• GIRFT study finds significant and “unwarranted” variation in ENT surgery
  • Readmission rates much higher than previously thought
  • Commissioners force “postcode lottery” for some procedures

Ear, nose and throat surgery in the NHS suffers from “significant unwarranted variation” in outcomes, a new study has found.

NHS Improvement’s Getting It Right First Time team found the specialty had much higher readmission rates than previously thought and was also struggling with a lack of senior staff.

The report, published this month, said patients faced a “postcode lottery” and that there were unexplained differences in what the NHS paid for some medical devices.

The GIRFT programme is looking at each surgical and medical specialty in turn. Its reviews combine an analysis of the available data with a questionnaire sent to providers. A visit is also made by an expert team to each unit in the English NHS providing that service.

Tonsillectomies, which account for £68m of the total annual £438m spend on ENT surgery, have a rate of “readmission and return to theatre much higher than previously reported in the literature, the report found.

The study by GIRFT ENT clinical lead Andrew Marshall also showed a five-fold variation in children readmitted following a procedure.

Mr Marshall’s team visited 126 units and the report claimed “a number” had mentioned problems in recruiting ENT consultants or locums.

It added: “Such recruitment issues were clearly affecting the ability of these departments to meet the referral to treatment rules published by the Department of Health and Social Care.

“It is reasonable to conclude that recruitment issues compound other difficulties – departments that may be less attractive to candidates find it even more difficult to recruit, leading to a vicious cycle of vacancy, service delivery problems and recruitment struggles.”

ENT is one of the NHS’s most challenged specialties. August 2019 data from NHS England showed that five trusts were treating less than two-thirds of their waiting lists within the target 18 weeks.

Performance was lowest at Brighton and Sussex University Hospitals Trust, at 46.4 per cent.

Surgeons reported that some clinical commissioning groups had created postcode lotteries by imposing referral restrictions on procedures, including ear-pinning.

HES data from 2016 showed ear-pinning rates per 100,000 people varying between 41 to one. Mr Marshall pointed out that this would mean a new generation of surgeons in those areas would not learn how to perform that procedure.

On procurement savings, the study singled out variations in spend on cochlear implants as something to be addressed.

Overall, it put the size of possible efficiencies in the specialty at between £24.5m and £33.5m, from the total ENT spend of £865m. This included procurement savings and the ensuring that the worst performers on daycase surgery matched that of those in the top quartile.

The GIRFT team also examined compensation cases and found “some evidence that claims cannot be defended effectively because providers do not have the necessary documentary evidence.”

Mr Marshall, a surgeon at Nottingham University Hospitals Trust, said: “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.”