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Open in new tab Ear, Nose and Throat Surgery
GIRFT Programme National Specialty Report
by Andrew Marshall BSC MBBS FRCS
GIRFT clinical lead for Ear, Nose and Throat Surgery
November 2019
GIRFT is delivered in partnership with the Royal National Orthopaedic Hospital NHS Trust, NHS England and NHS Improvement
Foreword from Professor Tim Briggs GIRFT Programme Chair
I am delighted to recommend this Getting it Right First Time review of Ear, Nose and Throat Surgery (ENT) by Andrew Marshall.
Andrew’s report brings the GIRFT approach to his own clinical specialty, combining a data-led view of outcomes and costs with
real insight into what is and is not working. I firmly believe that, with the support of clinicians and managers, it can lead to the
redesign of services to improve care and patient outcomes – as well as saving the NHS millions of pounds.
GIRFT and the other Carter programmes, together with the Evidence Based Interventions programme, are already
demonstrating that transforming provider services and investing to save can bring huge gains in stabilising trusts, and healthcare
systems, financially and improving care for patients.
The programme began following my review of orthopaedic surgery in 2012. That review was driven by a desire to ensure better
care and outcomes for patients and to fix the issues faced by colleagues in my own specialty. With a small team, we visited more
than 200 sites, meeting more than 2,000 surgeons, clinicians, support staff and trust managers. Almost everybody
acknowledged that the NHS must review all unwarranted variation in the quality and efficiency of the services we deliver.
Together we set out to understand the impact of that variation by reviewing data, discussing challenges and debating solutions.
At the end of the process we were able to make evidence-based recommendations and to share the good practice we found.
Today, with the support of my fellow clinicians and the British Orthopaedic Association, those recommendations are helping
to improve care and patient outcomes, as well as saving the NHS millions of pounds.
That support is crucial. GIRFT cannot succeed without the backing of clinicians, managers and all of us involved in delivering
care. So I am most heartened to hear how supportive people have been as Andrew has been carrying out his review.
My greatest hope is that GIRFT will provide further impetus for all those involved in the delivery of ENT surgery to work
together, shoulder to shoulder, to create solutions and improvements that have appeared out of reach for too long.
GIRFT programme Chair and National Director of
Clinical Improvement for the NHS
Professor Tim Briggs is Consultant Orthopaedic Surgeon at the Royal National
Orthopaedic Hospital NHS Trust, where he is also Director of Strategy and
External Affairs. He led the first review of orthopaedic surgery that became the
pilot for the GIRFT programme, which he now chairs.
Professor Briggs is also National Director of Clinical Improvement for the NHS.
Professor Tim Briggs CBE
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Contents
Introduction from Andrew Marshall ……………………………………………………………………………5
Statement of support ………………………………………………………………………………………………………7
Recommendations …………………………………………………………………………………………………………..8
Executive summary……………………………………………………………………………………………………….13
ENT surgery today …………………………………………………………………………………………………………18
About our analysis …………………………………………………………………………………………………………20
Findings and recommendations………………………………………………………………………………….21
Day case treatment ……………………………………………………………………………………………………….21
Non-elective cases…………………………………………………………………………………………………………31
Non-elective spells (admissions) not followed by a dominant procedure ………………………….31
The assessment setting……………………………………………………………………………………………………………………32
Variation in out-of-hours admission……………………………………………………………………………………………..33
Out-of-hours network arrangements ………………………………………………………………………………………….34
Out-of-hours expertise ……………………………………………………………………………………………………………………36
Daytime first-on-call expertise………………………………………………………………………………………………………36
Tonsil surgery………………………………………………………………………………………………………………….38
Target rates for day case tonsillectomy……………………………………………………………………………………….38
Day case treatment for obstructive sleep apnoea (OSA) ……………………………………………………….39
Readmission rates following tonsillectomy ………………………………………………………………………………..40
Cancellations…………………………………………………………………………………………………………………..43
Making best use of consultant out-patient time……………………………………………………..45
Follow-up after grommet insertion for glue ear………………………………………………………………………..47
New to follow-up ratios……………………………………………………………………………………………………………………48
Access and commissioning…………………………………………………………………………………………..52
Local policies and procedures ………………………………………………………………………………………………………..53
Approval policies to monitor and/or control activity ……………………………………………………………….54
Restrictive referral policies …………………………………………………………………………………………………………….55
Septoplasty indications ……………………………………………………………………………………………………………………56
Procurement …………………………………………………………………………………………………………………..58
Potential procurement savings………………………………………………………………………………………………………58
Cochlear implants ……………………………………………………………………………………………………………………………..58
Bone-anchored hearing aids (BAHAs)…………………………………………………………………………………………60
Reviewing procurement in ENT…………………………………………………………………………………………………….61
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Outcome metrics……………………………………………………………………………………………………………62
Self-reporting data sets……………………………………………………………………………………………………………………62
The potential benefits of a standard, national dataset…………………………………………………………….62
Patient reported outcome measures (PROMS) ………………………………………………………………………..62
National Clinical Improvement Programme (NCIP) ………………………………………………………………..63
Data and coding ……………………………………………………………………………………………………………..64
Coding within admitted patient care……………………………………………………………………………………………65
Coding of non-consultant-led out-patient activity …………………………………………………………………..70
Understanding the reasons for variation in coding ………………………………………………………………….71
Service costs……………………………………………………………………………………………………………………73
Other opportunities………………………………………………………………………………………………………76
Theatre productivity…………………………………………………………………………………………………………………………76
Recruitment issues……………………………………………………………………………………………………………………………77
Litigation………………………………………………………………………………………………………………………….78
Activity and notional financial opportunities ………………………………………………………….82
About the GIRFT programme ……………………………………………………………………………………..85
Glossary……………………………………………………………………………………………………………………………86
Acknowledgements ………………………………………………………………………………………………………89
Appendix 1: Examples of paediatric day case analysis from data packs…………….92
Appendix 2:
Giving commissioners notice of changes in the way you record activity …………..96
Appendix 3: Treatment setting for paediatric ENT…………………………………………………97
Appendix 4: Readmission rates following tonsillectomy ………………………………………99
Contents
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Introduction from Andrew Marshall
GIRFT National Clinical Lead for ENT surgery
It has been a privilege to visit so many of my colleagues in our specialty over the past months and I would like to thank all who
have taken part for being so engaged in the process.
As I have stressed during the visits, GIRFT is not an inspection. It is about allowing all of us in the specialty to discuss what our
data tells us about where we sit in relation to our colleagues in other units. There may be clear reasons why a unit’s data suggests
it is an outlier. We have found institutional factors, such as day case settings closing at 6pm, and the obvious equipment and
resourcing factors. Some units have felt the presence of differences in generational practice, while others are shaped by
geographical considerations, such as the distances patients need to travel. All of these are factors for a number of units across
the country. The important point is to identify the situations where a unit is an outlier, the reasons why, and establish ways of
working that can mitigate potential negative consequences.
This report recommends how the many examples of good practice in the delivery of ENT services could be adopted in order
to improve patient care and outcomes. We have been careful not to prescribe how ENT in the UK must be delivered.
I would also like to stress that this is a review of all of ENT. Although tonsillectomy is only one area of ENT work, it accounts for
17% of the total elective workload and around £68m, almost 8%, of the total ENT budget. This means the opportunities to
improve patient care by reducing variation in this area are significant. For this reason, we have chosen to treat tonsillectomy
as a distinct theme. All of the general findings and recommendations in the other themes apply to tonsillectomy just as they do
to other procedures.
Figure 1: ENT elective in-patient and day case reference costs by procedure
Tonsillectomy (alone or with adenoidectomy)
Other mouth or throat procedures
Other ear procedures
Neck procedures
Thyroid / endocrine / diabetes
Sinus procedures
Cochlear / BAHA procedures
£68m
£47m
£36m
£31m
£29m
£28m
£28m
Other nose procedures / diagnosis
£26m
Septoplasty
Grommets
£19m
£19m
Tympanoplasty
£16m
Diagnostic Laryngoscopy or Pharyngoscopy
Mastoid procedure
Adenoidectomy (without tonsillectomy)
Septorhinoplasty
Other
£13m
£12m
£11m
£11m
£0
£10
£20
£30
Total spend in £m
£40
£50
£60
£70
£80
Data source: 2017/18 Reference costs
£44m
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