What are the costs and benefits of the functional separation of elective and emergency surgery. Report 1 Service Innovations Background Research Rapid Reviews (SIBR3)

Hospital productivity has increased substantially over the 1980s and 1990s. Over two thirds more patients were treated using two fifths fewer beds, between 1982 and 1997/8. The dramatic activity increase, in the face of shrinking acute bed numbers, was seen to be at its height at the end of the eighties. Since 1991 the main source of increasing activity has been a result of day surgery which has seen four to five fold increases. During this period the acute hospital throughput rate doubled, (the equivalent to an effective increase in capacity).

There has been a concomitant growth in the private sector, particularly in the provision of nursing home beds, but also in social care and local authority care provision and the private acute sector, (although this peaked in the early nineties). The volume of first attendances at outpatients has increased less dramatically suggesting that the smaller increases in individual access have in turn been provided with larger amounts of inpatient and day care services. It is suggested that the inexorable increase in throughput and shortening length of stay must sooner or later plateau as external constraints such as nursing home placement, limitations of social services and other discharge difficulties exert their effect. (Hensher & Edwards1999)

As utilisation rises against a background of very high occupancy rates, the difficulties seen with pressures on the system at peak times in recent years may be an indication that the maximal efficiency of current service configurations has already been reached.

The debate has thus turned to questions of reconfiguration with a number of stakeholders joining and producing reviews and reports on potential pathways for change. The government has set down a ten year strategy for modernisation, and substantial contribution from various clinical working parties has been made particularly in the area of surgical services. (NHS July 2000, Royal College of Surgeons in England (RCSE) Nov 2000, RCSE Dec 2000, RCSE BOA July 2000, JWP BMA, RCP Lon. RCSE, July 1998, Royal Surgical Colleges of Great Britain and Ireland, July 1998, RCSE June1997, Royal College of Anaesthetists and RCSE 1996, Royal College of Nursing 2000, Department of Health 1996).