If you have tonsillitis you might expect to be able to have them out, or if your child has glue ear that he or she could have grommets.

But in line with Kingston Primary Care Trust's (PCT) "turnaround plan" these operations are happening less often than before.

Strict criteria for these operations, among others, were approved by the board last December and since then the PCT's clinical advisory group has added more areas which need a stricter treatment protocol.

These areas include treatment for snoring in adults and eligibility for the hearing aid service.

A spokeswoman for the PCT said: "The approach adopted by all PCTs in south-west London is in line with the advice from the Chief Medical Officer who has stated with finite resources available for the provision of healthcare, it is important that effective therapies to relieve significant conditions are adopted and that ineffective interventions are abandoned."

But some GPs have expressed worries about the guidelines.

One local GP, who did not want to be named, said: "Rationing patient appointments at hospital is an issue as we're angry that our experience and clinical judgement are practically ignored.

"A child with glue ear, for example, can dramatically improve their hearing - which will improve their performance at school during the crucial years - but grommets are limited. We get very upset about not allowing a child to see a consultant."

The GP added that the system had led to some disasters.

"There was a patient with horrible tonsils - big and raw looking. Her case was turned down and that girl ended up on a drip in St George's Hospital casualty with quinsy - an old-fashioned infection. Kingston PCT did then do the right thing and agreed to the operation."

The full statement from Kingston PCT

The PCT has a responsibility to ensure that the funding it receives is used appropriately.

The approach adopted by all PCTs in south-west London is in line with the advice from the Chief Medical Officer who has stated with finite resources available for the provision of healthcare, it is important that effective therapies to relieve significant conditions are adopted and that ineffective interventions are abandoned.

There are some clinical interventions that should usually not be funded by the PCT because of one of the following reasons:

  • There is limited evidence of the effectiveness of the procedure.
  • Initial conservative therapy is appropriate rather than an interventional procedure.
  • There may be a threshold below which intervention is not justified.
  • NHS funding for cosmetic procedures may be inappropriate, based on a judgement as to whether the NHS should provide that particular procedure.

Tonsillectomies: there is limited evidence for the effectiveness of tonsillectomies. There is no evidence from randomised controlled trials (the gold standard for judging whether an intervention is effective or not) to guide the clinician regarding whether surgery should be performed or not.

Most patients experience a reduction in the frequency of sore throats over time whether tonsillectomy is performed or not. Also, there are risks associated with the operation including a small risk of dying as a result of the procedure.

Grommets: there is limited evidence for the effectiveness of grommet insertion. A study looked at 'watchful waiting' of children with glue ears as opposed to inserting grommets and found the clinical outcome to be similar.

There is a lack of evidence of the long-term benefits of inserting grommets and in addition there is a high rate of natural resolution of glue ear in young children, so the condition improves without the need for surgical intervention.

In addition, about one third of children who have grommets inserted suffer from complications as a result of their surgery.

Varicose veins: these are common in the adult population, and most people do not suffer from symptoms or complications. Given this, many operations for varicose veins in the past were for cosmetic reasons and so continuing to fund these procedures is inappropriate.

Some patients do have symptoms from their varicose veins, but for many of them conservative therapy (compression stockings, leg elevation several times a day and exercise) will give relief from their symptoms.

Breast reduction surgery: this is primarily a cosmetic procedure so funding most of these operations is inappropriate. There are some people who develop symptoms (such as severe and prolonged back pain) as a result of having large breasts; surgery may be appropriate in these exceptional circumstances and the PCT deals with these cases on an individual basis.