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Improving theatre operational productivity with the NHS 6-4-2 model

Introduced into the NHS in 2019, the 6-4-2 model is an improvement process, by which surgical staff:

– declare their annual leave six weeks in advance of their surgery schedule

– arrange their surgical lists four weeks before for sign off and;

– review their plans two weeks ahead of the surgery lists being ‘locked down’.

According to the NHS improvement hub, Productive Operating Theatre, the 6-4-2 model supports theatre teams to work more effectively together; to improve the quality of patient experience, the safety and outcomes of surgical services, the effective use of theatre time and overall staff experience.

642 planner

Lead Associate of the NHS’ Productive Operating Theatre, Amanda Fegan, said;

At the Productive Operating Theatre visioning sessions, scheduling, and more specifically, over-running lists are consistently highlighted as one of the three biggest barriers to achieving the teams’ vision of the perfect operating list.”

This followed a report commissioned by NHS Improvement (NHSI), ‘Operating theatres: opportunities to reduce waiting lists, that found theatres regularly lost time due to late starts, early finishes, and delays between operations, prompting the regulator and NHSI to recommend hospitals adopt a simpler model of scheduling surgeries and booking holidays.

The 6-4-2 scheduling model, used in theatre departments across the country, provides a universal approach to replace unclear, inconsistent and disparate processes. Supported by the NHSI Productive Operating Theatre guide, 6-4-2 enables theatre teams to be more productive and efficient at work, whilst providing individuals with a practical approach to understanding theatre scheduling systems and processes; supporting teams to identify where improvements can be made to deliver a reliable and achievable list.

The NHSI model below also explores the benefits and outcomes of having a scheduling system in place and what this means for patient experience, safety and reliability of care, team performance, staff wellbeing and value and efficiency.

patient experience

In support of the 6-4-2 model, the Getting It Right First Time (GIRFT) tool helps NHS trusts deliver quality and productivity improvements for patients across many surgical specialities. It has shown that putting clinicians and clinical leadership at the heart of any change process is vital to realising real and sustainable improvements.

But, at times of escalation, planning in this way is often deprioritised. During the Covid-19 pandemic, theatres across the country moved away from the 6-4-2 model in order to be reactive to staffing schedules changing daily, the increasingly high volume of surgical cases and the evolving Covid-19 guidance for healthcare providers. post-pandemic it has been reported that NHS England data featured in a BBC article shows that there is a 12% lower operation carried than the year before the pandemic. Outpatient clinics, which include minor procedures, tests and assessments, are down by 5% to just over one million a month on average.

According to the article, the struggle to return services to full strength is why the backlog is growing because the number of new referrals for treatment has not actually gone up above its average before the start of the pandemic.

Following the pandemic, Four Eyes Insight worked with Cardiff & Vale University Health Board to improve the patient experience by implementing an efficient 6-4-2 scheduling process for theatre sessions, supporting the reduction of the post-pandemic backlog.

“The main challenge for us was how we conducted 6-4-2 and the scheduling process. When Four Eyes Insight came on board with us they spent time understanding the challenges facing us and worked very hard to help launch Task and Finish Groups and worked alongside the team. They looked at the team’s capacity and capability, increasing our team’s establishment to ensure lists can be booked further in advance.” Paul Bracegirdle, Interim Deputy General Manager,  Perioperative Care.

Senior Consultant and Delivery Lead at Four Eyes Insight, Sarah Nolasco said:

“We worked with the theatre managers to ensure they had a good process in place following the pandemic, obviously many things have changed during that period of time, and like many hospitals, they have had to find new ways of doing things. The key to this was supporting their 6-4-2 scheduling process to ensure they have the clinicians to cover the lists and are able to use the resources they have effectively.”

Implementing an effective theatre scheduling process is a critical part of organising how an operating theatre department runs. For teams getting to grips with scheduling, this can make the difference between a well organised, efficient and effective department and disarray and increased stress for the teams involved.

To find out more about how Four Eyes Insight can help your NHS theatre team improve its patient experience and take advantage of the efficiencies that the 6-4-2 scheduling process can offer, contact our team of experts at