT has been allocated a client manager to oversee the process and assist with the improvement plans, which PCTs must submit to their respective SHAs by 31 October.

Ref: NatPact

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Child psychiatric disorder and relative age in school

This BMJ article set out to test the hypothesis that younger children in a school year are at greater risk of emotional and behavioural problems. It was a simple cross-sectional survey of a community sample of children from England, Scotland, and Wales. The participants were 10,438 British 5-15 year olds.

Younger children in a school year were significantly more likely to have higher symptom scores and psychiatric disorder.  The adjusted regression coefficients for relative age were 0.51 (95% confidence interval 0.36 to 0.65, P<0.0001) according to teacher report and 0.35 (0.23 to 0.47, P=0.0001) for parental report.  The adjusted odds ratio for psychiatric diagnoses for decreasing relative age was 1.14 (1.03 to 1.25, P=0.009).  The effect was evident across different measures, raters, and age bands.  Cross national comparisons supported a ‘relative age’ explanation based on the disadvantages of immaturity rather than a ‘season of birth’ explanation based on seasonal variation in biological risk.

The younger children in a school year are at slightly greater psychiatric risk than older children.  Increased awareness by teachers of the relative age of their pupils and a more flexible approach to children’s progression through school might reduce the number of children with impairing psychiatric disorders in the general population.

Ref Web

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Risk of smoking after a coronary

All of us deal with risk every day. If you drive on the roads in the UK, you accept a (roughly) 1 in 18,000 chance of dying in a road accident in one year. Given the volume of traffic on our roads, that is a risk most of us are willing to accept.

A new systematic review quoted in Bandolier tells us  that smokers with coronary heart disease have an extra 1 in 10 chance of dying over five years because of their smoking.

Carrying on smoking carries a five year risk of 1 in 10 of dying because you smoke. By contrast, the risk of dying on the roads over five years would be more like 1 in 4000. Smoking in those circumstances is 400 times more dangerous than driving.

Perhaps, rather than quitting, we should describe stopping smoking as delivering, freeing, or liberating.

Ref Bandolier

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