Profile: John Petri - the Dual Operator
Have you ever wondered if NHS waiting lists will be a thing of the past? John Petri may well have the answer as Florence Hogg explains
John Petri dislikes waste - waste of time, waste of resources, waste of talent and waste of opportunities. Efficiency personified, the consultant orthopaedic surgeon at the James Paget Hospital is now somewhat of a celebrity, one could even say an NHS pin up. In 2005 he received a Medical Futures Service Award in recognition of his innovation. Following on from this accolade he has been a topic of debate at Prime Ministers Questions, has met and advised Tony Blair and has even appeared on the popular Uk TV show, Richard and Judy. The reason behind the hype isn’t the typical dinky gadget that one may expect from the more innovative breed of orthopod. His innovation is painfully simple, highly effective and not at all lucrative: it is a system of surgical practice with the potential to transform all NHS waiting lists, a scheme he calls ‘dual operating.’
I first met John Petri at the Medical Futures i2 Event 2006, and recognised his story from news coverage of the previous year. I was thoroughly impressed by his presentation which described the system of dual operating and its transforming effects. Like all good entrepreneurs Petri had identified a problem and found a solution. His problem: half of his operating time was spent in the coffee room between procedures. His solution: to use two theatres and two teams per list. His rationale: contrary to the government’s new plan to reduce waiting lists to 18 weeks by maximising the use of operating theatres, Petri believes in maximising the use of the hospitals greatest and most expensive commodity: the surgeon. He told me: “They pay me the most, but they don’t use me any more than they use any one else, it is illogical. Filling theatres without a framework of efficient practice is of no use to anyone.”
Since he began dual operating, he has performed three times the amount of procedures that he would have using a standard list.
Mr Petri was born in Italy, where he qualified as a medic. He split his junior posts between Italy and the UK, working in the NHS from 1985 to 1989, and moved to France in 1990. He spent three years as “Assistant Spécialiste” (akin to specialist registrar) at the Centre Hospitalier d’Annecy before landing his first consultant job at the Centre Hospitalier de Mâcon. He returned to the UK in 1994 and was appointed as Consultant Orthopaedic Surgeon at the James Paget Hospital (JPH) in Great Yarmouth. From seeing the NHS as a Junior, he was well aware of the looming waiting lists to which the British Public are so accustomed; but his experience of French hospitals where far fewer surgeons have far shorter waiting times, made him confident that the British status quo was not unshakeable. The challenge of culling these lists became Mr Petri’s driving influence.
Mr Petri’s dreams of French efficiency were soon dispelled. In the UK he found himself doing far fewer operations and drinking far too much coffee. Outraged, Mr Petri wrote a paper, comparing the JPH to the Centre Hospitalier d’Annecy, hospitals comparable in size and demographic but not efficiency. His results spoke for themselves: the French hospital, with half the numbers of consultant orthopaedic surgeons, was performing 400 more operations per year than the JPH, with each surgeon individually performing double the number of operations each year (Tables 1 and 2).
Mr Petri was convinced that the explanation for the results lay in the JPH’s underutilisation of surgeons. In France, his list began between 7am and 8am, ending when the list was complete (usually 3pm or 4pm) and while the surgeons operated in one theatre, the next patient would be anaesthetised and prepared for operation in the other. At the JPH his lists ran in office hours (9am to 12.30 and 2pm to 5.30pm) and he waited in the coffee room as his last patient was taken off the table and the next was anaesthetised. Mr Petri was outraged: “If you were running a factory, you wouldn’t allow your most important and most expensive machine to stand idle. The same is true in a hospital.”
Mr Petri’s solution was to adopt the French way, which he has done with extraordinary results - an audit in 2004 showed that with dual operating lists, he had trebled the number of operations that he would have done with a conventional surgical list.
|
Table 1 Comparison of staff and orthopaedic operating rooms in 1997 (1) *5 consultant surgeons, 3 associate specialists |
||
| Centre Hospitalier d’Annecy | James Paget Hospital | |
| Trained Orthopaedic surgeons | 4 | 8* |
| Anaesthetists | 12.5 | 23.5 |
| Theatre Staff | 52.75 | 84.57 |
| Orthopaedic theatres | 3 | 2 |
|
Table 2 Comparison of operations in 1997 (1)
|
||
| Centre Hospitalier d’Annecy | James Paget Hospital | |
| Total orthopaedic operations | 2,980 | 2,574 |
| Operations per surgeon | 745 | 322 |
With aspirations to a career in surgery and a similar loathing of waste, I arranged to spend some time with Mr Petri watching his ‘Dual Operating.’ I observed two lists and was staggered by the difference his system made. The afternoon shift began promptly at 1.30pm with a carpal tunnel decompression (theatre 1), followed by a cemented total hip replacement (theatre 2), then a total hip replacement (theatre 1) and finished at 5.30pm with a total knee replacement (theatre 2). The only time ‘wasted’ was that walking between the theatres. The following morning was even more impressive, kick off was 8.00am and by lunch Mr Petri had performed two minor procedures and three major joint replacements.
The greatest surprise from my time spent with Mr Petri was that, despite huge publicity, his scheme still remained unique to the JPH and indeed himself. When I put this to him he sighed deeply: “I was too naïve. I thought that if and when I proved my point, people would be inspired to change - but things are more complex. It is true; some surgeons are concerned about the risks of dual operating i.e. when complications occur in one operation and the patient lies anaesthetised next door. I am well aware of this, and only perform operations of predictable length and difficulty in my dual lists and never call for the next general anaesthesia without being well on my way to closure. I am afraid the real reason for poor uptake of my scheme is that by cutting lists, I reduce the amount of private work that is available and the scope for overtime pay. There is no energy to change the NHS landscape, if the patients are prepared to accept the waiting lists why should the doctors not?”
Despite being embraced by his managers, his colleagues are not so forthcoming: “My system requires confidence. When a patient is waiting anaesthetised in the next room, there is an added pressure on the surgeon especially if complications arise in that operation. I get round this stress by only performing operations of predictable length and difficulty in my dual lists. I have also trained an excellent team that I trust to prep and position the other patient, although I always check that the position is correct. Sadly I don’t think that these concerns are the main reason why my system has not been adopted. I attribute its failure to its lack of financial incentive. I myself have lost money since I started dual operating, because there is so much less private work to do.”
With the excitement and hype of 2005 a distant memory Mr Petri is disillusioned at the lack of change: “Perhaps my hopes were too high, but when you meet Tony Blair with a solution to a problem you assume change will come.”
Sadly the NHS has lost its pin up. Disillusioned with the poor enthusiasm and criticism for his dual operating, Mr Petri has now moved to Switzerland. In his swan song article, Mr Petri concluded: “All I wanted was to give the NHS good value for money and to prove a point. Next week I am moving to Switzerland. I shall certainly have a job explaining to the Swiss what surgical waiting lists are.” (2)
John Petri is an inspiration. As a budding surgeon, theatre rarely fails to exhilarate but the energy and buzz I experienced with his team was different. Perhaps it was fumes from the cement he used to secure the prosthetic joints, or the warm welcome I was given - but I suspect it was more to do with observing the achievements and energy of a man addicted to efficiency and patient service, whom at the expense of his career and purse, remained unprepared to accept anything else.
Florence Hogg
4th year Medical Student
Bristol BS6 6ET
UK
fh3905@bris.ac.uk
(1) Petri GJ and Banerjee TS Dual operating - an old innovation. Ann R Coll Surg Engl (Suppl) 88: 208-10 2006
(2) Petri J Liste d’attente? Pourquoi? BMJ 335:210-211 2007
Further Reading
Petri John Letters to the editor Ann R Coll Surg Engl (Suppl) 2006; 88:284-286
Carr-Brown J, Health Correspondent. French factory’ surgeon cuts NHS queues. The Sunday Times October 23, 2005
House of Commons Hansard Debates: Orthopaedics 2 Nov 2005 : Column 316W
http://www.publications.parliament.uk/pa/cm200506/cmhansrd/vo051102/halltext/51102h04.htm