Will fast-track surgery centres change the way we think about the general hospital - or are they just politically expedient? Ann McGauran reports

The love affair between all things modern and prime minister Tony Blair is hotting up again. He was sounding off about the new generation of fasttrack surgery centres last week, when he promised 29 new hospital schemes - of which over half will be such units.

Similar projects dedicated to what health secretary Alan Milburn calls 'fast and convenient non-urgent appointments, tests and operations in a single centre' have been agreed at 10 more sites.

But what are they going to be like and how bold is the vision?

The answer lies at the Central Middlesex Ambulatory Care and Diagnostic Centre (ACAD) in Park Royal, north-west London - a place politicians are tripping over themselves to visit. Mr Blair opened it in 1999, it was plugged in the NHS plan and the prime minister popped down there again to launch the building plans last month.

As far back as 1994, the then Central Middlesex Hospital trust came up with a strategy to separate elective care and emergencies, and that was the beginning of the ACAD project.

The unit provides both day surgery and elective inpatient treatment - strictly ring-fenced from emergency work and run like a production line Heinz would be pride of.

Generally, the elective case-mix, with its strong emphasis on hernias, varicose veins and such like, is 'very predictable', according to the centre's clinical director, Dr Giordano Abbondati.

'We can plan for it, and if we do that we start looking at length of stay. Also by doing the right thing at the correct time, the period the patient stays in hospital falls dramatically. '

The unit realised there was 'quite a lot of elective diagnostics that is plannable' and it could be 'streamlined like mad'.

With the length of hospital stay a known quantity, it can schedule when interventions are booked and match beds with demand.

The results are no cancellations due to a lack of beds - pointing to 'improvements in the quality of consumer care'.

By standardising processes of care there are improvements in quality of clinical care too, argues Dr Abbondati.

Nurse-led, protocolised screening, such as x-rays, electrocardiograms and pre-operative assessments, is the key to cutting the length of time patients remain in hospital. That has involved extra training for nurses and breaking down the strict divisions between nurses' and doctors' areas of work.

'On the elective side in surgery we are well down the line in having protocols, ' says Dr Abbondati.

With the aid of a 'safety-net' from doctors when there is deviation from the norm, nurses have been 'empowered' to make the right decisions. The results achieved speak for themselves (see panel).

Royal College of Nursing adviser in nursing practice Susan Scott believes the approach is 'the way forward' - but stresses that 'we all need to be aware of the problems that may arise when working purely to protocol-given care'.

Health systems researcher for the King's Fund Tony Harrison says the Central Middlesex set-up is 'good', but he asks: 'Why can't it happen in every unit in the UK?'

According to the NHS plan, the model allows staff to 'concentrate on performing operations, not coping with emergencies'.

The principle of ring-fencing is a good one, according to Dr Peter Hawker, chair of the British Medical Association consultants' committee. 'But what happens when A&E is full and patients are waiting on trolleys?

'It would be a very brave chief executive who, during a winter crisis, had 30 people waiting in emergency on trolleys and 30 beds empty in a ring-fenced area. '

Former Central Middlesex Hospital trust chief executive Andy Black was responsible for the concept planning of the centre and now runs planning and management consultancy Durrow.

He says that although it is a 'nice example of its style', there is no requirement for it to be 'cloned'. Neither does he see the fast-track centres as 'something you can just lay alongside a general hospital'.

They could also make cancelled operations a thing of the past, says Mr Black, who predicts they could eventually handle half of hospital activity.

What the government wants is for health authorities and all the local primary care groups and trusts to 'seize the opportunity' to redesign the whole local health economy.

New private finance initiative waves will have to consider the option of a vertical integration model in their outline business cases, with one private sector consortium responsible for re-developments across the acute, intermediate and primary care sectors.

According to Mr Black, fasttrack centres will cause the general hospital to be 'fairly seriously re-thought'.

People are 'taking the idea and pulling it around', he says, with primary care trusts 'helping to provide a potential ownership group for smaller centres'.

We are not going to see some instant transformation, he believes. 'It is not a lightbulb switching on, It is a trend the government is spotting. But even if that government vanished, the trend would continue. '

Top speed at Central Middlesex

Day cases rose by over 2,000 last year.

Most cancellations are now for clinical reasons or patient-initiated.

Waiting lists for the hospital fell from 2,452 to 1,814 between January and December last year.

Four-day average stays for transurethral resection of prostate operations have been reduced to two overnight stays.