A patient is allocated a healthcare resource group of ‘S22’ when they are admitted to hospital but their procedure is cancelled. There are three people who can cause this.

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The patient who decides they no longer want the procedure, the surgeon who feels the procedure is not necessary and the anaesthetist who discovers the patient is not ready for surgery, for example not starved properly, investigated or optimised.

Cancellation is costly; with each admission costing£434, it leads to an annual expense to the NHS of£82m. The incidence of S22s has been increasing steadily, as shown in the first chart.

The rate differs hugely from trust to trust. The second chart shows an enormous variation (up to 700 per cent), which is highly unlikely to occur by chance. It strongly suggests this is a trust-specific matter. The same degree of variation is not seen between geographical regions.

There is little significant variation when the rate for cancellations is examined by sex or age, other than an increase in the five to 10-year-old category, readily explainable by an increase in coryzal infections (colds) within this group. An interesting statistical finding, however, is that the higher a person’s level of deprivation the more likely they are to have their operation cancelled after admission (see third chart). It can be shown by a variety of statistical measures that this cannot have occurred by chance.

The reasons for the overall increase can only be speculative. But anecdotal experience suggests an increase in incidence where a senior surgeon feels the procedure listed by a more junior surgeon in clinic is not appropriate. As a result it could be argued that selection for a procedure should only be made by a senior clinician.

The increase in incidence related to deprivation is likely to involve compliance issues, for example not fasting or not turning up for preoperative tests as well as a higher level of unhealthiness and lack of fitness for surgery.

The fact that some trusts perform so much better than others would indicate that much can be done to improve on patient selection and preparation. This is supported by the fact that trusts with a very high day case rate have a low cancellation rate.

Again this highlights the importance of an effective pre-admission process, which should be seen as essential in improving a trust’s efficiency and cost-effectiveness.