Day-case tonsillectomy: is the NHS demanding unobtainable ...

DOI: 10.1308/003588414X13814021679393

D AY- C A S E T O N S I L L E C T O M Y :
IS THE NHS DEMANDING
U N O B TA I N A B L E TA R G E T S ?

A Trinidade Specialist Registrar in Otolaryngology
JS Phillips Consultant Otolaryngologist
AP Bath Consultant Otolaryngologist
Norfolk and Norwich University Hospitals NHS Foundation Trust

In its 2002 document Delivering While the main morbidities associated In this article, we explore some
the NHS Plan, the Department with tonsillectomy are postoperative demographic factors that preclude
of Health set a target of 75% of haemorrhage, nausea and vomiting, and tonsillectomy as a day-case procedure
all surgical procedures being hypoxia (in patients with obstructive in a significant proportion of our
performed as day-case procedures.1 sleep apnoea), tonsillectomy can be population. We examine the effect that
Tonsillectomy is quoted as one of performed safely as a day case with low this has on our ability to meet published
the operations in the ‘basket’ of rates of these morbidities, as several targets, and discuss the medical and
25 procedures deemed suitable recent UK-based audits have shown.4–6 financial implications.
by the Audit Commission and However, because of these risks, and that
the British Association of Day of haemorrhage in particular (5.7%),7 all Materials
Surgery (BADS).2,3 With respect to UK trusts provide guidelines outlining The Norfolk and Norwich University
tonsillectomy alone, the target is which patients should be deemed suitable Hospital is the main tertiary referral
quoted as 70% for children and 80% for day-case tonsillectomy based on a centre of the county of Norfolk in
for adults.3 variety of demographic factors, including England. It is a 987-bed hospital that
minimum age, weight, distance from the serves a catchment population of 654,900.
Ann R Coll Surg Engl (Suppl) hospital and medical issues. A summary of Norfolk is the fifth largest county in the
2014; 96: 188–190 the guidelines used in our trust is outlined UK with an area of 5,371km2, making
in Table 1. it approximately 3.5 times the size of
Greater London.
Despite the targets outlined by the NHS
plan, audits have shown that most trusts The medical notes of the last 300
have failed to meet these targets in the consecutive patients undergoing a
past.1 Reasons cited include inappropriate tonsillectomy were reviewed and
and inefficient use of day-case units; poor a record was made of patients’
management and organisation; clinician demographic data, including their age and
preference for inpatient procedures; postcode. Google Maps™ was used to
mixing of inpatient and day-case calculate the distance that each patient
procedures on the same list, leading to lived from the hospital to determine
cancellations; and failure to recognise day how long it would take him or her to
surgery as a priority. However, factors reach the hospital should a bleed occur
not mentioned include the inherent following the tonsillectomy. Data were
demographic details of trust catchment analysed using Excel® 2010 (Microsoft,
areas, which may preclude the performing Redmond, WA, US).
of basket procedures (which, in turn,
may also lead to a failure in achieving Results
targets). Such factors cannot be ‘blamed’ The medical notes of all 300 patients
on trusts and, especially in the case of were retrieved in full. The female-to-
tonsillectomy, if guidelines are ignored, male ratio was 1.6:1 (183 female and 117
this may compromise patient safety. There male patients). More than half (164/300,
is a financial dimension to performing 55%) were children aged 15 years or
day surgery as its continuing expansion younger and a quarter of these (43/164,
is aligned closely with the ‘Payment by 26%) were under the age of 4 years.
Results’ (PbR) scheme. Patient ages ranged from 1 to 66 years.

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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN

Driving distances from the hospital TABLE 1
ranged from 5 to 81 minutes.
Approximately 35% of patients EXCLUSION CRITERIA FOR DAY-CASE TONSILLECTOMY IN CHILDREN AT THE
(106/300) lived in postcodes that NORFOLK AND NORWICH UNIVERSITY HOSPITAL
were more than 30 minutes’ drive
from the hospital (Figure 1). Based on Children Adults
these figures and on trust guidelines,
in terms of postcode alone, only Age <4 years Age >65 years
65% of all patients were eligible for
day-case tonsillectomy. Weight ≤18kg Body mass index >30kg/m2

With respect to age, three-quarters Home >30 minutes’ car drive away Home >30 minutes’ car drive away
of our paediatric population (121/164,
74%) were aged 4–15 years and History of obstructive sleep apnoea History of obstructive sleep apnoea
were therefore eligible for day-
case tonsillectomy. However, when Significant medical illness or anaesthetic Significant medical illness or anaesthetic
postcode was taken into account, 37 concerns* concerns*
of those children lived more than 30
minutes’ drive away, reducing the total No access to telephone at home No access to telephone at home
number of children eligible for day-case
tonsillectomy to 84. Consequently, the Child with only one adult at home on No other adult at home on night after
total percentage of children eligible night after surgery surgery
for day-surgery tonsillectomy was
approximately 51% (84/164). With Parents unhappy with day-case Patient unhappy with day-case
respect to adults, 54/136 (40%) lived tonsillectomy tonsillectomy
more than 30 minutes’ drive away,
reducing the total percentage of *includes obesity, diabetes, bleeding tendency, poorly controlled epilepsy, cardiac
adults eligible for day surgery to 60% surgery, cerebral palsy/learning difficulties, family history of anaesthetic problems,
(Figure 2). poorly controlled asthma needing admission or oral steroids in past three months

Discussion FIGURE 1
Best practice tariffs, a part of the
PbR scheme, are defined as enablers MAP OF NORFOLK SHOWING GEOGRAPHICAL POSTCODE REGIONS FROM
for the National Health Service to WHERE PATIENTS UNDERGOING TONSILLECTOMY DURING THE STUDY
improve quality that do so by reducing PERIOD ORIGINATED
unexplained variation and universalising
best practice. They therefore ‘reimburse All Patients living<30 mins PE36 Wells-Next-The-Sea NR25 Sheringham NR6
and incentivise high-quality and cost- from hospital NR23 Holltt NR26 NR5 NR3 NR7
effective care’.8 First used successfully for
cholecystectomy in 2012, best practice Majority of patients living NR22 NR27 NR2
tariffs were extended to cover a total of <30 mins from hospital NR1
15 procedures, including tonsillectomy. Majority of patients living NR24 NR11
The increase in the number of basket >30 mins from hospital NR21 NR4 Norwich
procedures to 25 was based on day- All Patients living
case rates that were suggested to be >30 mins from hospital Fakenham
achievable by BADS.3
PE31 NR28

PE35 Aylsham

PE30 NR20 NR10 NR12
King’s
PE34 Lynn PE32
Swa ham
Dereham NR8 NR29
PE37 NR19 NR9 Norwich

Wisbech PE33 NR13 NR30
PE14 Downham Acle
Market
IP25 NR18 NR14 NR31
Watton NR35 NR32

Loddon

PE38 IP26 NR17 NR15

IP24 NR16 NR34 NR33
Thetford
IP27 IP22 IP20
Diss IP21

IP19 IP18

The argument for this is inherently is a lack of robust evidence to support (versus a 70% target) for children and
sound: the over-reimbursement for such targets, which seem arbitrary. 60% (versus an 80% target) for adults.
suitable procedures done as day surgery This translates to a total of only 166 for
and under-reimbursement if done In this paper, our data consider only the target of 224 patients.
otherwise gives healthcare providers a demographic exclusion criteria and do
clear incentive to shift clinical activity not take into account other factors As a result, given an idealised clinical
to the day-care unit. The latest tariff for such as patient co-morbidities. The and managerial environment, our trust
tonsillectomies performed as a day case exclusion criteria of age and geography still struggles to meet published targets
is £1,087 and for inpatients it is £787.3 are evidence-based9,10 and similar to the based on factors beyond our control
Nevertheless, while tonsillectomy is a criteria used in other trusts (personal (patient age and postcode) and suffers
procedure that is suited to this type of correspondence). Based on demographic £17,400 of unrealised reimbursement
shift in clinical activity, current targets data alone, our day-case tonsillectomy for this population of 300 patients
are likely to have been set too high and rates could not be any better than 51% (£300 [difference between day-case
made too inflexible. In addition, there

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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN

and inpatient tonsillectomy tariffs] x FIGURE 2
58 [difference between target patient
number and those actually eligible based DAY-CASE TONSILLECTOMY RATES COMPARED WITH PUBLISHED TARGET
on exclusion criteria]). Applying further RATES BASED ON DEMOGRAPHIC DATA ONLY
exclusion criteria in the interest of
patient safety would increase this loss.
Achieving published targets and therefore
attempting to recoup such losses would
ultimately put a significant portion of our
patients at unacceptable clinical risk.

Our trust is unlikely to satisfy the References 6. Youshani AS, Thomas L, Sharma RK. Day case
current targets set by the Department tonsillectomy for the treatment of obstructive sleep
of Health and it is effectively being 1. Department of Health. Delivering the NHS Plan. apnoea syndrome in children: Alder Hey experience.
financially penalised for acting in the London: DH; 2002. Int J Pediatr Otorhinolaryngol 2011; 75: 207–210.
patients’ best interests. Current systems
need to be flexible enough to allow 2. Department of Health. Day Surgery: Operational 7. Impact of NICE guidance on rates of haemorrhage
trusts to tailor day-case tonsillectomy Guide. London: DH; 2002. after tonsillectomy: an evaluation of guidance issued
to their patients’ needs and benefit from during an ongoing national tonsillectomy audit.
proposed reimbursement rates. 3. British Association of Day Surgery. BADS Directory Qual Saf Health Care 2008; 17: 264–268.
of Procedures. 4th edn. London: BADS; 2012.
Conclusions 8. Audit Commission. Best Practice Tariffs and Their
The current best practice tariffs system 4. Bajaj Y, Atkinson H, Sagoo R et al. Paediatric Impact. London: AC; 2012.
of the PbR scheme has set targets day-case tonsillectomy: a three-year prospective
that are potentially unachievable for audit spiral in a district hospital. J Laryngol Otol 2012; 9. Bhattacharyya N. Ambulatory pediatric
many trusts for a variety of reasons. 126: 159–162. otolaryngologic procedures in the United
Flexibility is needed in the system to States: characteristics and perioperative safety.
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case tonsillectomy to the needs of and vomiting following paediatric day-case
the populations they serve while still tonsillectomy: audit of the Epsom protocol. 10. Drake-Lee A, Harris S. Social conditions
being able to benefit from current J Laryngol Otol 2011; 125: 1,049–1,052. and paediatric day case tonsillectomy.
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