COMMISSIONING POLICY

Transcription

1 COMMISSIONING POLICY Tonsillectomy (Adults and Children) July 2010 Version: 1.0 Ratified by (name of Decision-Making Group Committee): Date ratified: Date issued: Expiry date: (Document is not valid after this Any revisions to the policy will be based on local and national evidence of effectiveness date) and cost effectiveness together with recommendations and guidelines from local, national and international clinical professional bodies Review date: Minimum 3 yearly Lead Executive/Director: Simon Hairsnape Name of originator/author: Chris Emerson based on West Midlands Regional draft policy Target audience: NHS Trusts, Independent Providers, GP s, patients Distribution: NHS Trusts, Independent Providers, GP s, patients, Worcestershire MP s, Public & Patient Involvement Forum Equality & Diversity Impact Scrutinised 8th September 2010 Assessment If you would like this document in other languages or formats (ie. large print), please contact the Communications Team on or communications@worcestershire.nhs.uk Page 1

2 CONTRIBUTION LIST Key individuals involved in developing the document: Name Chris Emerson Dr Stuart Bourne Mr Martin Porter Mr Lance Hollis Dr Susanna Panton Dr Chris Perks Debbie Hinton Rosemary Williams Jo Tomlinson Designation Head of Acute Commissioning, NHSW Deputy Director Public Health NHSW ENT Consultant, Worcestershire Acute Hospitals NHS Trust (WAHT) Clinical Director for ENT, WAHT GP Spa Practice Droitwich GP Pershore Head of Audiology Services, WAHT S.Worcestershire PBC Cluster ENT Directorate Manager, WAHT Consulted with: Name NHS Worcestershire s Policy Group Mrs J Thomas Designation PPI Representative CONTENTS Section Page 1. Scope of policy 3 2. Background 4 3. Criteria for eligibility 4 4. Implementation 5 5. References 5 Page 2

3 SUMMARY NHS Worcestershire does not normally fund Tonsillectomy unless the eligibility criteria outlined in this policy are met. Definitions: Exceptional clinical circumstances refer to a patient who has clinical circumstances which, taken as a whole, are outside the range of clinical circumstances presented by a patient within the normal population of patients with the same medical condition at the same stage of progression as the patient. An individual funding request (IFR) is a request received from a provider or a patient with explicit support from a clinician, which seeks funding for a single identified patient for a specific treatment. Exceptional refers to a person who demonstrates characteristics, which are highly unusual, uncommon or rare. If there is demonstrable evidence of a patient s clinically exceptional circumstances, the referring practitioner should refer to the NHS Worcestershire Individual Funding Request Commissioning Policy document for further guidance on the process for consideration. For a definition of the term clinically exceptional circumstances, please refer to the Definitions section on page two of this document. 1. Scope of Commissioning Policy: This policy should be considered in line with all other NHS Worcestershire Commissioning Policies. Copes of these Commissioning Policies are available on the PCT s website at the following address: This policy covers tonsillectomy procedure coded F34. NHSW considers all lives of all patients whom it serves to be of equal value and, in making decisions about funding treatment for patients, will seek not to discriminate on the grounds of sex, age, sexual orientation, ethnicity, educational level, employment status, marital status, religion or disability, save where a difference in the treatment options made available to patients is directly related to the patient s clinical condition or is related to the anticipated benefits to be derived from a proposed form of treatment Page 3

4 2. Background: Surgical removal of the tonsils (tonsillectomy) is one of the commonest major operations carried out on children. Increasingly, it is performed on adults who in the past would almost certainly have had their tonsils removed in childhood as a matter of routine. However, the procedure is a controversial one, and opinions vary greatly as to the relative risks and benefits. The risks of surgery include those of the associated general anaesthetic and those specific to the procedure, for example bleeding immediately after surgery or as a result of secondary infection in the 10 to 14-day period after surgery. 1 Tonsillectomy can prevent recurrent acute attacks of tonsillitis, but not recurrent sore throats due to other causes. Before considering tonsillectomy, the diagnosis of recurrent tonsillitis should be confirmed by history and clinical examination and, if possible, differentiated from generalised pharyngitis. The natural history of tonsillitis is for the episodes to get less frequent with time, but epidemiological data are lacking in all age groups to allow a prediction of this to be made in individual patients. Tonsillectomy requires a short admission to hospital and a general anaesthetic, is painful, and is occasionally complicated by bleeding. Return to usual activities takes on average two weeks, with a corresponding loss of time from education or work. Evidence on exactly which children with sore throats benefit from tonsillectomy is not available, but current evidence suggests that the benefit of tonsillectomy increases with the severity and frequency of sore throats prior to tonsillectomy. Apart from adults with proven recurrent group A streptococcal pharyngitis (GAHSP), evidence on which adults will benefit from tonsillectomy is not available Eligibility Criteria: Tonsillectomy is automatically recommended when : There is suspicion of malignancy, typically squamous carcinoma or lymphoma; Severe tonsillitis or peritonsillar abscess (quinsy) resulting in hospitalisation; Tonsillar enlargement causes upper airways obstruction or sleep disruption in children witnessed by their parents or carers. The following criteria are indications for consideration of tonsillectomy for both children and adults: 3 seven or more well documented, clinically significant,* adequately treated** sore throats in the preceding year or five or more such episodes in each of the preceding two years Page 4

5 *A clinically significant episode is determined as symptom duration of several days, which is disabling and prevents normal functioning 4 (e.g. school or work loss, lost sleep and inability to eat). ** Adequately treated means treatment with antibiotics in cases of proven or suspected streptococcal infection. In considering whether a patient meets these criteria, there may be difficulty in documenting the frequency of episodes because patients do not always consult when they have an episode. There may also be uncertainty about whether the sore throats are due to acute tonsillitis or other causes. When the incidence of cases cannot be clearly ascertained, a period of watchful waiting of at least six months, during which the patient or parent can more objectively record the number, duration and severity of the episodes, should be undertaken. This allows a more balanced judgement to be made as to the likely benefit or otherwise of tonsillectomy. This should be reported back to the GP after six months, to enable an appropriate referral decision to be made. When outside the three automatic referral criteria, a clear statement is required in the GP referral letter indicating that the patient meets the eligibility criteria for surgery. This should reference the number of episodes of tonsillitis over a specified time period, or that a six month period of watchful waiting has been undertaken. The basis for any referrals made outside these criteria should be made clear in the referral letter. 4. Implementation Consultants in secondary care and Provider Contracts departments need to be aware that the Commissioner will not usually pay for Tonsillectomy unless the patient meets the eligibility criteria or there is evidence of exceptionality. It would be legitimate for the referral, at the request of the Commissioner, to be rejected by secondary care if this information is not included in the referral letter. Should a clinical decision be made to treat the patient who does not meet the eligibility criteria the clinician will record why the patient is exceptional. If the referral letter fails to provide sufficient evidence to indicate that the patient meets the eligibility criteria for referral the Commissioner supports the Provider in returning the referral to primary care. To ensure compliance with this Commissioning Policy NHS Worcestershire may request Providers of tonsillectomy services to undertake an annual audit of 30 randomly selected case notes and report the findings of the audit to the Commissioner. Page 5

6 5. References 1 Burton MJ, Glasziou PP. Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD DOI: / CD pub2 2 Scottish Intercollegiate Guidelines Network (2010) Management of sore throat and indications for tonsillectomy : A national clinical guideline 3 Paradise JL, Bluestone CD, Bachman RZ, Colborn DK, Bernard BS, Taylor FH, et al.efficacy of tonsillectomy for recurrent throat infection in severely affected children. New England Journal of Medicine 1984;310(11): [PUBMED: ] 4 Indications for Tonsillectomy: Position Paper ENT UK SIGN 117 Management of sore throat and indications for tonsillectomy Documents which have informed this policy NHS Worcestershire: IFR Operating Procedures NHS Worcestershire: Prioritisation Framework for the Commissioning of Healthcare Services West Midlands Strategic Group Commissioning Policy 1: Guiding principles and considerations to underpin priority setting and resource allocation within collaborative commissioning arrangements West Midlands Strategic Group Commissioning Policy 4: Use of costeffectiveness, value for money and cost effectiveness thresholds West Midlands Strategic Group Commissioning Policy 16: Prior approval West Midlands Strategic Group Commissioning Policy 9: Individual funding requests Page 6

7 Equality Impact Assessment Report Template Your Equality Impact Assessment Report should demonstrate what you do (or will do) to make sure that your function/policy is accessible to different people and communities, not just that it can, in theory, be used by anyone. 1. Name of policy or function NHS Worcestershire Tonsillectomy Commissioning Policy 2. Responsible Manager Christina Emerson, Head of Acute Commissioning 3. Date EIA completed 8 th September Description of aims of function/policy To provide guidelines to patients and clinicians in both primary and secondary care on the medical/clinical requirements against which a tonsillectomy procedure will be funded on the NHS within Worcestershire. 5. Brief summary of research and relevant data Not Applicable 6. Methods and outcomes of consultation Not Applicable Results of Initial Screening or Full Equality Impact Assessment Initial or Full Equality Impact Assessment? Equality Group Race Gender Disability Age Sexual Orientation Religion or Belief Human Rights Full Equality Impact Assessment Assessment of Impact 7. Decisions and or recommendations (including supporting rationale) - Not Applicable 8. Equality action plan (if required) - Not Applicable 9. Monitoring and review arrangements (include date of next full review) see front sheet Department Acute Commissioning Directorate Delivery Director Simon Hairsnape Report produced by and job Chris Emerson, Head of Acute Commissioning title Date report produced August 2010 Date report published August 2010 Page 7

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