More than half of surgery cases treated in a day

Hospital revolution: New technology transforms acute health care and brings first ever fall in patients staying overnight

NICHOLAS TIMMINS

Public Policy Editor

More than half of all patients treated from surgery waiting-lists are now in and out of hospital on the same day in one of the most dramatic transformations in treatment seen since the foundation of the NHS.

The increase in day surgery has produced the first fall since 1948 - outside of periods of industrial action - in the number of in-patients treated as overnight stays. Treatments involving a hospital stay peaked in 1991, according to the latest Department of Health figures, with day- case treatment - usually surgery - becoming the most important form of acute hospital care last year.

This revolution in the style and pattern of health care has come about in less than a decade as a wide range of new technology has become available - from miniature cameras and lasers to new forms of wound closure, and new-style stitches which "melt away". Improved anaesthetics and better anaesthetic techniques have contributed to the change, as has the way hospitals have organised the care they provide.

In the mid-1980s, barely 20 per cent of treatments were day cases. By 1989 that had risen to one-third, but since then day cases have been increasing at a rate of about 20 per cent a year, the rise more than offsetting small falls in the numbers of in-patient treatments.

Brendan Devlin, president of the British Association of Day Surgery, said conditions now widely treated on a day-case basis include hernias, varicose veins, much knee surgery, cataracts, and a wide range of gynaecological procedures, including treatments for cancer or pre-cancer of the cervix and the womb. Some of the rise in day- case treatment has occurred because surgeons have begun to abandon unproven procedures such as the routine removal of tonsils and adenoids.

"In the past, surgery for hernias would have involved a hospital stay of three to six days," Mr Devlin said. "A cataract patient might have been in for five days, and varicose veins for six days or more.

"The change occurred because surgeons have learnt both that they can get better results with day surgery and that patients want to go home, not be in hospital." Big improvements in anaesthetics, both general and local, have allowed patients to recover faster and have been as important as new surgical techniques. "An equally big issue has simply been developing systems for day surgery so that it is well planned, patients turn up on time and are treated in dedicated beds, not stuck at the end of a 30-bed ward in which everybody else is desperately ill."

Worries still remain about how well surgeons are trained in the new techniques, Mr Devlin, who chaired a Royal College of Surgeons working party which recommended big improvements in training, said. "And there is an argument that some of these procedures need not be carried out by fully qualified doctors - that you could train up podiatrists to undertake day-surgery procedures on the foot, for example."

With existing technology, he said, a limit has probably been reached on the number of procedures which can be transferred from standard in- patient treatment to day surgery. "I don't think we are going to see the day when hip replacements or heart transplants are done as day cases." But many surgeons still provide traditional treatment and, in time, as much as 70 per cent of elective, waiting-list-type surgery could be done on the day, without patients needing to stay in overnight.

The advent of day surgery is one reason why the NHS has managed to cope with rising demand, Mr Devlin added. "Daycase treatment lets you treat more patients for the available money. And careful day surgery done by experienced surgeons results in very little discomfort and very good long- term outcomes."

The latest NHS statistics show health authorities bought 8.6 million treatments last year - a rise of 6.6 per cent. Of these, almost half were emergencies, admitted immediately. But of the 4.6 million waiting-list treatments, 2.4 million were day cases, a rise of 20 per cent on the previous year, while the number of in-patient treatments fell almost 2 per cent to just over 2.2 million.

How day operations have increased

Waiting-list-type treatments purchased 1992/93 to 1994/95

Day cases Ordinary Day cases as % of in-patients all elective treatment

1992/93

+19.4 % -1.3% 42%

1993/94

+17.5% -3.2% 47%

1994/95

+20.4% -1.9% 52%

Source: Department of Health