Free Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice by Simon Paterson-Brown MBBS MPhil MS FRCS Page A

considered.
    Further development of day surgery occurred not in the UK but in North America, where cost savings associated with day surgery in privately run healthcare systems led to the early development of day units within hospitals, and by 1969 the first free-standing ambulatory surgical centre in Phoenix, Arizona. The huge commercial success of such units led to a significant shift in surgical care out of hospital inpatient beds, and forced surgeons, anaesthetists and hospital managers to study and improve the safety and efficiency of surgical care.
    The UK, with its state-run NHS, was much slower to introduce day surgery. The few existing units were poorly utilised and there was little support for the expansion seen in the USA. In 1980 Paul Jarrett, in the day unit at Kingston Hospital, demonstrated once again the benefits of dedicated day surgery lists for hernias, including the rapid reduction of waiting times from 3 years to 3 months. 8 This time the government was quick to see the advantages, and supported day surgery expansion throughout the UK for a decade. In 1985 the Royal College of Surgeons of England published a report (revised in 1992) entitled
Guidelines for day case surgery
. 9 At that time, it was estimated that only 15% of elective surgery was performed on a day case basis and the report suggested 50% as an appropriate target. In 1989, the gathering momentum of day surgery demonstrated a need for a professional body to promote the speciality and set quality standards of care. The result was the British Association of Day Surgery (BADS) encompassing surgeons, anaesthetists, nurses and managers involved in day surgery. The same year the NHS Management Executive's value-for-money unit demonstrated that the cost of treating patients as day cases was significantly less than as inpatients. 10 By 1990, the Audit Commission had taken over the role of external auditors within the NHS and it introduced the concept of a ‘basket’ of 20 surgical procedures suitable for day case surgery to allow benchmarking between health authorities. 11 The audit figures also demonstrated wide variations between hospitals.
    By 1991, the Audit Commission Report
Measuring quality: the patient's view of day surgery
found that 80% of day case patients preferred this mode of treatment to traditional inpatient treatment, adding further impetus to the development of day surgery. 12
    By the end of the decade, the introduction of newer surgical and anaesthetic techniques to the day unit and the loss of others to the outpatient department forced a reassessment of the surgical basket to reflect modern-day case activity, as many day units were already performing more complex procedures on a day surgery basis. In 1999, continuing the supermarket analogy, the BADS recommended an additional 20 operations to form a ‘trolley’ of procedures suitable for day surgery in the more experienced day unit ( Box 3.1 ). The trolley included major operations such as laparoscopic cholecystectomy, thoracoscopic sympathectomy, partial thyroidectomy and laser prostatectomy. The concept of the trolley was that a target of 50% of these procedures on a day case basis would be realistic.
     
    Box 3.1    British Association of Day Surgery ‘trolley’ of procedures 1999, of which 50% should be suitable for day case surgery
    Laparoscopic hernia repair
    Thoracoscopic sympathectomy
    Submandibular gland excision
    Partial thyroidectomy
    Superficial parotidectomy
    Wide excision of breast lump with axillary clearance
    Haemorrhoidectomy
    Urethrotomy
    Bladder neck incision
    Laser prostatectomy
    Transcervical resection of endometrium
    Eyelid surgery
    Arthroscopic meniscectomy
    Arthroscopic shoulder decompression
    Subcutaneous mastectomy
    Rhinoplasty
    Dentoalveolar surgery
    Tympanoplasty
    Laparoscopic cholecystectomy
    Bunion operations
    Following this lead by the professions, the Audit Commission updated its own basket of procedures ( Box 3.2 ) and this was incorporated