The commitment by government and NHS England to develop elective surgical hubs is a strategic response to the need to ramp up planned care activity. The central support for hubs is aimed at more streamlined delivery of elective surgical services and care backlogs which were exacerbated by the Covid-19 pandemic. The Royal College of Surgeons of England has recommended the approach (RCS England, 2021), building on the successful use of surgical hubs for cancer services during the pandemic. The college said the model is particularly applicable to specialties such as orthopaedics, which continue to face long waits.
Successful case studies exist across the NHS, some dating back many years before the pandemic. Across London for example, elective hubs have demonstrated increased productivity levels, reduced on-the-day cancellations, improved staff and patient experience, better financial position, and higher quality of care (Wall J., et al. 2022). The South West London Elective Orthopaedic Centre (SWLEOC), established in 2004, has been a notable success.
The national Getting It Right First Time (GIRFT) programme has set out the three types of surgical hub that exist (GIRFT, 2022):
- Integrated hub: elective surgical unit within an existing acute hospital site, with all facilities physically segregated from acute areas.
- Standalone hub: an elective surgical unit in a dedicated building fully separate from any acute provision. This could include, for example, specialist orthopaedic hospitals.
- Ring-fenced hub: elective surgical hub exists as a dedicated area within an existing acute site, with ring-fenced elective theatres within the main theatre complex and with dedicated in patient or recovery area.
NHS England's GIRFT programme has defined hubs as exclusively performing planned surgery, with ring-fenced facilities and staff, and adhering to the principles of six-day operating, 48 weeks per year, 2.5 session days and 85% theatre utilisation (GIRFT, 2022a).
Multiple benefits of hubs have been identified, from improvements in quality and productivity, to creating more efficient care pathways. Some of these benefits are brought about by the following:
- Separating elective and non-elective surgery: This hot/cold split was first introduced by GIRFT in orthopaedics where separating elective and trauma surgery was shown to improve clinical outcomes and performance and, importantly, patient safety and staff morale.
- Increasing day case surgery rates: Considerable productivity improvements are also possible with specialised high throughput lists. This has been evidenced by the high volume, low complexity (HVLC) programme which advocates dedicated lists pooling straightforward cases of common operations including joint replacements, hernia repairs and cataract surgery.
- Improving the utilisation of assets such as operating theatres, x-ray equipment and other complex equipment: Hubs also offer the ability to streamline theatre processes, leading to more efficient care, and reducing the need for additional treatment.
The hubs also have the potential to address variation in performance between trusts, as guidance on national standards prescribes the suggested numbers of operations, theatre usage and a focus on discharging patients on the same day as their operation. These prescribed standards aim to reduce variation in experience and outcomes.
The most recent development for hubs has been the piloting and roll-out of the Elective Hub Accreditation Programme (GRIFT, 2023a). This was piloted by GIRFT during the second half of 2022/23 and is now being incrementally rolled out across all hubs. The scheme provides a formal assessment of trusts' hub sites and gives external recognition that they work to a defined set of clinical and operational standards. This has been seen as an important improvement tool, ensuring best practice is being used, and that productivity gains are made. Thirty-five hubs had received accreditation as of April 2024 (GIRFT, 2024).
The elective hub programme continues to evolve, as trusts and systems are looking to expand the types of patients referred to their hubs and ensure that they continue to respond to changing local and national demands. To make significant reductions in the scale and length of waits for planned care, these hubs will require sustained investment and protected staffing. This will be necessary, alongside system-wide backing and support, if they are to fully deliver on their potential.