The reconfiguration of clinical services report provides new insights into the drivers of reconfiguration and the underpinning evidence. It builds on a major analysis, commissioned by the National Institute for Health Research (NIHR), of reviews of service reconfigurations conducted by the National Clinical Advisory Team (NCAT).
This page summarises the report's findings on the reconfiguration of elective surgical care.
Proposals reviewed by NCAT
All the reconfigurations of elective surgery reviewed by NCAT involved the separation of emergency surgical care from elective surgery.
Key drivers of elective surgical care reconfiguration
Cost and workforce were the primary drivers of this type of reconfiguration.
Context and relevant policy
- The number of elective day case surgery admissions in England has risen by nearly 80 per cent over a decade, from 3.2 million in 2002/3 to 5.7 million in 2012/13.
- At the same time, the number of other elective inpatient admissions remained broadly static, at around 1.5 million admissions each year.
- The NHS Plan in 2000 included the development of a number of diagnostic and treatment centres focused on providing elective surgery and diagnostic procedures.
- In addition to independent sector treatment centres, the Department of Health launched a strategy in 2002 to increase the proportion of elective procedures conducted as day cases.
The current evidence base
Professional guidance and the available evidence support the separation of elective from emergency surgery (either geographically or through the provision of dedicated facilities and staff). Patients deemed high risk should only be admitted to a facility with the appropriate critical care and other support. Elective surgical units should be consultant-led.
Telemedicine ICUs (or tele-ICUs) where patients are monitored remotely by a critical care team can improve the quality of critical care. Emerging evidence suggests that non-medical staff such as surgical care practitioners can provide safe care for minor surgical procedures.
Relevant college and other guidance
The Royal College of Surgeons of England (RCS) recommends separating elective surgical admissions from emergency admissions, suggesting that this can result in earlier investigation, definitive treatment and better continuity of care, as well as reducing hospital-acquired infections and length of stay (particularly medical emergencies) wherever possible. It also advises streaming elective care into minor, intermediate and complex cases. Hospitals providing complex elective surgery or minor/intermediate surgery for higher-risk patients with co-morbidities should provide ‘sufficient critical care support appropriate to patient need’.
Work conducted by the RCS and Department of Health on high-risk surgical patients showed that mortality rates for this group exceed the rate for cardiac surgery by between two and three times, with complication rates of 50 per cent not uncommon. They recommend that patients with higher predicted hospital mortality should have greater consultant input and/or supervision.