Endoscopy surveillance image of clinicians using an endoscope

Q&A: Why is endoscopy surveillance important?

Endoscopy surveillance is a crucial aspect of healthcare that involves monitoring patients at a higher risk of certain conditions, particularly gastrointestinal diseases.

We spoke with our resident endoscopy expert and lead JAG assessor, Debbie Johnston to find out more.


Debbie, what is the purpose of endoscopy surveillance?

Endoscopy surveillance is important for detecting abnormalities early, preventing cancer, monitoring chronic conditions, guiding treatment decisions, and improving patient outcomes and quality of life.

The primary goal of surveillance is to detect abnormalities or early signs of diseases, such as upper GI and bowel cancer, in patients who have specific risk factors. By closely monitoring high-risk individuals, healthcare providers can intervene promptly if any concerning changes are observed.

It also helps in planning appropriate treatments and interventions based on the patient’s condition.


Who Benefits from Endoscopy Surveillance?

Surveillance is essential for high-risk individuals, or patients with a history of certain conditions, for example, inflammatory bowel disease, who are at an increased risk of developing gastrointestinal cancers.

It is also key for post-treatment monitoring, as timely detection and treatment ensure that patients receive surveillance endoscopies at appropriate intervals according to national clinical guidelines

For patients, timely surveillance allows for the early detection of abnormalities and prompt intervention, particularly particularly cancer, which can improve treatment outcomes and prevent disease progression.

It is also worth noting that it benefits NHS organisations and endoscopy services to manage patients identified for surveillance efficiently this patient cohort as per agreed timelines and ensure that any overdue patients are transferred to the active waiting list promptly.


Are there any challenges that come with endoscopy surveillance?

As with all services, challenges are met, for example, balancing new referrals with planned surveillance cases can be challenging for many NHS Organisations.

It can also impact resource allocation, prioritising surveillance for high-risk patients with often limited and time-stretched resources.

We also need to ensure that patients understand the importance of surveillance by offering them educational materials and knowledgeable staff to help reduce any DNAs that may occur from people not thinking their appointments are important.

quote from Debbie Johnston about endoscopy surveillance

How can Four Eyes Insight support NHS organisations with endoscopy surveillance management?

Ensuring thorough and timely follow-up is crucial for patient care and something that Four Eyes Insight can help with, including:

  • Demand and Capacity Modelling: We can deliver clinically credible, robust, and granular D&C modelling that supports long-term planning and operational control of waits.
  • Data Analysis and Management: We can assist in analysing backlog data to identify trends, assess the impact on patient outcomes, and develop strategies for preventing future backlogs.
  • Resource Allocation: Limited resources, such as staff and equipment, can impact surveillance efficiency. We can provide support in optimising resource allocation based on patient risk stratification and procedural requirements.
  • Resource Optimisation: We can provide support on allocating resources efficiently to address the backlog, whether it involves scheduling additional clinic hours, redistributing staff responsibilities, or outsourcing certain tasks.
  • Workflow Streamlining: We can help identify bottlenecks in your surveillance workflow and suggest strategies for streamlining processes to reduce wait times and improve efficiency.
  • Quality Governance: Maintaining high-quality surveillance practices is essential for the accurate detection and monitoring of gastrointestinal conditions. We can assist by keeping you updated on best practices, guidelines, and quality indicators in endoscopy surveillance.
  • Communication: We can assist in communicating with patients to explain the importance of their surveillance appointments and encourage them to schedule follow-up visits promptly.


You mention Demand and Capacity Modelling, what is the importance of this?

Balancing demand and capacity for endoscopy surveillance is vital for providing timely, efficient, and high-quality care. It supports early detection and management of diseases, ensures optimal use of resources, and informs effective endoscopy service planning and policy making. Demand for endoscopy tests is increasing and can be influenced by various factors, including public awareness, referral practices, and changes in screening guidelines. Hospitals need to be adaptable to these changes. Understanding capacity helps in the efficient allocation of resources, including staffing, equipment, and facilities, ensuring that the endoscopy service can meet current and future demand without overburdening providers or facilities.

We already know that our NHS partners value the service that we offer. What Four Eyes Insight offers is a clinically credible, robust, and granular D&C model that supports balancing demand and capacity, reducing endoscopy backlogs.

A strong D&C model for all tests is important to patient care, ensuring they receive timely and quality care. Our modelling contributes to service planning and efficiency, and with granular data, we can really get into the nitty-gritty and identify any improvements and/or opportunities to enhance productivity and system-level planning. It’s also worth mentioning that all these elements have a strong impact on staff well-being, leading to reduced pressure and stress.


Thanks, Debbie, any final thoughts?

Yes, I always say data is king. You need to measure and understand performance before you do anything else. So, ditch the spreadsheets and get the right technology in place to make data collection and analysis easy and accessible.

If you’d like to hear how we can help your endoscopy service, contact us today.

Connect with Debbie on LinkedIn:  Debbie Johnston | LinkedIn

Transforming planned care

Transforming Planned Care

Transforming planned care for the NHS is something we are passionate about.

As the NHS continues to revise national forecasts and update targets, eliminating long waits and prioritising cancer pathways remain a focus.

The transformation of planned care and clinical services needs to be ambitious, with higher expectations of delivery and a focus on creating a sustainable service that will meet targets.

Our philosophy is to use small teams of highly experienced operational and improvement specialists, with a track record working for and in the NHS, to support your teams and give them the capacity to improve and deliver core services to patients.

Download our Transforming Planned Care brochure to learn more about what we do and how we can support the NHS >>

Transforming planned care

Programmes that support planned care and the patient pathway

Working across the full planned care pathway our mission is to target clinical optimisation that delivers local priorities:

We have vast experience in delivering national and regional large-scale programmes, working partnership with NHS organisations systems across the country, Four Eyes Insight team has delivered a significant impact, including:

Click here to download our brochure to learn more.

Patient Focus and health inequalities Walsall Healthcare NHS Trust

A Patient Focus: Walsall Healthcare NHS Trust

Our Trust serves a population in the most deprived decile of the country. Whilst of course reducing Did Not Attend rates and increasing Clinic Booking Utilisation rates are about improving productivity, at its heart they are also about reducing the health inequalities that many members of our community experience.Ned Hobbs, Chief Operating Officer & Deputy Chief Executive Officer at WHNT   

Following on from our previous blog on Understanding the Impact of Health Inequalities in the UK, this article looks at the links between socio-economic status and DNAs, how they impacted Walsall Healthcare NHS Trust (WHNT) and how a patient focus approach was key to addressing issues.

A crucial part of our Outpatient Improvement Programme with WHNT was addressing health inequalities among patients in the region, improving access, and reducing safety risks associated with long waits.To learn more about the full programme of work we undertook at WHNT, click here to read the case study. 

Links between socio-economic status and DNAs indicate a higher likelihood of DNA where the patient is from an area of high deprivation. The scale of the problem is vast, nationally, in 2021-2022 there were an average of 650,000 DNAs per month, each reported to cost £120, totalling £936,000,000 for the year.  

In WHNT over 44,000 DNAs were recorded in 2020-2021, straining healthcare resources, leading to inefficiencies in clinic utilisation and delaying care for patients. The patient population served by the Trust is characterised by its diversity in terms of socio-economic status, introducing unique challenges related to digital disparities, language barriers, and financial constraints.  


A Tailored Approach to Healthcare Access 

The Four Eyes Insight (FEI) programme needed to address the challenge of digital inclusion, ensuring that solutions considered the nuances of the diverse patient population. While digital solutions offer benefits, they could inadvertently exclude individuals lacking access to or proficiency with technology.  The programme aimed for a dynamic approach that addressed the unique needs of patients who might face ‘digital exclusion.’  

In order to maximise clinic utilisation and operational efficiency, innovative solutions to the problem of last-minute appointments and cancellations were required, while engaging patients effectively and ensuring they were informed about their appointments and healthcare options was essential. 


Patient Focus and Engagement 

“The importance of access to healthcare appointments has never been as relevant. Ensuring the barriers to attending hospital appointments by listening, hearing, and understanding the patient’s voice is crucial to preventing DNAs and reducing health inequality. FEI acknowledged this and supported patient involvement in the task and finish group so that the intended outcomes had the patient at the forefront.”Garry Perry, Associate Director of Patient Relations and Experience at WHNT.  


Collaboration with patients and end users was prioritised throughout the process to ensure that the implemented changes were sustainable. 

The importance of patient involvement was recognised and several key strategies were employed to ensure the patient views were considered in all interventions. Patient involvement included:  

  • Patient Focus Groups: The partnership facilitated patient focus groups in the community to gather insights into patients’ challenges related to appointment attendance. These sessions ensured that patients’ voices were heard, and their perspectives considered in designing solutions. 
  • Surveys and Feedback: Surveys and feedback mechanisms were introduced to capture patient experiences and reasons for missed appointments. This feedback was integral in shaping the programme’s approach. 
  • Pilot of Transport Changes: Recognising that patient experience extends beyond the clinical encounter, the partnership piloted transport changes aimed at improving accessibility and convenience for patients. The pilot prompted the Trust to actively promote the range of reimbursements and support options available to patients, particularly concerning transport costs. 

These insights served as guiding principles, ensuring that the programme was finely tuned to address patient needs and concerns, ultimately resulting in improved patient experiences. 

“Working in collaboration with WHNT on the outpatient services programme was a genuine partnership. It was truly inspiring to see how this joint effort enhanced patient care and streamlined clinic operations. Together, we made a meaningful contribution to improving healthcare accessibility, and I’m proud to have played a role in this journey.Gurpreet Rai, Consultant, FEI. 


Improving DNA rates by addressing health inequalities 

Actions were taken to improve the DNA rate, focused on process change that ensured hard-to-reach patient groups that may experience health inequalities were not disadvantaged, including: 

  • Appointment Reminders: rolled out to over 200 previously excluded clinics, voice reminders were introduced for patients without mobile phones and efforts were made to provide reminders in multiple languages.  
  • Transport Support: Following a pilot project assessing the impact of offering free transport options to patients, a streamlined process for claiming travel costs was introduced. Patients could now be reimbursed on the day of the appointment, eliminating the need for lengthy processing. Information sheets explaining the process and eligibility were included with appointment letters, resulting in increased financial support uptake and reduced DNA rates.  
  • Letter Enhancement: Letter language was simplified, and patients were encouraged to check in at the outpatient reception desk to receive directions.
  • Webpage Translation: A dedicated webpage was created to translate appointment reminders into different languages, ensuring inclusivity for patients with diverse linguistic backgrounds and enabling automatic translation during phone calls with hospital staff.
  • Bespoke Processes: Specialty operational and clinical leads collaborated to develop targeted approaches where DNA rates were high. Examples include overbooking slots in some clinics, implementing Patient Initiated Follow-Ups (PIFU), and using bespoke text messages to address specific challenges in various specialties.
  • Validation Initiatives: Validation exercises initiated in specific specialties, such as Gynaecology, Trauma and Orthopaedics, expanded across the Trust. FEI drafted Standard Operating Procedures (SOPs) which the Trust rolled out across specialties. 

An average decrease of 52 DNAs per week was achieved (19/06/23 – 13/08/23) compared to the same period in 2022. Annually, this will equate to more than 2600 patients who will now be seen who would previously have missed their appointment.  

To learn more about how Four Eyes Insight can help your Trust improve DNA rates by addressing health inequalities, contact us today to arrange a call with Outpatient Subject Matter Expert and Delivery Director, Samantha Sullivan.  

Connect with Samantha on LinkedIn.

Prioritising NHS Management Training

Prioritising NHS Management Training

“We should have high expectations of our leaders, but I think if we are going to have high expectations, we have to bake in an expectation that there will be ongoing training, there will be ongoing development, that it will be high quality, that it will be assessed, and that it will give people the skills that they need to do these jobs.” Amanda Pritchard.

To preserve high standards of care quality and guarantee the security of those providing and receiving care, training is crucial for NHS managers, as it:

  • Equips them with the necessary knowledge, skills, and tools to effectively carry out their roles in a complex and dynamic healthcare environment.
  • Provides a deep understanding of healthcare systems, policies, and procedures.
  • Helps them stay updated on the latest developments in the healthcare sector, including medical advancements, regulatory changes, and best practices.


Arguing that introducing statutory regulation would improve the development of managers, Amanda Pritchard highlighted that this work should become a priority in order to continue to attract a high calibre of leaders into the NHS.


NHS management training to improve patient safety

Investing in management training will aim to set standards and hold those accountable if and when dangerous circumstances arise.

By giving priority to an NHS management training programme that is centred around the patient, risks to patients can be mitigated, resulting in an enhanced and safer experience for them. By integrating components such as efficiently communicating with their teams and effectively managing individuals with behavioural challenges, managers can actively pursue organisational objectives while ensuring the preservation of patient safety.


How can Four Eyes Insight help NHS managers?

Our experienced, expert staff design and deliver training for NHS management teams to achieve optimal performance. Our training approach moves through a cycle of designing and delivering bespoke training for management, clinical services and teams with e-sessions, expert speakers and a blended approach of face-to-face and self-paced online learning sessions.

Our training packages aim to support our colleagues in the NHS with improvements and efficiencies, ensuring they can create a sustainable service for the organisation and, most importantly, patients.

We also offer Admin and Clerical Modules to support Band 3 – 5 staff with core skills to deliver their roles. All of our training can be customised to cater to your specific needs.

If you would like to learn more about our NHS management training modules, please contact us today.

Health inequalities in the UK

Understanding the Impact of Health Inequalities in the UK

What Are Health Inequalities?


Health is a fundamental human right, yet not everybody in the UK has equal access to it. In this latest blog post, we delve into the complex issue of health inequalities in the UK, examining their causes, impacts, measurement, and strategies for combating them.

Health inequalities refer to the systematic differences in health between different groups within a population. These differences are often unjust and avoidable, stemming from social, economic, and environmental disparities. In the UK, these disparities have a profound impact on healthcare and health outcomes.

What Causes Health Inequalities?

There are many drivers that contribute to health inequalities in the UK, with four of the main factors highlighted in the graphic below.

domains of health inequalities in the UK


Socio-economic deprivation

One of the primary drivers is socioeconomic status. Individuals from lower-income backgrounds often face barriers to accessing healthcare, including financial constraints, limited education, and inadequate housing, all of which affect their health outcomes.

In addition, education plays a crucial role as limited access to quality education can lead to poor health literacy, making it harder for individuals to make informed health decisions and access healthcare services effectively.

Unemployment or precarious employment is also a contributor to stress, financial instability, and, consequently, poorer health.

Equality and diversity

Health inequalities are also associated with ethnicity as minority groups may experience discrimination within the healthcare system, leading to disparities in health outcomes.

Inclusion health

Vulnerable or inclusion health groups – for example, migrants, Traveller communities, and people experiencing homelessness may not have easy access to healthcare.


Geographical location matters. People living in deprived areas often have reduced access to healthcare facilities and face environmental challenges like pollution and limited green spaces, impacting their overall health.


The Impact of Health Inequalities on Healthcare and Health Outcomes

Health inequalities have far-reaching consequences, not only for individuals but also for healthcare systems:

  • The strain on healthcare resources: the unequal distribution of health resources places additional strain on healthcare services. Areas with high health inequalities often require more healthcare interventions, leading to resource disparities.
  • Increased healthcare costs: Health inequalities result in higher healthcare costs as individuals with poorer health may require more extensive and expensive treatment.
  • Reduced life expectancy: Those in disadvantaged groups generally have shorter life expectancies, leading to a decrease in overall population health.
  • Lower quality of life: Health inequalities diminish the quality of life for those affected, limiting their opportunities for personal and professional growth.


Progress and looking forward

It would be amiss when covering health inequalities, not to mention the Marmot Review. Published in 2010 and updated in 2020, the review has been a seminal document in the UK’s efforts to tackle health inequalities that emphasizes the importance of addressing the social determinants of health, such as income, education, and employment, in reducing disparities. It also calls for action at local, national, and international levels to create a fairer and healthier society.

Significant progress has been made through a range of initiatives and interventions, including reducing the prevalence of smoking, reducing teenage pregnancies, and improving cancer survivorship rates, to name a few. Despite this, there remain many complex challenges to overcome, not least the gap in healthy life expectancy between those living in the most deprived areas when compared to those living in the least deprived areas, which can be as much as 19 years.

Reducing health inequalities in the UK is a complex and ongoing challenge that requires a concerted effort from various sectors. The government, healthcare providers, local authorities, and community organizations must collaborate to implement policies and interventions that address the multifaceted nature of these disparities. By focusing on socioeconomic factors such as ethnicity, geography, gender, age, disability, and digital literacy, we can work towards a healthier and more equitable future for all residents of the UK.

Addressing health inequalities in the UK is not only a matter of social justice but also a crucial step in improving overall public health. By acknowledging and understanding the factors that contribute to these disparities and implementing evidence-based strategies, we can pave the way for a healthier and fairer society. It is a challenge that requires sustained commitment and collaboration, but the benefits of reducing health inequalities are immeasurable in terms of improved well-being and quality of life for all.

Further reading
Outpatient improvements: protecting and expanding elective capacity

Outpatient improvements: protecting and expanding elective capacity

Last week, NHS England wrote to Acute Trusts about protecting and expanding elective capacity, highlighting that significant improvements still need to be made within outpatients. The letter outlined that NHS Trusts need to support new approaches to increasing wider outpatient productivity and reduce follow-ups.

In addition, NHS England has set the following targets:

    • No patient in the 65-week ‘cohort’ (patients who, if not treated by 31 March 2024, will have breached 65 weeks) will be waiting for a first outpatient appointment after 31 October 2023.
    • Maintain an accurate and validated waiting list by ensuring that at least 90% of patients who have been waiting over 12 weeks are contacted and validated by 31 October 2023
    • Restoring normal levels of productivity post-covid has been challenging. With continued long wait times, a lack of patient-initiated follow-up pathways (PIFU) and in many cases, poor communication with patients regarding appointments.

      Samantha Sullivan, Delivery Director at Four Eyes Insight explains, “What we’re seeing on some of our programmes is that Trusts are struggling to get back to the basic good practices that were in place before covid. For example; templated slot reductions put in place through the pandemic have, to some extent, remained, reducing appointments available.

      There are also a number of long-standing issues Trusts are still struggling to resolve, such as, basic utilisation reports not accurately capturing the true clinical capacity, hampering visibility of core metrics and poor interfacing of IT systems that lead to a lack of effective communication with patients.

      In addition, the recruitment and retention of support functions in outpatient departments are a challenge and trying to meet the demands of the team has been difficult, especially with systems and technology not always interfacing well and limited resources for validation. All this contributes to a poor patient experience.”

      Data is king

      The question of what good performance looks like in outpatients doesn’t need to be complex. Productive and efficient outpatient departments are those that have embraced data and technology, implemented processes to ensure short notice available capacity is well utilised,  validated patients on waiting lists and improved patient communication – especially with those who may not have English as a first language.

      How can Four Eyes Insight help?

      As Trusts continue to work towards these outpatient targets, using our framework and subject matter expertise, we aim to support your team with the tools and techniques needed to reduce unnecessary appointments, clear backlogs and increase efficiency with measurable results.

      We understand the pressure placed on the NHS, which is why we work shoulder-to-shoulder with outpatient teams to implement interventions, optimise productivity and ultimately help you provide great patient care and satisfaction.

      To learn more about how we can help you improve outpatient utilisation and transform service delivery, contact us at

The Hewitt Review: A Case for Change?

“Achieving the ambitions reiterated in the Hewitt Review, and creating the conditions for ICS success will require sustained commitment from all partners across the health and care system and we at NHS England are committed to playing our part.”

Steve Russell, Chief Delivery Officer and National Director for Vaccinations and Screening, NHS England.

Essentially, The Hewitt Review advises how Integrated Care Systems should be run to create a more sustainable NHS.

The case for change: The Hewitt Review

With an end goal of preventing ill health and improving NHS productivity, the main objective of the review was to evaluate how to best enable integrated care systems (ICSs) to succeed by balancing greater autonomy and robust accountability.

Identifying six key standards for change, the review recommended the following principles that will support the long-term sustainability of the NHS and its patients:

  1. 1: Collaboration between systems and national bodies, treating each other as partners with complementary and interdependent roles and creating mutual accountability.
  2. 2: A limited number of shared priorities that provides local leaders with flexibility about how they apply priorities to their local circumstances.
  3. 3: Give local leaders space and time to lead by avoiding adding new targets and initiatives that make it hard to plan, while wasting valuable NHS resources.
  4. 4: Systems need the right support, with ICSs needing whole system support, rather than individual providers or sectors.
  5. 5: Balancing freedom with accountability between authorities, local government and systems, including a new role for CQC as the independent reviewer of ICSs as a system.
  6. 6: Enabling timely, relevant, high-quality and transparent data essential for integration, improvement, innovation and accountability.

Examples of change: Acute Provider Collaboratives

“We’re seeing Acute Provider Collaboratives crop up across the country, some seem to be working well, however, some seem to find it a struggle, which is understandable. It will be difficult for NHS Trusts to step up to the plate and start collaborating, as they’ve spent the past 20 – 30 years in a highly competitive survival mode.” Explains Brian Wells, Founder of Four Eyes Insight.

Like ICSs and ICBs, Acute Provider Collaboratives (APC) are designed to improve efficiency, sustainability and care for patients by combining several Trusts to work alongside each other, providing many similarities to the Hewitt Review and moving towards increased collaboration and autonomy for organisations.

Towards the end of last year, NHS Confederation invited provider collaborative leaders to respond to a survey on the development of their collaboratives, with an interesting 70% of respondents highlighting that they still consider themselves in the early stages of set-up.

Although it seems positive relationships are being established between APCs and ICBs, working in co-operation rather than a ‘top-down’ model, as suggested in the Hewitt Review, the main challenges faced are around workforce and resourcing and the time it will take to set up collaboratives properly.

One of the key principles in the Hewitt Review is to give local leaders space and time to lead by avoiding adding new targets and initiatives that make it hard to plan. This is crucial to the success of these collaborations between providers, ICBs and ICSs –creating new targets every few months will do more damage than good, leading to diminishing patient experiences and access to healthcare.

Compelling Narrative: Maximising Patient Safety

Demand and access to healthcare services often outstrip available resources within elective care. Four Eyes Insight’s recent work with an APC in South England shows that organisations working together can provide system-wide capacity, improve productivity and maximise patient safety.

Supporting the establishment of an Elective Hub with the APC, we’ve identified that when fully operational, the Hub will significantly impact the high-volume demand and capacity gap, and release capacity for more complex surgical activity in specialist sites including ENT and Urology.

An estimated overall capacity increase of approximately 4500 -5100 additional surgical day cases per year could be achieved – providing the collaboration of services is developed and maintained.

Having a compelling narrative for APCs, ICSs and ICBs should be at the heart of these collaborations, without them teams would lack direction, engagement, and affect morale.

8 Ways to Improve Effectiveness of Elective Hubs

“Bringing together the skills and expertise of staff under one roof will ensure we keep pace with future demand and rapidly reduce waiting times, getting patients access to vital procedures when and where they need them.”

Health and Social Care Secretary Steve Barclay

In this latest instalment of our Elective Hubs blog series, we look at the dynamics that can make these centres highly effective.

Previously we spoke about when setting up or transforming an elective hub, what is its purpose? In addition to the critical aspect of treating patients quickly, efficiently and safely, there must be a focus on the mission of the hub.

As Four Eyes Insight Founder, Brian Wells explains, “productivity is key to an elective hub’s existence, therefore seeking every way to deliver care in the most effective and efficient way should be central to its ethos.”

Wells, who spent six years as Managing Director of the South West London Orthopaedic Centre (SWLEOC) and then moved on to Director of Orthopedics at Guy’s and St Thomas’ NHS Foundation Trust has gained much experience and understanding of the complexities around elective hubs and ring-fenced elective pathways.

It is this experience that led to the notion that creating an effective ethos can make a significant difference to elective hubs, highlighted in the following eight key elements:


  1. 1: Create dedicated clinical and operational teams who are masters at their skills and competencies, to create stability, “we’ve seen that elective hubs can easily lose staff quickly due to the pressures on the acute trusts – staff get pulled into other sites and there is no stability for the staff or the hub.” Wells highlights.


  1. 2: Have dedicated and accountable senior clinical and managerial leadership with strong governance processes that monitor and measure detailed quality and performance KPIs closely.


  1. 3: Be on a mission to be best in class on clinical outcomes, providing great training and, critically, delivering high levels of productivity, “to be world-class you need to be looking at, monitoring and pursuing new ways of doing things. Think about what the future of the service should look like. Are you looking at developing and modernising your pathways to meet them? Where does digital come into play and AI? These are all important elements that have a role to play in the future of the NHS – moving into a flexible, digital world.”


  1. 4: Standardise clinical pathways and protocols that safely allow the wider clinical team to extend their roles and skills. “If standardisation becomes a philosophy, everybody then knows what they’re doing and staff will understand how to make the service work productively, efficiently and above all – safely.”


  1. 5: View standardisation as a great philosophy then every effort to standardise the clinical pathways is expected and pursued.


  1. 6: Pilot, test and advance new ways of achieving higher levels of productivity, such as HVLC lists, Superlists and High-Performance lists, with an ambition to go beyond historic levels of performance.


  1. 7: Measure the outcomes of what the elective hubs do, monitoring and reflecting on these outcomes to perfect the clinical approach and pathways.


  1. 8: Acknowledge incentive schemes to reward efforts beyond BAU performance, if this is done in the correct way, incentives can be a real enabler for the whole team and service.


Elective hubs can make a huge difference to the NHS in reducing the elective care backlog. With the right level of ambition and expectation, providers can take them beyond the performance levels of an acute setting where services face daily complex challenges from emergency pressures. Wells concludes, “all staff need to invest in a vision to be the best of class, seeking opportunities to refine and advance their input to the mission. To do this the NHS need to coach and train the workforce on what it really means to deliver high levels of productivity safely and with positive patient outcomes, by sharing emerging best practices for high performance and then developing their services through an accountable improvement programme.”

Contact us today to learn more about our work with Elective Hubs


About Brian Wells

Brian is a Founder of Four Eyes Insight who trained as a Registered Nurse in the Army specialising in theatres and anaesthetics.

Following a long clinical career, he went on to hold senior management posts in the NHS including, Managing Director of SWLEOC (a centre of excellence in elective orthopaedic care), and Director of Orthopaedics at Guy’s & St Thomas’ NHS Foundation Trust where he provided senior leadership with a focus on clinical productivity, process standardisation and operational grip and control.

Connect with Brian on LinkedIn.


elective hubs surgery room

Elective Hubs: struggling to achieve productivity

An estimated 780,000 more patients in England will benefit from additional surgeries and outpatient appointments by 2024, according to NHS England, thanks mainly due to Elective or Surgical Hubs.

Recently, Brian Wells, Founder of Four Eyes Insight hosted a webinar, discussing if Elective Hubs could help ease NHS winter pressures, in response to the NHS setting out steps to rapidly boost capacity and resilience prior to the current winter pressures.  A main element of the webinar was to examine the challenges faced by elective hubs.

Elective hubs, whether stand-alone or integrated, ring-fenced or part of acute capacity; are predominantly dedicated elective services that focus on a narrower cohort of low-complex elective procedures treated through highly productive clinical pathways. The emphasis here is achieving higher levels of productivity than would be seen within an acute service, where clinical complexity and emergency pressures can directly impact throughput along the elective pathways.

Within the healthcare system, demand and access often exceed available resources, but this has been seriously compounded by the considerable impact on elective pathways from the recent pandemic.

There are approximately 90 elective hubs across England suitable to treat over 60% of patients currently waiting for surgery, an opportunity acknowledged by NHSE South East which has a number of elective hubs and dedicated ring-fenced elective pathways established on its patch. Therefore, assurance that these elective hubs or dedicated ring-fenced elective pathways were being used to their full potential was critical to the region’s elective recovery plans.

Elective hubs should achieve higher levels of productivity through a mission to target patients requiring lower complex procedures treated through consistent and standardised pathways where each element of the patient’s treatment is predictable and efficiently planned. However, that isn’t necessarily the case, as Brian Wells explains:

“What we’re seeing in the data coming out of these surgical hubs is that they are struggling to achieve the high levels of productivity that is possible. There are the usual signs of operational challenges inherent within elective pathways such as under-scheduled operating lists, start delays and cancellations, but there are several cross-cutting themes that have emerged that need to be addressed if the ambitions for high performance are to be met. These themes include;

– A need for dedicated leadership with the ambition and capacity to transform the pathways for high performance,

– Having a dynamic workforce plan designed to deliver higher productivity. Moving beyond the standard guidance for the traditional operating lists of ‘one after the other’ but towards HVLC, Superlisting and HIT listing, where dynamic flow planning allows for parallel activities from enhanced teams that increases in-list utilisation and productivity and reduces downtime.

– Achieving a cultural shift towards productivity through a compelling narrative that effectively engages clinicians and secures buy-in to the principles of high-volume operating lists, and,

– The complete adoption of the core principles for optimising elective pathways as business as usual.”

Following the success of the Elective Recovery Support Programme completed in partnership with the region, Four Eyes Insight was invited to complete a programme of work that included assessing if these elective hubs or dedicated ring-fenced elective pathways were planned or being used to their full potential.

The programme had a significant impact in several areas, with highlights including the trialling of a ‘super list’ ahead of further rollout, the completion of a series of best practice workshops to facilitate the upskilling of staff in best practice processes to maximise elective capacity, and the completion of analytical scenario modelling and delivery targets set to meet productivity expectations.

“Ever since I started Four Eyes Insight back in 2014, I’ve been involved in supporting elective services. We know the exemplars, such as SWLEOC and now hubs across NHSE South East are looking to gear up their capabilities with those exemplars in their sights. Can elective hubs make a difference? Absolutely they can, As stakeholders gain a greater understanding of the things that make the difference and focus on those themes that are challenging progress we’ll see the hubs rebound and deliver”.


About Brian Wells

Brian is a Founder of Four Eyes Insight who trained as a Registered Nurse in the Army specialising in theatres and anaesthetics.

Following a long clinical career, he went on to hold senior management posts in the NHS including, Managing Director of SWLEOC (a centre of excellence in elective orthopaedic care), and Director of Orthopaedics at Guy’s & St Thomas’ NHS Foundation Trust where he provided senior leadership with a focus on clinical productivity, process standardisation and operational grip and control. Brian led the development of the national theatre productivity methodology and analysis and continues to advise on high-performance elective transformation.

Connect with Brian on LinkedIn.