Dr Andrew Greenland: 0:00

Welcome to Voices in Health and Wellness. This is the podcast that spotlights clinicians, founders, and operational leaders driving innovation in patient care. I'm your host, Dr. Andrew Greenland, and today I'm joined by a truly inspiring guest, Mr. Muralii Bhat, an consultant orthopedic and upper limb surgeon with over 32 years of experience in medicine, including more than 15 years practicing in the UK. Morali's work expands across NHS and private practice. He's led virtual fracture clinic implementations, pioneered cost-saving approaches to hand surgery using wide awake local anesthesia, and is an expert in lean management within healthcare settings. His innovations have earned national recognition, and his focus is always on delivering better care through smarter systems. So, Murali, thank you very much for joining us this afternoon and welcome to the show.

Murali Bhat: 0:47

Thank you for having me, Andrew.

Dr Andrew Greenland: 0:49

So maybe we could start at the top. Perhaps you would mind talking about what sort of first drew you into orthopedics and later to specialize in hand and upper limb surgery.

Murali Bhat: 1:00

That's a very interesting question. Actually, I was an athlete. I was a sportsman as a as a as a child and a young person. I did gymnastics at a very high level back in India where I was born and brought up. During those days of uh competing, there were lots of sports injuries that I saw, lots of uh gymnasts retiring because of injuries that I was hearing could be fixed in the in the Western world. Um, and where I was um uh in India, that those facilities didn't exist. So there was always an initial desire and drive to try and help out by learning how to fix sports injuries. So that got me into thinking maybe I should go and uh graduate in medicine and then go on to do something like orthopedics or sports medicine. Um that was how the desire to do medicine and orthopedics came up. Um, when I was uh doing my postgraduate training in orthopedics in uh Bombay, um I was involved in dealing with somebody with a very nasty wrist injury after they came off a high-speed motorcycle accident. And um there was nobody who was able to fix that injury. It was one of those complex wrist injuries that there was just not anyone who was trained to be doing it. So I took an interest in that particular patient and decided to uh read about it and persuaded my boss to allow me to do the operation. As a result of that initial uh efforts and going ahead and doing the operation, um, it turned out quite well. So that inspired me into thinking uh that there was a room and a scope for developing my skills in hand surgery, and I looked towards the UK in order to go and train in hand surgery. So that's how that came about. Uh, and the rest is history.

Dr Andrew Greenland: 3:03

Thank you. I mean, you just mentioned there's sports medicine, and sports medicine is very much a specialty in its own right. I mean, who owns sports medicine? I mean, obviously, you have an interest from from your background and the gymnastics, but you're currently in orthopedics. But who owns a specialty of sports medicine and how does it how do the different things get managed within it?

Murali Bhat: 3:21

So uh I mean sports medicine, uh I've subsequently learned um that it's mostly to do with sports physiology and nutrition and um prevention of sports injuries. And what I was actually looking for was to try and treat sports injuries. Um, and that got me into thinking the only way to do that would be to be an orthopedic surgeon with an interest in things like knees and shoulders, which was the common areas that sportsmen got injuries in. So I don't know if that answers your question.

Dr Andrew Greenland: 3:55

No, it does. Thank you very much. Um and you mentioned that you trained in both India and across several NHS centers in the UK. What were the kind of key moments that helped shape your clinical approach that you now have?

Murali Bhat: 4:07

So the first thing, the most striking thing that uh I noticed having worked in two different countries, um, was that I felt like the NHS was a fantastic resource for healthcare, but I also felt that there was a lot of there was there was a room for avoiding uh the wastage that I was seeing. I know it sounds bad when I use the word waste. What I mean is in a patient pathway, there was a lot of there were a lot of things that were costing unnecessary expenses. And so I was looking at leaner ways in trying to give the patients the best experience with much much less in the way of costs, and also increase the efficiency. So, for instance, using theaters efficiently and trying to deliver close to 100% uh efficiency were some of the things I initially started looking at. Um, so I got involved in uh a management program when uh Jeremy Hunt used to be the health secretary all those years ago. Uh, he got interested in uh something called the Virginia Mason uh production system. So that's basically the Virginia Mason Institute in Seattle, who got uh into the Toyota production philosophy and the Toyota production system and became one of the most efficient and lean hospitals um in the world from being a failing hospital all the way to becoming the most efficient. So he brought that learning into the UK, and five trusts in the UK were uh piloted for that uh training program. So my hospital, Surrey and Sussex Healthcare, became one of those trusts, and I took a keen interest in that program. So we had to do a one year training in that um lean management um program, in which I had to implement a lot of things within my own um department, which was a revelation. Uh so we're we're now able to measure um uh the process, we're now able to measure wastes. Um, and so I implemented the virtual fracture clinic through that training. Um, so and uh along the way I will explain, I think we're going to cover virtual fracture clinics during the rest of this talk. You'll hear me talk a lot about it. Yeah, I'm very passionate about and proud about the achievements uh in the virtual fracture clinics.

Dr Andrew Greenland: 6:39

Quite rightly, and we will cover that a little bit later on. So, what is your typical week? And I dare say there is no such thing as a typical week in terms of how you sort of split your time between NHS, private work, training, research, and all the different hats that you wear.

Murali Bhat: 6:54

So I work in a in a large district hospital. Um teaching hospital, but we are quite busy because of where we are located, next to Gatwick Airport and next to two major motorways and a rail link between Brighton and London. So we get a lot of trauma coming into uh our hospital in East Surrey. Uh so when I started my consultant career in Red Hill, I was uh doing weeknights and weekends work on call. Uh we looked after people with broken arms, legs, everything. Uh so in the last five to ten years, as I've become a senior consultant, I no longer work um during the weeknights and weekends. I don't do the on-calls. I only do the specialty trauma, the hand trauma, uh, which uh which which is which means I'm uh I'm lucky not to have to be up at night to be doing surgery. So I'm in a nice position where I can um choose what I like and enjoy and not do what I don't necessarily enjoy. Um I also have the privilege of being able to train uh um uh registrars and SHOs who come through the hospital. Um and I I developed the hand unit in East Sarah Hospital uh from scratch, and it's become one of the most uh desirable hand units for uh trainees to come along. So I spend um about half of my time in the National Health Service and the other half in the private sector. Uh in the National Health Service, I'm mostly taking uh my team through operations rather than doing the operations myself. Um and and there's formal and informal education that's going on around it, and I love that.

Dr Andrew Greenland: 8:53

Amazing. I mean, and having a job where you can do everything that you like, I think is fantastic. And we just try for that. I'm very keen to talk about the um virtual fraction clinic, which is something you developed during the COVID lockdowns, if I remember correctly. Can you talk us through that and where we are today with it? Because it isn't just something that ended at the end of COVID. So where where are we yeah, talk us through the journey of the uh the virtual fracture clinic?

Murali Bhat: 9:16

So we were uh we were getting um extremely busy uh in our fracture clinics to the extent that people didn't have sitting space in the waiting room and was getting a little bit um it was getting out of control. Um this was even before COVID. So in 2019, the management program that I talked about earlier um was done uh was something I did in 2017, and then in 2019 I decided that I needed to manage my own fracture clinic better and brought in the virtual fracture clinic concept within my fracture clinic. So the training allowed me to develop the virtual fracture clinic without any investment. Okay. Um, so that meant that for about a year I ran the virtual fracture clinic for my own um clinic and found that I could actually discharge 50% of my referrals before they arrived to my clinic. So what happened was the week before their appointments, I would look at all the patients on the system. I would review their x-rays, I would review their history, and I would ring them and explain that they didn't need to come and that they could manage themselves uh in the comfort of their own house and send them some care plans to recover. So that meant that they were happy not to have to come. Uh what I'm trying to say is that nearly half of what we were saying were you'd regard them as minor injuries that actually didn't require them to have a plaster or an operation or any intervention for that matter. So they just needed advice. And we were able to, I was able to give them advice before they arrived into the fracture clinic. And obviously, we gave them a chance to come if they still wished to. So we found that a very interesting experience that 50% of our patients could be discharged without them attending. So when COVID uh came along in 2020, the hospital was was extremely keen, if you remember, to keep patients at home. So we got a budget for COVID in order to try and help people do that to avoid spreading the virus. And so then I was allowed to invest in a software system. Um, it's called Pathpoint, um, which I think Andrew you're familiar with.

Dr Andrew Greenland: 11:43

I am, we have it in our unit as well, so I'm very familiar.

Murali Bhat: 11:47

So I went and visited Northwick Park Hospital in Harrow to see how it functions uh with a team of people from my hospital. We we liked it and we then implemented that across the entire trauma and orthopedic department based on the audit and the data that I'd collected in my unit. So that was in 20 uh we implemented that in 2020, the COVID year. So we are running that now for five years. So we see something like 300 virtual referrals every week. We've opened up the doors to urgent GP referrals because of where we are near Gatwick Airport. We get a lot of people who come uh from holidays abroad, uh, skiing accidents and such like, where they've had the initial treatment uh abroad. And so these kind of patients were finding it difficult to come to our fracture services um without having to reattend AE. So now we've allowed GPs to refer such patients through the VFC. So um in 2023 uh we had uh we had uh we got three national awards for our VFC for how lean we were uh running it, uh how how lean it was and how safe it was, uh, and how carbon neutral and carbon friendly the VFC was. So we got three national awards, which uh which was a record. So I'm I'm very proud of that.

Dr Andrew Greenland: 13:17

No amazing work. And obviously the impact is probably fairly clear from the hospital perspective. What about your team members, colleagues, and I guess the patients themselves? How how has it generally been received?

Murali Bhat: 13:27

Like like with most uh initial, like with most changes, initially um for the uptake, um for for the buy-in to uh to happen takes time. But we're now got to the stage where people are people won't do without the VFC. The VFC can't go anywhere. Um it's it it was it took about a year or two for my consultant colleagues to appreciate what the VFC can do. Uh, we as doctors are brought up to see patients face to face, examine them, uh, whilst I agree that it's a good practice in general. In the context of a fracture clinic, uh there are a number of patients who don't need that, who don't need to be examined uh or made to wait in a fracture clinic for an hour to be seeing one of our junior doctors for two minutes. So um so I so we uh I found that uh the uh initially the doctors who I worked with were struggling to understand what we were doing, but now they're all on board um and won't do without the VFC. If the VFC was to be taken away, we'd be in deep trouble.

Dr Andrew Greenland: 14:36

Sure. I think you mentioned before that the videos used in the system were um hosted on Vimeo. How important was that multimedia component to scaling the patient self-management?

Murali Bhat: 14:47

Yes, so I uh didn't mention earlier that I went around because we were not the first people to start the VFC. There were other trusts that were doing it, everyone was doing it differently. Um so I went around visiting different hospitals around me to see what they were doing. So Brighton uh was uh running a VFC for a number of years, and they were actually given funding uh by NHS England to produce videos uh for the common injuries that patients would sustain, orthopaedic injuries that patients sustain. Those videos were sitting on Vimeo and is available to the general public. All I needed to do was to bring those videos together with the appropriate written care plan, um, and which meant that all these hospitals were doing different things, but they were not put together, if you know what I mean. So, for instance, but Brighton was running a pediatric VFC, they were running a hand VFC, they were running a general VFC, and I thought I'll bring all of that together. So we got the hand and the pediatric and the general VFC together in East Surrey Hospital, and I put the videos into the care plans. So it be so we had about 134 care plans that I developed in that way, and I found that for wrist injuries, there weren't enough in the way of care plans, so I designed a few. So it became something uh that is the crux of the VFC. The 134 care plans that I developed was in that first month, you remember, when the main first lockdown took place. So I had lots of time at on hand and I just went on doing that work.

Dr Andrew Greenland: 16:26

Brilliant. I mean, can you there must be obvious other obvious applications of the platform in other aspects of healthcare? Where else could you see this being used if it's not already been taken up?

Murali Bhat: 16:37

Uh well, I've heard that um the urologists uh run something called the virtual stone clinic. Um the dermatologists uh do virtual clinics. It's very, very amenable for dermatology. And I'm sure there are there'll be other specialties if they look into it, they might find um um its application. Uh, certainly for virtual fractures, uh just as we have virtual fracture clinics, you can have virtual elective clinics, for example, hip replacement follow-ups, knee replacement follow-ups. You just you can actually have a chat with the patient, they can demonstrate their wounds or whatever it is. Um, and so you can reduce the face-to-face follow-up rate, even for the elective orthopedic patients.

Dr Andrew Greenland: 17:23

Amazing. Um, I think another one of your initiatives is the WALLANT. I don't know if I pronounced that correctly because I know it's an acronym. Um why is that so perhaps you tell us a little bit about it for the audience and also why it's so significant in hand surgery?

Murali Bhat: 17:36

That's another uh thing that has come out from COVID, and it's my new baby at the moment. Um when when we when COVID came along, you'll you may remember that patients had to self-isolate for two weeks initially before they could have an operation. They had to be COVID-negative, swabs had to be negative a number of times before they were allowed to have surgery. So if you imagine minor operations like carpal tunnel release requiring two weeks of isolation and all of that uh, it just became uh it became impossible to deliver operations. So at that time I was thinking dermatologists are removing moles in clinic. Um uh plastic surgeons are doing little flaps and things like that uh in the clinic, small procedures. And I read a little bit about the sterility uh in minor operating rooms, and it became clear that actually soft tissue hand surgery, minor surgery, like carpal tunnel releases, can safely be done in the outpatient setting. So the Americans call it office surgery, and they've been doing it for decades. So I thought, oh, why is it we couldn't do that? Um, and at the same time as me thinking about all this, uh, this thing called Wallant came about. Wallant stands that's W-A-L-A-N-T, stands for wide awake, local anesthesia, no tunique. So what it is is hand surgery, historically, and even now, a lot of hand surgeons still put a tunique on the arm to stop the blood flow to the hand so they can operate without any bleeding. And so that was the tradition. And if you have to put a tunique on the arm, you have to be in main operating theaters. So, with the introduction of Wallant, it meant that we could inject local anesthesia with adrenaline. And you may be aware that adrenaline causes uh vasoconstriction and it stops bleeding. So it was acting like a tunique. You just could inject adrenaline to the wound and it would stop the bleeding. So that meant that tunique was not required. So we could then move these operations out of main theaters and do it in outpatient. So from about 2019 till date, I have done something like 300 or so carpal tunnel operations in the outpatient setting. Um, I still haven't seen it widely uh done across the country, although a few hand specialists are starting to do uh do the same thing. So now actually the volunt is uh being extended to the high street now. So we can actually do carpal tunnels on the high street. I'm actually now developing a service in a private GP facility where they're already doing things like vasectomies. Um, and so it's a very clean setup. Um, and we we're setting up this carpal tunnel service, which means that the secondary gain from this approach is that you can subsidize the costs of this surgery for self-paying patients. The costs drop by something like 70%. Um, so and the outcomes are exactly the same as uh doing it in main theaters. There's no risks, additional risks involved, and the patient experience with doing it as an outpatient procedure is far superior because they only come for 45 minutes instead of half a day. They're not having to be pre-assessed, they're not fasting unnecessarily. You know, all those things that come with admitting a patient is not required. So they come as an outpatient, they sit down, they come out from the chair, have their procedure, they have a sling, and they go back to the chair and they get driven away.

Dr Andrew Greenland: 21:34

Amazing. Obviously, this got national recognition. How did this stand out to whoever makes the decisions about um awards for you know initiatives? Because clearly this is something amazing. But what was it about your approach that really stood out and got you the um recognition?

Murali Bhat: 21:51

Uh if I understand your question correctly, you you want to know how it um how national guidelines were set up in relation to the.

Dr Andrew Greenland: 21:59

I just want to know how you obviously this is a great initiative. I just wondered how the how it got nationally recognized and what it was about your approach that kind of made you stand out against all the other people that may have initiatives that they're trying to implement in the NHS.

Murali Bhat: 22:13

So uh a few years after I started doing the Wallant procedure, um the British Hand Society uh they were talking about this and they produced uh guidance. Um and the guidance booklet, which is about 30 or 40 pages, um, actually then uh made it okay to go ahead and do carpal tunnels and trigger fingers. And in fact, they they listed a few more operations that can be done as outpatients. So I was very um chuffed that it has now become official, and the the National Hand Society is actually recommending that this shouldn't be done in many theatres and should be done in outpatients. So it almost feels like it was a little bit ahead of the guidance coming out. Um and and they even recommend that you can fix finger fractures as long as you're not cutting open the uh finger. It's called closed K wiring and things like that can also be done as outpatient procedures.

Dr Andrew Greenland: 23:15

Um with all the training that you've had and the management and the lean training that you've had, what what's still left to do from your perspective? Where do you still see that there are roadblocks or inadequacies in the system that you would like to try and fix?

Murali Bhat: 23:29

Um I feel as though uh we need to sustain our desire to keep the change going, and we need um we need we need people to stay on board. Uh I find that if the these changes can only sustain if the person who implemented that change is highly disciplined, hardworking, patient, uh we get the entire team slowly to learn. It takes quite a long time for people to get interested in the changes that you make, as you as you can imagine. So being patient and getting people trained, we assume that all consultants are ready to start implementing changes, but the biggest problem most senior consultants have is the lack of training. So, for instance, if you implement uh a software system to see X-rays overnight, there isn't that structured training that's available to consultants who are busy on the shop floor to start using it. So it is quite nervous. I find it very difficult. I'm 60 now, and I find it very difficult um to start implementing these kinds of changes if someone hasn't discussed it with me or trained me in implementing it. Does that make sense?

Dr Andrew Greenland: 24:48

No, it does, absolutely. Thank you. Yeah. So if you had a magic wand that could fix one thing in how care is delivered in your world, what would that be at the moment?

Murali Bhat: 24:59

Um I think there's a lot of uh scope for triage. Um so um the in the NHS referrals come from different different uh different areas. So GPs and physiotherapists and various other people refer patients. I think there's scope for triage. All the referrals can be, whether it's elective or trauma, we've already shown that uh virtual fracture clinics are a good triage system. And elective referrals also, I think, can and should be triaged. Um and a lot of the a lot of this is about it it requires skill. Doing the triage requires skill. It requires a senior person who is willing to accept that it's a tool that has to be used carefully and it and should know the limitations of it. So I believe that uh triaging all the referrals is a useful exercise. The other thing I've noticed is over the years, not everything in orthopaedics requires an operation. I actually do less and less operating as I'm getting older. Um, I find myself having some of those conditions that have previously treated patients with surgery, you know. Um, so I feel as though a lot of the musculoskeletal conditions, things like tennis elbow, golfers elbow, we shouldn't be doing as much surgery as we were we were doing previously because they get better without having to do surgery. So I'm a big believer in uh natural treatments, uh physio and such like. Does that make sense?

Dr Andrew Greenland: 26:31

No, absolutely. Um, not everything is um involving a knife, which I think is important and uh for that. So obviously, working in private practice essentially is a business. And if your practice suddenly saw a doubling in your patient volume, um what part of the system would break first? And I guess it's probably going to be you because you're the person that deal you're the person that actually sees all the patients. But how would that work out? Because I mean it is a business at the end of the day. What would happen if you had this massive influx?

Murali Bhat: 26:58

Well, thankfully, uh with my management hat on this, I have thought about it. Um so I, for instance, I have uh a few upper limb consultant colleagues. Uh, one of them is quite new with young children and things like that. So let's assume that my workload goes up to a level where I have to deliver more operating, uh, and it's double the usual, and I can't do all of them. Then I can get set up a group of upper limb or hand surgeons working together. And and uh and and you know, even though overall the practice will be managed by me, the operations can be delivered by trained consultants. It doesn't have to be me. Does that make sense?

Dr Andrew Greenland: 27:44

Yes, of course.

Murali Bhat: 27:46

Yeah.

Dr Andrew Greenland: 27:47

And with all your experience, is there anything you'd do differently if you were starting out again in the medical world, orthopedic world tomorrow?

Murali Bhat: 27:54

Um that's that's a very good question. I think that um I would be I'd be much less aggressive, much less abrasive. Um I uh maybe my communication skills would have been better, my management skills would have been better if I'd started off being more patient. So when I started as a young orthopedic consultant, uh I wanted everything fixed instantly. I was black, it was black or white, there's nothing in between. Uh but unfortunately you learned that life is not like that. Um you've got to take everybody for who they are, and you've got to see their positives and what they can contribute rather than the negatives. Uh I also found that a lot of people were trying to thrash out uh differences in the corridor, which I didn't like. So I started setting up consultant meetings to discuss things. So many attitudes have improved as I've grown older. I've become much more patient. Um, other than that, I've enjoyed the journey. I wouldn't change a thing. I actually like the fact that I came to a department that was so different from what I'd expected. It allowed me to shape it, it allowed me to develop it in the way that I thought was um uh appropriate. I mean, I don't think I would have enjoyed it if I had gone to a large teaching hospital where the department is all up and running and there was nothing for me to do. Do you see what I mean?

Dr Andrew Greenland: 29:28

I do, and thank you for that very honest reflection. I really appreciate that. So, what's next for you in the next uh six to 12 months or so? Are you looking at any particular initiatives or projects that are on the cards, or are there any trends or tools that you're looking forward to seeing coming online that's going to improve orthopedic care in the coming years?

Murali Bhat: 29:44

So the minute I'm going, because one of the one of the things um in hand surgery, um, even though it sounds like a minor issue, carpal tunnel syndrome is an extremely common condition. Nearly 80,000, 75 to 80,000 people every year. End up having carpal tunnel procedures in the country. And a lot of these people are in a lot of pain and spending sleepless nights. And they are waiting to have the operations for one year. And that that breaks my heart. Including in my own hospital. The waiting time is 12 months. So you constantly get messages saying, can you do something about it? So my thinking was obviously in the NHS, it's the floodgates, there's only certain things you can control. Certainly in the private sector, I have the capacity to do these kind of new things, in which I talked about moving carpal tone surgery to the high street, subsidizing costs for um to the extent where around a dinner table dinner table a family can family crowdfund their grandma to have a carpal tone procedure overnight in two weeks. So that kind of thing actually to see people become pain-free from a minor procedure seems like an easy win and something I'd like to popularize and make it available to the masses, if you know what I mean. So we're opening up this service, the Wolant service, to the country. So we're marketing this because of where we are near Gatwick and uh the connection for transport, we're well connected to the rest of the country. So people can come from anywhere to have carpal tunnel surgeries for a for a reasonable cost. So that was that is my current um uh project. And when I when I'm uh uh when I'm set up with that, then I'll think of something else.

Dr Andrew Greenland: 31:38

Amazing. And on that note, Morale, I'd like to thank you so much for your time this afternoon. It's been a truly insightful conversation from system design to surgical innovation. Your work offers a clear reminder that great care doesn't have to be complicated, just has to be thoughtful. So thank you again. Really do appreciate your time this afternoon.

Murali Bhat: 31:56

Thanks, Andrew. I appreciate that.