Mr. Seamus McCarthy:

Irish acute hospitals report that in 2012 they carried out surgical procedures on almost a quarter of a million admitted patients. Around 50,000 of these admissions occurred after emergency presentation for treatment. The bulk of the surgical procedures, 80%, or just under 200,000 cases, were elective or planned surgery cases, and two thirds of these were treated on a day surgery basis.

Day surgery refers to surgical treatment provided in hospital, generally under anaesthetic, where the patient is expected to return home on the same day. It requires formal admission of the patient to the hospital and is different to minor surgical treatment provided in an outpatient clinic. Day surgery has a number of benefits over the same procedure provided on an inpatient basis, where the patient occupies a hospital bed for one or more nights. These benefits include reduced risk for patients of contracting a hospital-acquired infection and reduced costs for hospitals. Properly managed, day surgery should also lead to a reduction in waiting time for elective procedures because of improved throughput of cases.

Since 2006, the HSE has required acute hospitals to provide details of the total number of admissions and the number carried out as day surgery for 24 targeted surgical procedures. The target procedures range across all the major specialties and accounted for 31% of all elective surgical procedures in 2012. Appendix A lists the target procedures, together with a layman's description of each one.

The examination was carried out to establish the extent to which there had been progress in switching the delivery of treatment from an inpatient to a day surgery basis, to identify factors that assist in that switch or that might be impeding it and to assess if there was scope for the use of day surgery to be extended. In view of the specialist medical knowledge required regarding the nature of surgical procedures and hospital processes, we contracted in two experienced medical consultants based in the UK to assist the examination team drawn from my office.

The examination report is presented in two main parts. Chapter 2 presents an analysis of the available data on elective surgical procedures designed to identify key trends and outcomes at individual hospital and procedure level over the period since 2006. Chapter 3 is a review of procedures adopted by hospitals in planning and delivering day surgery treatment and supporting patients after discharge. It includes recommendations aimed at ensuring hospitals are in a position to deliver elective surgery in the most appropriate and effective setting.

Figure 2.1 indicates that the volume of elective surgery reported by hospitals increased by around a quarter between 2006 and 2012. There was a small reduction in the volume of elective surgery carried out on an inpatient basis. This contrasts with a big increase in the volume of day surgery. As a result, the proportion of elective surgery carried out on a day surgery basis increased from 55% to 69%.

For the years 2009 to 2012, the HSE set all acute hospitals a target of achieving an overall day surgery rate of 75% for the set of 24 procedures. In 2012, the rate achieved across all hospitals was 74%, just below the target. However, there was significant variation in performance between the different acute hospitals that have a significant surgical case load. In 2012, the day surgery rate for the target procedures in individual hospitals varied from 50% to 92%.

The HSE specified only a single day surgery target rate even though existing practice varied widely for the different types of procedures. The mix of surgical procedures varies between hospitals and this influences the overall hospital day surgery rate relative to the target.

Figure 2.5 shows how treatment delivery has changed regarding each of the target procedures since 2006. The diagram can be seen on the screens. The darker bands indicate the balance between inpatient and day surgery in 2006, while the lighter bands show the 2012 balance. Overall, the relative shift to the right of the lighter bands reflects a trend towards delivery of more treatment via day surgery.

For some procedures there was little change over time in the balance between inpatient and day surgery.

For example, more than 75% of operations for correction of a squint were carried out on an inpatient basis in 2006. By 2012, the balance had reversed with 75% of squint correction carried out on a day surgery basis. There have also been considerable shifts towards day surgery for removal of cataracts and to relieve a condition that results in contraction in the hand. In contrast, there were only minor changes in the day surgery rates for tonsil removals and removal of bladder tumours.

It is notable that across hospitals several of the procedures targeted by the HSE for improvement in day surgery rates were already at or above the 75% day surgery level in 2006. This included cases involving post-fracture removal of pins or plates, internal examinations of joints, treatment of glue ear and treatment for nasal fracture.

Some clinicians expressed the view to the examination team that several of the 24 target procedures monitored by the HSE are not suitable for day surgery. This viewpoint may be reflected in very low day surgery rates for some high volume procedures, such as removal of tonsils, 5,200 cases in 2012, with an 8% day surgery rate and gall bladder removal, 3,700 cases in 2012 with a 27% rate. The examination found that in three hospitals, the day surgery rate for gall bladder removal increased from 1% in 2006 to between 56% and 70% in 2012. In other hospitals, the day surgery rate for gall bladder removal remained low at around 1%. Figure 2.7 in my circulated paper indicates the very considerable variation that existed between hospitals in two other high-volume target procedures, namely laparoscopy and repair of hernia. We found that across all hospitals, the day surgery rate increased for both procedures between 2006 and 2012 while the gap in performance between hospitals narrowed.

The overall conclusion from the data analysis is there has been a significant increase in the day surgery rate for many of the targeted procedures but that scope exists for further improvement. We recommended the HSE should seek to identify the factors associated with increased day surgery rates and transferable good practices. We also recommended that instead of a single global target, appropriate targets should be set for different procedures and that targets should be set for a wider range of elective procedures. It is important to acknowledge that setting a target rate for day surgery for a category of procedure cannot override the professional judgment of the relevant clinicians in deciding on the appropriate delivery setting in any individual case which must take account of all factors, including the patient’s condition and circumstances.

The HSE estimates day care surgery is, on average, almost 60% less costly than performing the same procedure on an inpatient basis. However, both the HSE and the Department of Health have pointed out that because a high proportion of hospital costs are fixed in the short term, the full potential savings of a significant shift from inpatient to day surgery will not accrue immediately. Related measures to reduce cost are also needed to achieve the potential cash savings.

The primary focus of the examination was on the procedures targeted by the HSE for monitoring and target setting. However, we also looked at the trends in elective surgery that were not subject to targeting. Figure 2.10 in my circulated paper presents a comparison of the numbers of targeted and non-targeted procedures reported which indicates a significant difference. The total number of elective procedures carried out in the target categories increased by only 3% over the seven years. Within the targeted procedures, it is evident the increase in day surgery admissions was broadly offset by a corresponding decrease in inpatient admissions. This suggests a strong substitution effect which over time should yield savings or free up resources for other activity. In marked contrast, the total number of elective procedures in non-target categories increased by 39% over the same period. There was little change in the number of inpatient admissions for those procedures but a very striking 74% increase in day surgery admissions. Underlying demographic changes such as an aging population are highly unlikely to explain a trend shift of that order of magnitude in one category without apparently affecting other categories.

The HSE concluded that an increasing number of minor surgical procedures are being carried out as day surgery cases when it would be more economical to carry them out in outpatient clinics or in primary care settings. It estimates it would be more appropriate to carry out as many as three in five of the non-target day surgery treatments in other settings and at less cost. It attributes this shift to the incentive effect of the current method of funding of hospitals under which the payment rate for a procedure performed in a day surgery setting is higher than if the same procedure is performed, appropriately, in an outpatient setting. This is an inefficient outcome and I have recommended the HSE should closely monitor cases currently classified as day surgery with a view to ensuring that all hospitals direct surgical cases to the most appropriate and economical settings.

The examination included a survey of hospitals and site visits to a number of hospitals where the medical consultants examined the processes around management and delivery of day surgery. The results were measured against criteria identified by the medical consultants based on established good practice for day surgery is UK hospitals. Procedures were examined at each stage of the day surgery pathway which is outlined in figure 3.1 in my report. Recommendations are presented in the report aimed at achieving improvements in the way day surgery is managed in hospitals. The HSE has agreed to implement the recommendations. It remains to be seen what impact this will have on efficiency and cost in the delivery of elective surgery, as well as on the quality of the service provided to patients.