History of Day Surgery
No perspective on day surgery should ignore the change in medical and nursing thinking that was required to move from the ethos of the therapeutic importance of rest following surgery. From the late 1800’s until the 1940’s rest was still seen as a major contribution to the recovery of patients following surgery (Hilton 1892). Indeed, bed rest for 2 weeks following major surgery was not unusual and many hospitals had separate convalescence units situated in the countryside or in sea resorts. However in the post-war period their was a gradual increase in the number of publications supporting a reduction in not only the duration of bed rest but also the length of hospital stay (Leithauser 1946, Asher 1947). The move to early ambulation following surgery had started. The evidence of the benefits of early ambulation and indeed the dangers of prolonged bed rest gradually mounted (Blodgett and Beattie 1946, Palumbo et al 1952). In the 1950’s the potential for early ambulation, shorter stay and indeed day surgery to provide economic advantages was first considered. Palumbo and colleagues mention the possibility of treating more patients through the same number of beds due to reduction in lengths of stay and Farquharson (1955) considered the potential impact for patients on waiting lists.
Even before this time, there were enthusiastic proponents of day surgery on both sides of the Atlantic. Nicoll (1909) reported his work on nearly 9,000 children who underwent day surgery for such conditions as harelip, hernia, talipes and mastoid disease at the Royal Hospital for Sick Children in Glasgow. This was the work of a gifted enthusiast who was quite simply years ahead of his time. Ten years later in the USA, Waters (1919) reported on his ‘Downtown Anesthesia Clinic’ which provided care for dental and minor surgery cases. It is interesting to note that Nicoll showed his understanding of successful day surgery by stressing the importance of suitable home conditions and co-operation with General Practitioners. These points were repeated nearly 50 years later by Farquharson and again currently in many articles about ‘good practice’ in day surgery.
The 1960’s saw the development one of the first stand alone day surgery units within a hospital in the UK at the Hammersmith Hospital (Calnan and Martin 1971), though this had became an increasingly common facility in the USA during this period. The 1970’s brought the first ‘free standing’ facilities - another concept that had been, and still is very successful in the USA.
What happened in the UK
The gradual move to day surgery in UK was largely being pushed by a few enthusiasts throughout the 1970’s and 1980’s until a report titled ‘Guidelines for day case surgery’ was produced in 1985 (revised in 1992) by the Royal College of Surgeons of England. This report stated that “day surgery is now considered the best option for fifty percent of all patients undergoing elective procedures” and was published at a time when the national average was less than 15%. Four years later the British Association of Day Surgery (BADS) was formed as a multidisciplinary organisation involving clinicians, nurses, ODA’s, managers and even architects. The common link was in their belief in day surgery and the potential advantages for patients and the NHS. They also recognised that to successfully increase levels of day surgery considerable attention had to be paid to quality.
The possibilities for day surgery were then recognised by two key reports. The first published in 1989 by the NHS Management Executive’s Value for Money Unit (known as the Bevan Report), supported the concept of day surgery and concluded that costs of treating patients as day cases were demonstrably less than treating them as inpatients. As this area was beyond the remit of this report a further detailed examination was commissioned by the VFM Unit which we will cover later. In 1990, the Audit Commission became responsible for the external audit of the NHS; this required them to explore health topics with respect to economy, efficiency and effectiveness in the use of resources. Their first report, entitled ‘A Short Cut To Better Services’ examined day surgery in England and Wales. There is little doubt that this publication was a major catalyst for the development of day surgery provision within the UK and we suggest it is well worth reading. In the preface, the report argues that “Day surgery has not expanded as fast as it might have done and performance varies considerably between health authorities.” The report introduced the concept of a ‘basket’ of 20 common procedures (accounting for 30% of all admissions in all surgical specialties) that could be performed as day surgery. The performance of 54 district health authorities in these 20 procedures was audited and when the results were compared the large variation became apparent. The largest variation was for carpal tunnel release with some districts performing them all as inpatients whilst others reported that they were all performed as day cases. The smallest variation was for repair of inguinal hernia but even here some units reported performing them all as inpatients whilst others performed 40% of them as day cases.
It was calculated in the report that if all units improved to the same performance as the top 25% for each procedure then 87,000 existing inpatients per year could be treated as day cases releasing £10 million which could then be used to treat an extra 98,000 day cases per year. The report went further as having found this variability in performance they state, “The Commission therefore decided to identify the obstacles to growth and to suggest ways of overcoming them consistent with maintaining and improving standards of patient care.”
The report then goes on to consider 6 main barriers to change which included lack of specialist facilities, poor management of existing units and clinicians’ preferences for more traditional approaches often backed up by a belief that patients do not like day surgery. Some possible solutions to these barriers are covered in considerable detail and the report ends with recommendations for hospitals, DHA’s, Regional Health Authorities, the Department of Health and the medical and nursing Royal Colleges.
The publication of this report was a major milestone in the development of day surgery in the UK and led the publication of two further important documents the first of which signalled the political interest in this field.
‘Day Surgery - Making it Happen’ was published by the VFM Unit of the NHSME (1991). This report though seeming to build on the lessons from the Audit Commission was actually commissioned due to recommendations contained in the Bevan Report previously mentioned. Though it was very much concerned with good practice in the design and management of day units, their staffing and the management of issues such as quality and training it also points out the potential financial gains for the NHS.
The next report of interest was a further publication by the Audit Commission in 1991 entitled ‘Measuring Quality: The Patients View of Day Surgery’. This introduced a questionnaire which allowed assessment of patients’ perception of the day surgery services they received. With this the Audit Commission provided part of the answer to two of the barriers they had previously identified -
1. the lack of information to assess current performance
2. the belief of many clinicians that patients did not like day surgery.
The results of the use of the questionnaire in three health authorities were included in the publication and demonstrated that 80% of day case patients said they preferred being treated as a day case and that 83% said they would recommend it to a friend in a similar situation.
These reports all played a part in the raising the level of knowledge and awareness about the potential for day surgery within the NHS and the Government. The early 1990’s saw the formation of Regional ‘Task Forces’ to oversee the investment of considerable sums of money to promote day surgery. This led to the formation of many new day surgery units - another one of the barriers to change envisaged by the Audit Commission. A National Day Surgery Task Force was formed and this group successfully published a ‘Toolkit’ which can be used by clinicians, nurses and managers as an aid to set up or review day surgery services.
It is evident that considerable encouragement was being given by the government via the NHSME, the Audit Commission and the Regional Health Authorities at this time. Targets were set for increasing the level of day surgery to 50% of elective surgery by the year 2000 and support provided (financial and organisational advice) to help providers achieve this.
Much of this information has been taken from
Cahill H and Jackson I.J.B. Day Surgery - Principles & Nursing Practice. Baillere Tindall.
London . 1997
References
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Asher RAJ
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1947
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The dangers of going to bed
British Medical Journal Vol.ii pp 967-968
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Audit Commission
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1990
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A short cut to better services: Day surgery in Egland and Wales. London : HMSO
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Audit Commission
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1991
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Measuring quality: The patient’s view of day surgery NHS Occasional Papers
London : HMSO
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Blodgett JB
& Beattie EJ
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1946
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Early post operative rising: a statistical study of post operative complications Surgery, Gynaecology and Obstetrics Vol. 82 p 485
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Calnan J
& Martin P
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1971
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Development and practice of an autonomous minor surgery unit in a general hospital
British Medical Journal Vol. iv p 92
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Farquharson EL
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1955
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Early ambulation with special references to herniorraphy as an outpatient procedure Lancet Vol. ii pp 517-519
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Hilton J
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1892
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Rest and Pain London : George Bell
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Leithauser
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1946
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Early ambulation and Related Procedures in Surgical Management. Oxford : Blackwell Scientific Publications
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NHSME
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1993
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Day surgery - Report by the day surgery task force Heywood: BAPS Health Publication Unit
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NHSME VFM Unit
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1991
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Day surgery - Making it happen London : HMSO
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NHSME VFM Unit (Bevan Report)
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1989
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A study of the management and utilisation of operating departments London : HMSO
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Nicoll JH
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1909
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The surgery of infancy British Medical Journal Vol. ii pp 753-756
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Palumbo LT
Paul RE
& Emery FB
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1952
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Results of primary inguinal hernioplasty Archives of Surgery Vol. 64 pp 384-394
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Royal
College of Surgeons of
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1992
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Report of the Working Party on Guidelines for Day Case Surgery (Revised Edition)
London : RCoS
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Waters RM
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1919
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The down-town anesthesia clinic American Journal of Surgery Vol. 33 (supp) pp 71-73
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Wolfson J . Walker G & Levin PJ
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1993
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Free-standing ambulatory surgery: Cost-containment winner?
Healthcare Financial Management July pp 27-32
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