Press Release – Special Report: Managing Elective Day Surgery

The Comptroller and Auditor General has completed a special report on the management of elective day surgery. The report has been presented to the Houses of the Oireachtas today, 19 August 2014.
Main Findings
Potential for improved day surgery rates
In 2006, the HSE identified 24 surgical procedures for which it monitored the day surgery performance rate.  
The overall day surgery performance rate nationally for these 24 target procedures increased from 57% in 2006 to 74% in 2012. However, there is significant variation in performance rates between individual hospitals. In 2012, the rates for individual hospitals for the target procedures as a group ranged from 50% to 92%.
There are also very significant differences in performance of day surgery for individual procedures.
The HSE should monitor day surgery rates at both hospital and procedure level, and focus effort on improving performance in those hospitals and specialties where there is the greatest potential for gain.
Procedures with low day surgery rates
Some clinicians expressed the view that a number 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. For example, for the procedure laparoscopic cholecystectomy, 3,700 procedures were carried out in 2012. Three hospitals achieved increases in the day surgery rate from 1% in 2006 to between 56% and 70% in 2012. In others the rates remained low, at around 1%.
The HSE should seek to identify the factors associated with increased day surgery rates in some hospitals and whether there are good practices in the hospitals with the higher rates that are transferable.
Potential savings
The HSE has estimated that day cases were on average almost 60% less costly to perform than inpatient cases.  However, the HSE and the Department of Health pointed out that a high proportion of the costs are fixed and that, if the level of day surgery increases, the full potential savings will not accrue in the short term. Related cost reduction measures would also need to be put in place to achieve the full savings.
Trend in non-targeted procedures
The number of elective surgical procedures carried out increased from 157,000 in 2006 to 198,000 in 2012. The number of target procedure cases was up only 3% over the six year period, while the number of non-target cases was up 39%. There was no drop in the number of cases admitted as inpatients for non-target procedures, despite the very rapid increase in the number of admissions for non-target day surgery.   
The HSE has 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 on an outpatient basis or in primary care settings. It estimates that as many as three in five of the non-target day surgery treatments could more appropriately be carried out in other settings at less cost.
The HSE's Accounting Officer pointed out that the current method of funding of hospitals does not provide an economic incentive to perform procedures in their most appropriate setting, because the payment rate for some procedures performed in a day surgery setting is higher than if the same procedure is performed in an outpatient setting. 
The HSE should monitor cases currently classified as day surgery cases with a view to ensuring that all hospitals direct surgical cases to the most appropriate and economical settings.
Bringing about improvements
The examination included a survey of hospitals and a number of site visits, using medical consultants, to examine the processes around management and delivery of day surgery. The results were measured against good practice and recommendations are presented in the report aimed at achieving improvements in the way day surgery is managed.
Note for Editors
Enquiries: contact John Riordan (01) 603 1027 or email
The Comptroller and Auditor General is an independent constitutional officer with responsibility for the audit of public funds. He reports to Dáil Éireann.