Professor Frank Keane:

I agree with everything that has been said. It is difficult and quite slow, and it is not unique. The English rate of 40% is quite high in terms of national figures for tonsillectomies and it took them a long time to get to that point. It has been difficult to persuade hearts and minds that the systems are in place for people to manage these patients safely. A combination of coaxing and persuasion of hearts and minds is required.

I have been in surgical practice for 30 years. When I started out we did absolutely nothing as day cases. If someone came in for a laparoscopic cholecystectomy they came in for two weeks and that was it. We have changed hugely over the years and in my practice we now do the majority of laparoscopic cholecystectomies as day cases.

The other issue is that for clinicians - and I am just articulating the truth behind it, without necessarily answering the Deputy's question satisfactorily - there is a comfort factor in having one's patients in hospital the night after they have been operated on. There is an intuitive comfort factor in knowing they are in safe hands. For the first while doing them as day cases, the surgeon goes home and thinks, "My God, what is happening to my patient tonight, how are they?" Returning to what Dr. O'Connell said about tonsils, it is very emotive on a practice basis. Many of the patients are children and people are very uneasy about the prospect of a child being put at risk because they bleed torrentially after they go home and something terrible happens to them. It is quite a significant risk, in other words.

When we try to encourage people to do day cases, the constant response is, "What will happen if I send somebody home and they bleed to death? Where will I be then? I can see it all over the newspapers". It is difficult to persuade people. It takes leaders and we can see that there are some places that are now doing much more, up to 20% or 25% of tonsillectomies being carried out as day cases. It is usually those people, the pathfinders, who show that it is safe and then it gradually trickles into the system.