Will robots help cut NHS waiting lists?

The Chief Executive of the NHS has pledged to use “every tool at our disposal” to help cut NHS wait times by 2029, and he included robot-assisted surgery as one of those tools. Except currently, robot-assisted orthopaedic surgery takes more time than conventional surgery, not less. YKC’s Dave Duffy unpicks the problem.

The NHS plans to expand the number of robot-assisted procedures it carries out to reduce wait times. In 2023/4, the number of robot-assisted procedures carried out in NHS hospitals was 70,000. By 2035, as reported in Health Tech World, that number is projected to rise to 500,000.

If you’re a regular reader of these pages, however, you might notice an issue with that ambition. There are lots of different opinions about the value of the current state of robot assistance in orthopaedics (which I’ll get to in a moment) but one area where there’s no disagreement is that robot-assisted knee replacement takes longer than conventional surgery.

It’s not a vast amount of additional time, but 30 minutes extra on every procedure doesn’t, on the face of it, sound like a short cut to shorter waiting lists. So why is there so much focus on the robots’ ability to cut wait times?

The value of a robot

Not all robots are the same. And in surgery, not all robots are used in the same way. The chief exec of the NHS, Jim Mackey, did specifically mention orthopaedic robots, but those weren’t the only robots mentioned.

While opinions may vary on the current value of robots in orthopaedics, there are no such debates in other areas of healthcare. Robot-assisted bladder cancer patients typically leave hospital in half the time of patients having traditional surgery. Prostate surgery has been transformed because the robot involved – the Da Vinci – can access cavities of the body the human hand can’t, and has degrees of rotation and manipulation that the human hand doesn’t.

The Da Vinci reduces blood loss. It reduces risk of complications. It shortens a patient’s length of stay. These things are proven, and there’s a clear benefit that absolutely could help support the NHS’ aim of cutting waiting lists.

So could the same be true of orthopaedic robots?

The robot in your knee replacement

When a surgeon performs a knee replacement, and when you strip things right back to basics, there are effectively only three questions they need to answer:

• Where should they place the knee implant?
• Having defined the right place, what are the acceptable limits around that?
• Having completed the procedure, did they put the implant exactly where they intended?

One of the big issues in knee resurfacing, particularly total knee resurfacing, is that there are numerous different philosophies as to how you should align a knee replacement. As long as the orthopaedic community remains somewhat divided over this issue, a robot can never help answer questions one and two, because there’s a philosophical question at the heart of them that only a human can answer.

A robot, then, can only help you answer question three. Once you’ve determined where your implant will be positioned, it will help ensure you make the cuts in the right place. Currently, then, orthopaedic robots are glorified satnavs. They tell you where you are. They’ll help you get to where you tell them to go. But they won’t tell you where the destination should be.

And they’ll take 30 minutes longer to do it than for traditional surgery.

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Cutting complications

There is some evidence to suggest that complications can be lower with robot-assisted surgery, reducing infections and length of stay compared with traditional surgery. On the face of it, this would offer some potential for reducing waiting lists, because some people would need to spend less time in hospital or be readmitted for treatment.

Yorkshire Knee Clinic’s position remains that these benefits are less clear when compared with the results achieved by specialist knee surgeons who perform hundreds of procedures every year. Much knee replacement surgery now involves just a single night in hospital. Occasionally these can be same day procedures. Complications are already very low.

It’s also the case that cutting the waiting lists can’t be at any cost. Robots are fearsomely expensive. They don’t last forever – they need maintaining and at some point they’ll need replacing. They require specific training. There are lots of consumables that must also be bought to support the use of a robot. All of this costs (a lot) of money.

Making the business case

For some surgery, the business case for robot assistance is absolutely proven. For some, notably robot assistance in orthopaedics, it’s much harder to say that, at the present time, increased use of robot assistance will lower waiting lists and/or do it in a cost effective way.

The NHS’ target date is 2035 and who knows what the state of robot interventions will be by then. But right now, the NHS needs to invest in the right robots in the right fields to make real inroads into waiting lists. I’d suggest the real cost benefit right now lies in areas other than orthopaedics.

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