Published: 01/09/2005, Volume II5, No. 5971 Page 22 23 24

The Healthcare Commission has found many trusts to be worryingly inefficient in day surgery, with 45 per cent of allocated theatre time going to waste. What's going wrong? Rebecca Coombes reports

Up and down the country, day surgery operating theatres are lying empty, with the worst performers using facilities only eight hours a week. So why are not they hives of industry?

The political will seems to be there - at least at the very top. The NHS plan set a target of 75 per cent of elective admissions to be day cases and the Modernisation Agency promoted the substitution of day surgery with inpatient stays as one of its 10 high-impact changes.

But as recently as July, the Healthcare Commission found many trusts to be worryingly inefficient in day surgery. Nationally, as much as 45 per cent of theatre time allocated to it is going to waste. The average day surgery operating theatre performs only 16 hours of surgery a week.

The best performers used 23 hours of theatre time, the least efficient eight hours.

The commission says an extra 74,000 patients a year could have day surgery if inefficient hospitals started learning from the best and freeing up valuable hospital beds.

Common failings include a failure to pre-assess patients, leading to high cancellation rates.

Almost 50 per cent of day surgery patients are not checked for suitability before their operations. In addition, unforeseen staff absence and technical problems with equipment led to an average of 14 per cent of planned sessions cancelled and not reallocated to other surgeons. List planning is also poor in some trusts, with operations overrunning or unnecessarily long gaps between operations.

York Hospitals trust consultant anaesthetist Dr Ian Jackson is unsurprised by the variation in performance around the country.

'We have got a huge patch of six health economies in my strategic health authority region and we echo the huge variation around the country. Some of that is about facilities - those that do not have the equipment or capacity to move into day surgery. But very little is actually about that, ' alleges Dr Jackson. 'When you take a look, it is usually a case of re-doing processes to provide some successful day surgery.' Dr Jackson, who is also president-elect of the British Association of Day Surgery, counts himself among the lucky ones. As well as his hospital work he is clinical lead for short-term elective care for North and East Yorkshire and Northern Lincolnshire SHA.

He is funded by the SHA and the Department of Health to spend two days a week encouraging day surgery in his region. He is one of only about 10 day surgery champions in England. In many areas there is no dynamic push for change.

'For many trusts it is just not that important, with other targets getting more focus, ' he says.

'The beauty of my SHA is that the chief executive is totally committed to moving this forward across the patch. Everywhere I go I can identify pockets of excellence.

'You do not go in and criticise but bring the best to the fore and spread it to other areas. But it is going to take several years - it takes time to get into an organisation, do the diagnosis and move them on.' Doug McWhinnie, consultant general and vascular surgeon at Milton Keynes General trust and BADS honorary secretary, agrees. 'People pay lip service to day surgery but if it is not pushed from the top, it will not happen, ' he insists. 'OK, there are some dinosaurs working out there, in terms of doctors and nurses, but that is not really keeping day surgery back any more. It is more about getting the design and infrastructure right.' He argues that throwing money at day surgery is not enough - change needs to be tightly managed. 'Day surgery works only if you have a group of dedicated professionals who want it to work, including the chief executive.' The 'gold standard' for day surgery is a standalone unit, with fixed hours, dedicated theatres and wards, free from the demands of accepting emergency patients. The highperforming day surgery trusts tend to fall into this category.

Norfolk and Norwich University Hospital trust is one example. 'We have a ringfenced day surgery unit which is open 7.30am-7pm. When it shuts, it shuts, so we do not have emergency admissions, ' says David Ralphs, consultant general surgeon at the trust and immediate past president of BADS. But he says that across the NHS there has been 'creep' of emergency work into day surgeries over the last five years, especially with the pressure to meet accident and emergency targets. 'As soon as you cross the boundary from day surgery to inpatient you erode the efficiency and compromise performance, ' adds Mr Ralphs.

Milton Keynes General trust has an extended day surgery unit, but Mr McWhinnie says that not having a standalone facility is no excuse for failing to boost day rates.

'You do not need a purpose-built unit, you can ringfence part of a ward. These units are as good as the people who run it, ' he says. And if you do not use beds, but do day surgery off trolleys and chairs, you will not be forced to lose beds to inpatients, adds Mr McWhinnie. Both he and Dr Jackson agree that two of the key processes to get right are preassessment and how you book lists.

'Trusts that do badly often have the wrong infrastructure. You need a trust-wide preassessment system where day surgery is opt-out rather than opt-in. Everyone should be considered as a day case [before pre-assessment], but many trusts do not adopt that position, ' says Mr McWhinnie.

Dr Jackson says the most efficient way of doing pre-assessments is to get them done on the same day as the outpatient appointment. 'The most successful trusts are doing this, ' he says. 'Then we follow up with a phone call six weeks before the operation to make sure nothing has changed. The advantage is we know that everyone on the waiting list is ready to go.

'A lot of people make a fuss about the need for pre-assessment a short time before an operation but the time interval between outpatient and surgery is going down all the time. When we have the 18-week target in 2008 [all patients to be treated within 18 weeks of seeing their GP] you will just have to do the pre-assessment at the outpatient appointment. This is the way forward.' Patients are also asked if, in the event of a cancellation, they would consider coming in at short notice. 'It allows us to run a 'short-access' time list. The majority want to get it over and done with, ' adds Dr Jackson.

Another effective change at York has been to keep the waiting list office in-house.

'The staff are part of our team. If something goes wrong they see the effects of it. It makes a huge difference to our effectiveness, ' says Dr Jackson. 'I know that the Modernisation Agency tried to centralise it, but it doesn't make sense to have a disembodied service. You lose the camaraderie. [This way] everyone is buying into it and making it a success.' Efficiency does not come without hard-wrought changes, even in the most successful of trusts.

Newham University Hospital trust is the most efficient in England for day surgery, according to the Healthcare Commission's report (see graph, page 23). The commission looked at productivity rates around the country for a list of 25 procedures - deemed 'true' day surgery because they normally require a general anaesthetic and the facilities of a fully equipped operating theatre.

As many as 80 per cent of these 25 procedures were carried out as day cases in Newham.

But treatment centre manager Denise Walters is candid that the trust still has further to go.

While certain specialties, such as arthroscopy or carpal tunnel, are automatically listed as day cases, with patients then pre-assessed for suitability, other specialties have yet to get that far.

The trust's purpose-built Gateway surgical centre, which opens this month, creates added pressure. 'We will have to move more quickly on cases as the ethos is more input, otherwise we are not financially viable, ' explains Ms Walters.

'We have cracked it in certain procedures but we need to do more work at the pre-assessment stage for others. It is very much a process, although we are champing at the bit to get those preassessments moving faster.' A big factor supporting this is a move towards nurse-led pre-assessments, championed by consultant anaesthetist Dr Otto-Ernst Mohr, who is from Germany, where day surgery culture is more entrenched. 'He's leading on it and That is helped us managers, ' says Ms Walters. 'We are building up a culture of people working together.' Mr McWhinnie says it was initially hard to persuade clinicians to work flexibly at Milton Keynes General trust.

'We needed to redo our schedules for operation lists to be more efficient. You need to do the biggest cases first, followed by the smaller cases, ending up with a hernia, for example. You have to start your list in the morning to make it happen.

If not, you have to stay open late at night. We had too many afternoon sessions.

'But what happens is that people's timetables evolve over decades. You need two years to achieve a change plan, ' he says.

But the hard work and negotiating is worth it, says Mr McWhinnie.

'The advantages of day surgery are you are not in hospital long enough to get deep vein thrombosis or MRSA, and you also have a dedicated team to process you very efficiently.

Most people would rather recover in their own home, than in a bed beside someone vomiting.

You have a purpose-built, well-looked after environment and excellent pain relief. There are two areas of the hospital where pain relief is good - intensive care and day surgery. Believe me, It is much better than on general wards.' .



One of the top 10 performers in the country for day surgery, Northumbria Healthcare trust has three hospitals, including a dedicated day surgery facility at Hexham General Hospital.

'It is a design tried and tested in the US and we have great, airy rooms, ' says clinical director of general surgery Stephen Attwood.

'Patients only have to walk a very short way from the waiting area to the operating table.

There are no porters or trolleys at this point.

The patient has the procedure in a fully set up operating theatre and is then wheeled to a receiving space until they wake up, ' he says.

The day surgery facility has no wards - at no point is a patient 'admitted to hospital'.

Short waiting times mean patients are offered an operation within four to six weeks.

The most laudable thing about Northumbria is the broad range of procedures it carries out.

'The quality and range of specialists we use is very high. They tend to work a day a week. We have 17 orthopaedic surgeons and 18 general surgeons, ' continues Mr Attwood. 'It allows us to do a wide range of complex procedures.' Although the three theatres available are mostly in use four to five hours a day, morning and afternoon, the lack of flexible working patterns makes it hard to fill in all the gaps. 'Surgeons do have very fixed schedules, ' concedes Mr Attwood.



Norfolk and Norwich University Hospital trust's Arthur day care procedure unit is designed to create a non-clinical atmosphere, with comfortable chairs and a widescreen TV in the waiting area.

There are six operating theatres, and separate areas for adults and children. Of the 15,000 patients treated every year, 6,000 have procedures under general anaesthetic.

Sandra Meadon, a former nurse manager of the day unit and now a trust general manager, says: 'Our list cancellations are very low. Patients like it.

They like to recover at home with their families.' Key to the trust's success is the multidisciplinary nursing team. 'Staff work in all areas: preassessment, anaesthetics, surgery and recovery. We can move nurses around if someone falls sick, which means we do not have to cancel a list. But It is time-consuming and needs the dedication of staff, ' explains Ms Meadon.

'It also requires the support of the surgeons and the anaesthetists as some of them like to have the same people in with them all the time.

Instead they have had to be patient with new staff coming in.

'Because we move nurses around there is high job satisfaction and turnover is very low.' The nurse-led preoperative assessment, gives patients a date up to three months before surgery. Nurses access all theatre sessions through Daynamics software.

Ms Meadon adds: 'Our nurses also compile the theatre lists for a lot of the surgeons. They know what case-mix they like. For example, in one session a surgeon may do three laparoscopies, two terminations of pregnancy, and three hysteroscopies.'

Key points

The Healthcare Commission has found 45 per cent of theatre time allocated for day surgery is going to waste.

Not having dedicated facilities is no excuse not to increase day surgery. Process change is more important, with political leadership from the top.

Trusts need an 'opt-out' culture in day surgery, where al l su rg ical pat ients are considered el ig ible un less proven otherwise.

To contribute articles to HSJ's clinical management section, e-mail ann. dix@emap. com