In July 2005, the Healthcare Commission set a target for all elective procedures: 75 per cent had to be day-case rates. While trusts should be striving to approach this figure, some still fall far short of this target.
Of the list of procedures judged suitable for day-case surgery by the Healthcare Commission, tonsillectomy has had a high level of clinical resistance. The first graph compares the day-case rates for all elective admissions with that for tonsillectomy. The overall rate shows a gradual rise, but despite a marked increase from 2005-06, tonsillectomy still remains substantially less than the overall rate.
The second graph shows trusts’ day-case rates for tonsillectomy. The shading represents conversion rates: the number of patients who were intended to be treated as day cases but ended up being treated as inpatients. It can be seen that trusts with high day-case rates tend to have low conversion rates and vice versa.
Trusts with high day-case rates tend to have above average levels of readmissions (see final graph). However, the five trusts with the highest day-case rate manage to combine low conversion rates with average readmission rates. Where trusts have a good patient selection process for day cases and excellent surgical and anaesthetic services, they are able to achieve high day-case rates with low readmission and conversion rates.
In many cases, a change in culture and attitude is all that is required. The Royal National Throat, Nose and Ear Hospital, for example, has improved its day-case rate for tonsillectomy procedures from 0 per cent to 90 per cent within two years. The results of these surgeries have remained unchanged.
But trusts with large rural areas may have a higher proportion of patients living too far away from the hospital to be eligible for day-case surgery. A wide variation in percentages of day-case procedures could be explained by poorer quality management and processes as well as the presence of intransigent clinicians.
As with day-of-surgery admission rates, day-case rates are a marker of the overall effectiveness and quality of a healthcare trust. However, as trusts increase their day-case rate, they must monitor measures such as conversion and readmission rates to ensure changes are not impacting negatively elsewhere on performance.