`I'd have liked one night in hospital'

Beryl Fordham had her first hernia operation about 12 years ago. She was in hospital for five days, had all her meals brought to her and did not go home until she was well on the way to recovery.

Mrs Fordham underwent very similar surgery recently. Only this time, she spent nine hours in hospital, was discharged at 6pm and two hours later was making her husband's supper. The wound in her abdomen had started bleeding again within 48 hours and she had to return to the ward. The three-to-four-inch incision had been held together by a couple of clips and covered by a small strip of bandage.

"I much preferred it the first time," says the 62-year-old retired book- keeper from north London. "I would have liked at least one night in hospital. I would have found it reassuring to have someone check the dressing."

The way Mrs Fordham was treated flouted at least four of the guidelines on day surgery laid down by the Royal College of Surgeons in 1992. She was cared for on a general ward, not a dedicated day unit; she was given no written material about the operation beforehand, no analgesics to take home and no telephone number to ring if anything went wrong.

Her case, and others like it, suggest that the stampede to day surgery is going too fast. About 40 per cent of the six million operations carried out in Britain each year are now performed on a day basis, some of the most common dealing with gall bladders, cataracts, varicose veins, anal fissures and bat ears. The NHS Executive recommends a rise to 60 per cent by 1997-98, with savings to be made of at least pounds 100m.

But Professor Alfred Cuschieri, consultant surgeon at Ninewells Hospital, Dundee, who chaired a working party on minimal access surgery, which reported in 1993, says the target is "wholly unrealistic".

"It ignores the fact that there is not sufficient aftercare in the primary sector and it ignores the fact that a lot of patients have serious co- morbidity [existing illness] unconnected to their surgery, such as lung or heart disease," he says. "Even if their surgery is minor, early discharge is not feasible. We should be expanding short stay rather than daycare units so that if a patient who is scheduled for day surgery is not well enough to go home they can be accommodated."

Mr Andrew Johnson, consultant general surgeon at Ormskirk Hospital, Lancashire, is also worried about this helter-skelter rush to nine-hour admissions. "There is a big push towards day surgery by management and health economists, but sometimes it is not in the interests of patients," he says. "People have a great fear of being in pain, or something awful happening to them during the night. If they are anxious, it makes their discomfort worse. Some patients might think their wound is going to explode or burst. If they are in a hospital ward, there is a nurse there who can reassure them, or if necessary give them extra pain relief. If people do not want to be discharged home, they should not be bounced into it.

"I can see why some clinicians choose to do day surgery, because there is a shortage of beds, but it only works if everything is set up for it. Patients need to know what to expect and local GPs and district nurses need to be geared up."

In addition, there is evidence that for many day-surgery cases, pain control is a major problem. A small study published in Nursing Times found that although most patients had anticipated some pain, they had also expected it to resolve quickly - and that when this did not happen they found it difficult to cope with. Most required something stronger than paracetamol; not all had received sufficient analgesia.

The study also found that all of the patients resumed "normal activity" too soon - often out of guilt, the need for money or pressure from employers. "Day surgery is not an easy option ... one-day surgery does not mean one- day recovery," comments Janet Thatcher, study author and senior lecturer in surgical nursing at the University of Greenwich, London.

Patricia Bottrill, clinical nurse manager at the Royal Victoria Infirmary, Newcastle-upon-Tyne, runs a nurse-led unit dealing with 3,000 day surgery cases a year. She says there have to be strict criteria to decide suitability: "We ask about their general health, their home circumstances, who will care for them after the operation and how far away they live. We go through all these matters, which surgeons are not good at discussing. We also give them a great deal of information, including written information, about the procedure."

If patients are properly selected, she says, day surgery can be successful. "Most people prefer their own beds and are more relaxed in their own homes."