Rising to the challenges of achieving day surgery targets

Transcription

1 doi: /j x SPECIAL ARTICLE Rising to the challenges of achieving day surgery targets I. Smith, 1 T. Cooke, 2 I. Jackson 3 and R. Fitzpatrick 4 1 Senior Lecturer in Anaesthesia, University Hospital North Staffordshire, Newcastle Road, Stoke-on-Trent ST4 6QG, UK 2 Professor of Surgery, North Glasgow University Hospitals Trust, Glasgow, UK 3 President, British Association of Day Surgery and, Consultant Anaesthetist, York District Hospital, York, UK 4 Professor of Pharmacy, New Cross Hospital, Wolverhampton, UK Summary Day surgery provides high quality and efficient care for a wide variety of surgical procedures. Patients appreciate the rapid recovery and effective analgesia, while the health service benefits from a streamlined service with lower costs. Despite the numerous advantages, day surgery practices vary enormously and many patients are still denied this excellent form of care. Fundamental to improving this situation is a change in emphasis, with day surgery becoming the default option for many surgical procedures rather than being applied selectively with inpatient care being used only where specifically indicated. Appropriate patient preparation is facilitated by consultant-led, nurse-run preassessment using modern selection criteria; only conditions which will still cause problems a few hours beyond the end of the operation should be barriers to day surgery. Preassessment also provides an excellent opportunity to begin patient education and ensures that pre-existing pathology is optimally treated. Efficient day surgery is best delivered by a specialised, dedicated, multi-disciplinary team, but consultant anaesthetists have a major role to play in co-ordinating policies and providing leadership. Individual anaesthetists should develop techniques that allow their patients to undergo day surgery with minimum stress, maximum comfort and the optimal chance of early discharge. Improving day surgery rates is a win win situation, with both clinical and financial benefits.... Correspondence to: Ian Smith damsmith@btinternet.com Accepted: 28 September 2006 Although initiatives to increase day surgery are welcomed by many surgeons, its expansion is proceeding very slowly [1]. Day surgery provides the best care for patients undergoing a wide variety of procedures by ensuring a smooth and efficient pathway with the use of high quality nursing, prompt recovery with minimal symptoms and effective analgesia. With adequate support, patients appreciate an early return to their familiar home environment. Day surgery also provides efficiency savings for acute hospital Trusts and the National Health Service (NHS) and is the subject of several government targets and initiatives. Under the new NHS funding system, hospitals are paid for each episode of care based on a National Tariff. Therefore, it is in the best interests of the hospital to utilise day surgery wherever clinically practical. Despite a number of documents offering advice on implementing best practice [2 6], the recently published 2005 Commission for Healthcare Audit and Inspection report on day surgery in England [1] found that there is great variability not only across the country but also within units, within specialties and for each consultant in terms of the number of various index cases [7] being performed as day surgery. The Healthcare Commission found that at least an extra patients each year could have day surgery, rather than be admitted as in-patients, if the least efficient units started employing the practices of the best. Also, despite the fact that more invasive procedures are being performed and new anaesthetic techniques, agents and analgesics have become available, the overall performance in day surgery has been slipping across the UK [3], with several barriers to achieving high rates of day surgery in existence (Fig. 1). In 2000, the NHS Plan [8] set an ambitious and muchdebated target that 75% of elective admissions should Journal compilation Ó 2006 The Association of Anaesthetists of Great Britain and Ireland 1191

2 I. Smith et al. Æ Special article: achieving day surgery targets Anaesthesia, 2006, 61, pages Inappropriate and insufficient use of day surgery units Poor management and organisation of day surgery units Clinicians preferences for in-patient surgery Figure 1 Barriers to achieving high rates of day surgery. be day cases. It is known that, in many Trusts, additional day case activity could be accommodated within existing day surgery units, with no increase to their capacity or resources [1]. However, this would require units to achieve resource utilisation currently achieved by the most efficient units in the country. This article gives practical tips as to how this can realistically be achieved by all day units, in line with our previous recommendations [2], but highlighting the simplest areas to address initially for maximal effect. Day surgery: what are the incentives? Using day surgery more efficiently could reduce pressure on ward beds, bring down waiting lists and improve care for patients [1]. The need for more day surgery is widely recognised by patients, clinicians, NHS managers and the Government [7, 9]. The NHS Modernisation Agency reported that nearly half a million in-patient bed days could potentially be released each year through improved methods of working [9]. In fact, increasing day surgery is the Number One of Ten High Impact Changes recommended by the Government, is emphasised to NHS Chairs and Non-Executive Directors in the document Delivering Quality and Value and is a key National Productive Time Key Performance Indictor of service improvement [10]. Some of the advantages of day surgery are shown in Fig. 2. Further advantages, including those relating to service delivery, can be seen in 10 High Impact Changes [9]. Note that, whilst increased theatre efficiency is frequently quoted as an advantage of day surgery, this is currently somewhat at variance with the HCC report [1], which shows many day unit theatres to be much less efficient than in-patient theatres. It is the combination of the advantages listed in Fig. 2 that led to the strong and continuing push from Government to set high targets for day surgery rates, Clinically Professionally Government Best practice Better for patients (including adults, elderly, obese and children) [1,3] Reduced waiting times Less risk of cancellation Patient preference Patients spend less time in hospital Care better suited to patient needs Reduced risk of Hospital Acquired Infection (HAI) Little or no additional community support required Outcomes are at least as good as those for in-patient surgery Professional challenge Job satisfaction Improved leadership and managerial skills Increased responsibility Benefits from multidisciplinary team work, e.g. share knowledge, skills, ideas Improved inter-team/interspecialty/inter-professional relationships Government targets, directives, guidance and documents [1,4] In line with Government incentives, e.g. Payment by Results, Patient Choice, reducing waiting lists, High Impact Change document, Modernisation Agency report Reduced hospital costs with National Tariffs, day surgery is more cost effective for selected procedures, with cost of anaesthetic agents very small relative to the overall cost of surgical procedures Figure 2 Advantages of day surgery Journal compilation Ó 2006 The Association of Anaesthetists of Great Britain and Ireland

3 I. Smith et al. Æ Special article: achieving day surgery targets stating Expanding day surgery and combating inefficiency in day surgery are key ingredients of NHS modernisation [11]. With the closure of the Modernisation Agency, the Department of Health recently ended its central funding for Clinical Champions in day surgery and this has now become the responsibility of Strategic Health Authorities (SHAs). However, this should not stop anaesthetists, as key members of the day surgery team, taking it upon themselves to drive this service forward to achieve the benefits offered by day surgery. In fact, the continued importance of day surgery was recently highlighted by the recommendation from the Department of Health that every day surgery unit should have representation at Trust Board level [11]. Champions of day surgery should ensure that day surgery guidance is included in Local Delivery Plans and Operating Frameworks. One problem with assessing day surgery levels and comparing units remains the unclear definition of day surgery, with different interpretations by Trusts around the UK [3]. For example, many anaesthetists feel that 23-hour day surgery should be considered day surgery. Allowance for 23-hour day surgery may be helpful for several reasons. It can facilitate the move of larger, more invasive, procedures into the day surgery arena, it can help those denied day surgery due to social problems and it allows procedures with long recovery times to be performed during afternoon lists. This may aid theatre efficiency. The disadvantage of 23-hour surgery is that the incentive to get the patient out of hospital can be lost and so day surgery rates may fall. The ambitious and much-debated target of the NHS Plan that 75% of elective admissions should be day cases remains a rather vague and ill-defined one. However, experience from North America and parts of Europe suggest that it is a realistic target to aim for, although not a minimum standard, as is currently implied. The recently issued NHS white paper entitled Our health, our care, our say [12] sets out the Government s agenda for improving care in the community in England, partly through shifting resources from hospital into primary care. Surgery undertaken on a day case basis, perhaps in a primary care setting, is one way of delivering this agenda, whilst maintaining the skills and expertise of hospital practitioners. Our 2004 publication, Achieving day surgery targets [2] highlighted the vast array of Government documents, guidelines and directives recently published that are attempting to drive day surgery forward. More such documents have followed since that time and are referenced throughout this article. However, the underlying drive to increase day surgery must remain its clinical benefits for the patient. Achieving day surgery targets Around 740,000 day surgery operations are performed in England each year. There is capacity within the NHS to treat 74,000 more patients a year in day surgery and free up hospital beds. NHS trusts need to investigate why more day surgery is not being done and the worst performers need to learn from the best [13]. So how can we increase day surgery rates within currently available resources? As highlighted in Achieving day surgery targets [2], the focus must be on maximising efficiency. Maximising efficiency Just 16 hours of surgery was performed per week in the average dedicated day surgery operating theatre [1]. Facilities in dedicated units are often used inefficiently. In particular, dedicated day surgery theatres are used for considerably fewer hours per week than main in-patient theatres and many planned sessions are cancelled or occupy less than the scheduled time [1]. The Healthcare Commission found that 45% of theatre time in England allocated for day surgery was going to waste because of cancelled operations, late starts and excessive delays between operations and at least an extra patients a year could have day surgery, rather than be admitted as inpatients, if the least efficient units started employing the practices of the best [1]. The result is that, on average, day surgery theatres are only being used for 16 h a week [1]. How can this be addressed simply in day surgery? Default to day case 10 High Impact Changes; Change No 1. Treat day surgery (rather than in-patient surgery) as the norm for elective surgery [9]. The first area is with patient selection and referral from out-patient clinics. Trusts should ensure that patients are defaulted to management as a day case and only transferred to in-patient management if found to be unsuitable. This will increase the numbers of patients being offered day surgery [4]. Pooling lists helps reduce variability between surgeons in day units and should be encouraged. Other ideas for increasing resource utilisation are given in Fig. 3. The HCC 2005 review [1] found unacceptable cancellation rates at some day surgery units, exceeding 20% at several. The HCC report also found that one in 10 units cancelled more than one-third of the available operating theatre sessions and many patients had their operations cancelled at short notice. Furthermore, it reported that one in four day surgery units cancel more than 9% of admissions. High did not attend rates are particularly problematic if facilities are to be used efficiently. Journal compilation Ó 2006 The Association of Anaesthetists of Great Britain and Ireland 1193

4 I. Smith et al. Æ Special article: achieving day surgery targets Anaesthesia, 2006, 61, pages Default to day case Pool theatre lists Maximise use of all day surgery facilities, including operating theatres Investigate and minimise cancellations/late starting operations/short-running operating lists/gaps between patients Prioritise for longer day cases to be performed at the start of your operating list Rethink the organisation of your hospital should you convert an in-patient ward into a day unit or an in-patient theatre into a day case theatre? Could surgeons increase their flexibility and work on in-patient surgery one week and day surgery the next? Could some surgical or medical beds become surgical trolley space? Investigate reasons for high cancellation rates Phone call prompts to patient a day or so before the scheduled procedure to confirm attendance, allowing time for reallocation Notify planned staff absences to the Trust well in advance Run a short-access time list for patients willing to come in for day surgery at short notice Keep the waiting list office within the day unit so that the booking staff are part of the day care team and can see the effects of filling surgery spaces Figure 3 Practical ideas for maximal resource utilisation in day surgery. Day surgery must be treated as a vital and important part of any surgical service. Cancellation of day theatre lists in favour of in-patient activity is no longer acceptable. Protocols should be developed for patients to postpone and re-book their procedure for medical or valid social reasons [3] and for their slot to be re-allocated immediately within the day unit to the same or another surgeon (i.e., pooling lists). Furthermore, late starts in day surgery are unacceptable they impact on the entire list, may result in some patients requiring an in-patient stay if their recovery time is longer and are highly unprofessional. Consultant in charge and staffing issues If the full benefits of day surgery are to be realised for patients, it is vital that there is a nominated consultant in charge of each day surgery unit [1]. A single consultant in charge of day surgery, in most cases an anaesthetist, has been shown to encourage more efficient use of resources [1]. Yet, nearly 40% of day surgery units still have no single consultant in charge [1] a factor that may be hampering more efficient use of resources. Anaesthetists in units without a consultant in charge should consider embracing this role one that will certainly be testing and is highly rewarding. Inappropriate staffing may be a contributory factor to poor utilisation of a unit [1]. Staffing a day unit is a challenging aspect of leading the unit. At present, staff numbers in day surgery units appear to be rising faster than their activity [1]. Each unit must carefully assess its own staffing needs, including numbers and grades required, and budget accordingly. The use of agency staff is discouraged. Two important indicators of good management are [1]: The DNA rate (patients who did not attend (DNA) without giving notice expressed as a percentage of all day case patients). A high percentage of DNAs is a waste of resources because it will be too late to offer the operating theatre slot to another patient. The same applies to patients who give notice on the day of their procedure. The stay-in rate (day case patients that have to be transferred to in-patient facilities rather than go home, expressed as a percentage of all day case patients). A high stay-in rate will have important resource implications for a Trust. Dedicated day surgery facilities To maximise efficiency it is recognised that, whilst this is not always possible, day surgery should ideally be carried out in a separate and dedicated unit with its own operating theatres, operating lists, ward, recovery unit, reception area and waiting list staff. Ideally, there should also be specific operating sessions for paediatric patients. Where this is not possible, all day patients must receive the same high standards of selection, preparation, perioperative care, discharge and follow-up [3]. Using dedicated day surgery areas for non-day care procedures, e.g. endoscopy, must not occur if day surgery is to run according to schedule. The increasing number of independent, stand-alone day surgery units in the UK need to work closely with 1194 Journal compilation Ó 2006 The Association of Anaesthetists of Great Britain and Ireland

5 I. Smith et al. Æ Special article: achieving day surgery targets NHS units to ensure maximal patient care. For example, consultant leads must ensure that their own surgeons are fully trained. Surgeon skills should be pooled where necessary, particularly in stand-alone units that specialise in only a few procedures. Case mix/selection criteria As discussed at length in Achieving day surgery targets [2], adequate selection criteria for day surgery are crucial to maximise efficiency in day surgery and all selection criteria must be updated to ensure that the most recent guidance is being followed. The Audit Commission Basket of 25 [7] is intended to provide a manageable list of key high volume procedures that are suitable for day surgery and are performed at a significant number of Trusts. Although this list is useful for audit benchmarking purposes, it is by no means all inclusive. Yet, there remains a wide variation between providers in day surgery rates for any particular basket procedure. Of interest, whilst it may appear that there has been some progress in substituting day surgery for in-patient admissions in recent years, the bulk of this overall increase in day surgery is accounted for by cataract operations. The percentage of day surgery is not rising for all suitable procedures and for six of the Audit Commission Basket of 25 procedures [7] the rate has actually declined [1]. This should be explored in each unit, for each basket procedure [7], within each specialty and for each consultant. More recently, the British Association of Day Surgery has published the BADS Directory of procedures [14]. This booklet suggests target rates for day (and short-stay) surgery for 160 procedures across a wide range of surgical subspecialties and also provides evidence to underpin these fairly ambitious day surgery rates. Pre-admission assessment All patients should be seen in advance of their surgery by someone trained in pre-assessment for day surgery [3] Pre-operative assessments are carried out to ensure that only suitable patients are offered day surgery [1]. Yet, the HCC 2005 [1] found that almost half of day surgery patients are not pre-assessed for suitability before they arrive for their procedures. There are many advantages of conducting a pre-assessment (Fig. 4). At pre-assessment, a decision is made as to whether there is a valid reason why the procedure determined by the surgeon cannot be conducted as a day case, i.e. default to day surgery. Preassessment units must not rely on out-dated criteria for this decision. The authors recommend that Modernisation Agency [4] and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) [3] guidance be followed for pre-assessment. Pre-assessment clinics should be consultant-led and nurse-run. Assessment criteria should be developed and agreed locally in conjunction with the local Department of Anaesthesia [3]. Pharmacists involvement in surgical pre-assessment clinics have ensured full drug histories, reduced waiting time for discharge prescriptions, and highlighted medication issues which may need to be addressed before surgery. With the advent of supplementary prescribing and the Government s announcement to allow nurses and pharmacists to become independent prescribers, pharmacists can free up valuable clinician time from these activities both pre- and post operatively [15 19]. There are advantages if pre-assessment is performed within the facility where day surgery will take place [3], as patients become accustomed to the environment and familiar with staff, thus reducing anxiety. By the end of 2005, Trusts were required to offer an admission date to each day surgery patient within 24 h of deciding that an admission is needed. At the time of the latest HCC survey [1], only 44% of day surgery appointments met this requirement. Multi-disciplinary team work Encouraging multi-disciplinary team work may sound like an NHS cliché but it is crucial for maximising the efficiency of day surgery (Fig. 5). With systems for pooling lists and default to day case ideally in place Figure 4 Some advantages of pre-assessment. Reduces cancellations [20] Promotes efficient bed usage [20] Starts education of the patient (and their carers) about their operation and postoperative care [3], thereby allaying patient anxieties [20], improving overall patient experience and reducing repeat visits Allows chronic medication to be reviewed and potential problems relating to surgery addressed. It also allows post-operative medication to be decided/prescribed, thereby reducing patient stay Journal compilation Ó 2006 The Association of Anaesthetists of Great Britain and Ireland 1195

6 I. Smith et al. Æ Special article: achieving day surgery targets Anaesthesia, 2006, 61, pages Become part of the Theatre Users Group, the Day Surgery Group or the Medicines Management group in your hospital If no such group exists, set one up (BADS can help with this, Liaise with colleagues in other hospitals/other areas. You do not need to work out new ways of working they all already exist. You only need to work out which methods will work best in your hospital and how to introduce them successfully in your unit. Work closely with surgeons, nurses, pharmacists, physiotherapists, social services, Trust/Directorate leads, all theatre sta ff, and consider multidisciplinary audit. Try to hold weekly or daily meetings to share the day case and in-patient theatre lists to help identify which procedures could be undertaken as day cases Figure 5 Practical ideas to enhance multi-disciplinary working. in your unit, multi-disciplinary team work is essential since making changes in one area has knock-on effects elsewhere. Anaesthetic management Each anaesthetist should develop techniques that permit the patient to undergo the surgical procedure with minimum stress, maximum comfort and optimise their chance of early discharge [3]. Section 7 of Achieving day surgery targets [2] discussed peri-operative care and the important role of anaesthesia in day surgery. Comprehensive peri-operative care can only be provided by an anaesthesia team led by a consultant anaesthetist [20]. Whilst no single anaesthetic technique is recommended nationally, non-heavy-handed anaesthetic techniques tend to lead to improved recovery. The most worrying patients for discharge are those who are still sick dizzy sleepy 2 3 h postoperatively. Patients wake up faster with sevoflurane and desflurane [2]. In more complex patients, i.e. those with co-morbidities, a newer agent such as sevoflurane makes it easier for the anaesthetist to manage day case procedures [2]. Postoperative recovery and discharge The anaesthetic techniques chosen should be designed to maximise the speed and quality of recovery in the first and second stages, and so facilitate discharge [3]. The use of modern drugs and techniques may allow early recovery to be complete by the time the patient leaves the operating theatre, allowing a significant number of patients to bypass the first stage recovery area [21]. Adopting this fast-tracking system may theoretically allow cost savings by reducing the staffing levels in the recovery area. Whether this concept is appropriate will depend on local factors, such as case mix [22]. Protocols should be established to identify when a patient may be fast tracked. Furthermore, it is more reassuring for the anaesthetist and the rest of the day care team if a patient is awake sooner after the procedure rather than later, ideally before the next procedure is started. Postoperative nausea and vomiting (PONV) remains a major issue. There is still insufficient evidence to recommend the use of routine prophylactic anti-emetics in day surgery except in certain patient groups. However, the use of anti-emetics in high-risk patients and none in low-risk patients may result in overall cost savings. Furthermore, the regimen should be appropriate for Use modern drugs and techniques Reluctance to give patients oral NSAIDs is still affecting recovery and should be addressed in local policies Individual anaesthetists find that some agents are better than others in minimising PONV and some techniques reduce PONV more than others, e.g. TIVA The routine use of intravenous fluids can enhance a patients feeling of well-being [3.23] Policies should exist for the management of PONV and discharge analgesia, and anitemetics should reflect severity of PONV. Patients do not need to be kept in recovery for a set length of time after a procedure a patient can be moved back to the day unit as soon as it is felt safe to do so Figure 6 Practical ideas to enhance patient recovery Journal compilation Ó 2006 The Association of Anaesthetists of Great Britain and Ireland

7 I. Smith et al. Æ Special article: achieving day surgery targets Patient presents Decision made to operate Default to day case according to patient selection procedures Pre-assessment Set day surgery date Patient receives written information Pre-admission reminder Admission for day surgery Anaesthetist visits patient Day surgery conducted (pool lists if required), ideally in dedicated unit Choose modern anaesthetic agents and use anti-emetics carefully Discharge as soon as safe, according to pre-agreed guidelines Patient receives written information Patient follow-up Patient satisfaction survey Figure 7 Flow summary of suggested patient route for day surgery. Each stage of the patient journey is amenable to audit. the surgery anaesthetic used. It is important that any PONV is treated seriously and promptly a standard management protocol can aid the anaesthetist, nursing staff and patient [3]. Nurse-led discharge according to set criteria is now most common. The prescribing of discharge analgesia should be the responsibility of the anaesthetist and each day surgery unit should set up an agreed system with their Department of Anaesthesia and pharmacy. Within this, there should be a choice of analgesic regimens to allow the anaesthetist to manage effectively those who cannot tolerate certain drugs (e.g. NSAIDs) and to deal with the range of operations performed on the unit [3]. Figure 6 summarises practical advice on enhancing patient recovery. Audit Effective audit is an essential component of good day stay anaesthesia [3]. All components of the day surgery service (Fig. 7) require regular evaluation and auditing, not only for the efficient use of resources but also for clinical quality [20]. There have been a variety of tools developed to determine measures of success in day surgery. For example: AAGBI 2005 audit advice [3]. The Royal College of Anaesthetists publishes a series of recipes for audit, including a section on day surgery [24]. The Yardstick Day Surgery Benchmarking Tool is an Excel-based application that allows users to compare Acute NHS Trusts day case rates for the Audit Commission s Basket of 25 [7]. The Department of Health day surgery benchmarking tool [11]. Figure 8 Top tips for achieving an increase in the rates of day surgery. There are many reasons to want to increase day surgery, the main ones being the numerous benefits to the patient Maximise use of day surgery facilities, including operating theatre space and minimise delays and cancellations by pooling lists, prioritising patients and consider re-assignment of wards/beds/surgeons to day case surgery Default to day surgery must be routine. There should be a nominated consultant in charge of each day unit for maximal efficiency together with appropriate staffing levels Keep day surgery separate from in-patient procedures Update your day case selection criteria use the most up-to-date selection criteria guidance, e.g., Modernisation Agency and Association of Anaesthetists Pre-assess all day surgery patients according to pre-agreed criteria Ensure good medicines management in anaesthesia Ensure prompt recovery with minimal PONV and adequate analgesia Audit all aspects of day surgery, including cancellations, pre-assessment criteria, anaesthesia, complications and unplanned stays, patient selection, multi-disciplinary team work, etc. Evaluate all procedures to assess your current systems and identify where increases in day care efficiency can occur relatively simply Journal compilation Ó 2006 The Association of Anaesthetists of Great Britain and Ireland 1197

8 I. Smith et al. Æ Special article: achieving day surgery targets Anaesthesia, 2006, 61, pages Many aspects of the day unit can be audited, such as unplanned overnight stays (these were as high as 15% in some units in the HCC 2005 report) [1], cancellations, number of staff and grade required, staff turn-over and staff vacancy rates, and staff absence rates. One company, Dr Foster ( is now responsible for preparing data on behalf of the Department of Health and has already produced some interesting information on day case rates [25]. Conclusions Patient selection Case mix Planning Staffing Pre-assessment Peri-operative care Choice of anaesthesia Economics of anaesthesia Recovery Discharge New treatment centres Audit Impact on primary care Figure 9 Thirteen Point Plan for achieving an increase in the rates of day surgery (reproduced from Achieving day surgery targets [2], with permission). There have been improvements in patient care during the past four years, but there is still considerable scope for improvement [1]. This article follows up on the publication Achieving day surgery targets [2] and has given practical ways of maximising day surgery efficiency (Fig. 8). Day surgery is a significant and challenging subspeciality for anaesthetists and surgeons that remains under-recognised in its complexity and demands. It requires skill and expertise and is an area of medicine that should be embraced. There are numerous incentives for this, both professional and personal, e.g. improved patient care, increased job satisfaction, professional challenge, and a rewarding team environment. Hospital managers will be looking at increasing day surgery rates to reduce costs and so improve the income expenditure balance under the new NHS funding system, Payment by Results (PbR). Whilst day surgery performance continues to improve nationally, the range of performance between NHS Trusts remains wide, leaving considerable scope for the poorer performers to improve [1]. Efficiency and good patient care go hand in hand. When operations are cancelled or when patients stay overnight for something that could be done in a single day, patients are inconvenienced and resources are wasted, said Anna Walker, chief executive of the Healthcare Commission [13]. All Departments of Anaesthesia should take a lead in the move from in-patient surgery to day surgery as all anaesthetic departments are likely to see substantial increases in day surgery over the next few years [3]. The Healthcare Commission said in its recent report that hospitals could reduce pressure on ward beds, bring down waiting lists and, at the same time, provide better care for patients by using day surgery more efficiently. Whilst the numbers of day surgery admissions have increased in recent years, this has been due more to the growth in overall demand than to substitution of day surgery for in-patient procedures. Further increases in activity would be possible if Trusts prioritise use of their day surgery units for true day surgery requiring full operating theatre facilities, moving more minor surgery to alternative settings. It must be remembered that changes take time to agree, implement and then take effect. We are moving in the right direction with day surgery but, by addressing the areas highlighted in this article and summarised in the Thirteen-Point Plan (Fig. 9), we can move forward faster, with the support of the entire multi-disciplinary team, to the benefit of our patients, ourselves and our hospital budgets. References 1 Healthcare Commission. Acute hospital portfolio review, Day Surgery July org.uk [accessed 4 August 2006]. 2 Cooke T, Fitzpatrick R, Smith I. Achieving day surgery targets: a practical approach towards improving efficiency in day case units in the UK. Advance Medical Publications, London, UK ISBN May, Day Surgery, Revised Edition. February [accessed 4 August 2006]. 4 NHS Modernisation Agency. NHS Modernisation AgencyNational Good Practice Guidance for Day Surgery September Cross+Cutting+Themes/access/elective/documents/ documents [accessed 4 August 2006]. 5 NHS Modernisation Agency. NHS Modernisation Agency Action On General Surgery programme Journal compilation Ó 2006 The Association of Anaesthetists of Great Britain and Ireland

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